+ All Categories
Home > Documents > ROYAL MEDICAL AND CHIRURGICAL SOCIETY

ROYAL MEDICAL AND CHIRURGICAL SOCIETY

Date post: 02-Jan-2017
Category:
Upload: vannhu
View: 216 times
Download: 2 times
Share this document with a friend
2
805 cæcum was slightly congested, aud the walls of the intestines were thin; the solitary glands were enlarged. Kidneys normal. On section, the appearance of the growth varied, cutting crisply in the centres of some of the smaller glands, whilst in other larger ones, which were also the more numerous, the centre was softened and of a soft cheesy con- sistence. The small ulcer found in the jejunum bore no specific character. ______________ Medical Societies. ROYAL MEDICAL AND CHIRURGICAL SOCIETY. Diffuse Lipoma.—Common Carotid Artery wounded by a Fish-bone. THE first ordinary meeting of this Society was held on Tuesday last, Mr. M. Berkeley Hill, Vice-President, in the chair. The attention of the meeting was drawn to the im- proved lighting and ventilation of the Society’s rooms. A copy of the new volume of the Transactions was laid on the table for inspection. Mr. MORRANT BAKER and Mr. A. A. BowLBY read a con- joint paper on Diffuse Lipoma, of which the following is an abstract :-The term "diffuse lipoma" is applied by the authors to certain cases in which there is a great increase of the subcutaneous fat, without any distinct boundary or capsule, such as is usual in the more common forms of lipoma. These growths are usually symmetrical, and are most common behind the ears, over the mastoid processes (not extending above the superior curved line of the occipital bone in the nape of the neck), and in the sub- maxillary regions. The same tendency to the development of fat is in many of the cases observed also in the arms and forearms, the scrotum, and the abdominal wall. The authors have observed and record thirteen cases, and refer to others already published. A point to which attention is directed is the fact that these fatty masses are prone to develop in the regions occupied by lym- phatic glands. Whether these latter are ever involved in the growth, the writers are not in a position to state. All the cases hitherto observed have been males, the ages varying from twenty-nine to sixty-three years, the majority of the patients being from thirty-five to forty-five years of age at the time the tumour commenced to grow. None of the patients have been exceptionally stout men. Some of them have been healthy and strong; others have suffered from phthisis, albuminuria, and other wasting diseases. All the swellings observed appear to have a similar structure, being composed simply of adipose tissue. With regard to the anatomical position of the swellings, the writers give reason for believing that they are situated in the subcuta- neous cellular tissue. The manner in which the growths are limited in the various regions in which they are found is discussed. The development of these tumours is somewhat rapid. The rate of growth, however, varies much in in- dividual cases. Another noticeable fact is that in some in- stances the swelling varies in size from time to time. Of this fact several of the patients were very certain, and in some cases the authors were able to verify this statement. Whether the tumours ever entirely disappear in the absence of anywast- ing disease cannot certainly be affirmed. The only circum- stance which seems to give any clue to a cause is (so far as the writers have been able to observe) the fact that, with one or two possible exceptions, the patients have been hard drinkers, Beyond the discomfort produced by the deformity, no symp- toms specially referable to the fatty tumours have been observed. Internal remedies have apparently little or no effect. In one or two cases, however, the administration of arsenic with steel seemed slightly beneficial. In accordance with Brodie’s suggestion, the writers have tried the effect of liq. potassse, but have not hitherto found it beneficial in reducing the size of the growths. They have administered the above-mentioned drugs, as well as iodide of potassium and mercury, in several cases for some months. Several typical living specimens of the disease were exhibited.- Dr. CREIGHTON said that he was reminded of a case that Mr. Henry Morris had related to him. There was a diffuse infiltration of the submaxillary region extending from ear to ear; it was of scirrhous hardness. He thought - that a sclerosis of the fatty tissue would account for this induration. He admitted there was no evidence of sclerosis in any of the cases that the authors had exhibited.—Mr. H. MoRRiS said that the case to which Dr. Creighton had re- ferred was one of diffuse cancer, and very different from diffuse lipoma, of which he had seen three cases. Recur- rence took place in two cases; in one of these there was cancer of the tongue which extended into the floor of the mouth, and then involved the glands beneath the jaw. After this time the lipoma softened and suppurated. In another case that occurred, also in a man, there was a large pendulous mass hanging from the abdomen, almost to the knees. Some chest and vesical disease were present, and the lipoma became severely inflamed and suppurated, so that enormous quantities of mixed discharge came from it. In a third case that he had seen, Sir William Mac Cormac’s observation was borne out. There was an enormous tumour of the scalp, which became inflamed and looked like a huge sebaceous cyst; it was, however, a large fatty tumour, situated beneath the aponeurosis of the scalp, and it had caused some depression of the bone, except at its margin, where the bone was "heaped up."—Mr. H. T. BUTLIN had seen a case in a woman aged about thirty; at least there was the same kind of enlargement, and extended down into the neck. He had benefited the case by large doses of liq. potassae. He did not remember the habits of this patient.-Mr. DAVIES COLLEY had seen a case of diffuse lipoma in a woman aged thirty ; it was situated over the trapezius, and he had removed it without seeing any of the muscular fibres. Other cases of diffuse lipoma he had seen in infants, which tumours were probably of congenital origin; they grew between the muscles and beneath the fascia. He had been under the impression that Brodie’s cases were examples of di6semi- nated lipomata.—Mr. F. B. JESSETT has seen a diffuse lipoma in the person of a gentleman who had been a total abstainer for many years, and had never been more than a moderate drinkerof alcoholic liquors.—Mr.MoRRANT BAKER, in reply, said that ordinary lipomata were liable to cal- careous hardening, but, with the exception of a heaping up of bone about the base of some of the diffuse lipomata, he did not know of an induration like that referred to by Dr. Creighton. He did not remember any case in which suppuration occurred, and he considered that there was no tendency in such tumours to suppurate. It was strange that the disease had not been met with by him or Mr. Bowlby in females. Alcoholism seemed to be the only antecedent that appeared to have a causative relation to the disease. Mr. RIVING1’ON read a paper on a case of Ligature of the Left Common Carotid Artery, wounded by a fish-bone that had penetrated the pharynx. The patient, aged nine, was admitted into the London Hospital, under the care of Dr. Sutton, on Nov. 14th, 1882. Six days before he had swallowed a plaice-bone. At the hospital a probang was passed, and he was sent home; not being relieved, he came back to the hospital and was taken in. His symptoms were pyrexia, stiffness of the neck, oedema of the upper eyelids, profuse salivation, and a small tender lump on the left side, opposite the cricoid cartilage. Pulse 120; temperature 101.3°; re- spiration 22. He could not swallow solid food, and was very drowsy. He had two attacks of haemorrhage from the mouth on the 17th and profuse haemorrhage on the 19th. Mr. Rivington was sent for, and, diagnosing wound of the left carotid artery from penetration of the fish-bone, cut down and tied the artery above and below the seat of injury. The operation was difficult, owing especially to inflammatory adhesions and uniform staining of all the structures, including nerves and bloodvessels, with effused blood. The pneumo- gastric was adherent to the artery for about two inches, and, being in front of the artery and undistinguishable, was necessarily included in the ligature. The fish-bone was found in the centre of a clot. The patient lived ten days after the operation, dying from abscess of the brain on the left side, which had probably commenced to form before the operation. Remarks were made on the salient features of the case, and the mischief which was often wrought by the incautious passage of bougies and probangs in these cases. In an appendix to the paper there was given an abstract of 44 cases of wounds of bloodvessels by foreign bodies intro- duced through the mouth. These included wounds of the following vessels: thoracic aorta, 22; carotids, 12; abnor- mal right subclavian, 1 ; pulmonary artery, 1; azygos vein, 1; heart and right coronary vein, 1 : vena cava, 3 ; inferior thyroid, 3. Comparison of these cases with one another, and the author’s case, necessarily suggested a variety of con-
Transcript
Page 1: ROYAL MEDICAL AND CHIRURGICAL SOCIETY

805

cæcum was slightly congested, aud the walls of the intestineswere thin; the solitary glands were enlarged. Kidneysnormal. On section, the appearance of the growth varied,cutting crisply in the centres of some of the smaller glands,whilst in other larger ones, which were also the more

numerous, the centre was softened and of a soft cheesy con-sistence. The small ulcer found in the jejunum bore nospecific character.

______________

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

Diffuse Lipoma.—Common Carotid Artery wounded by aFish-bone.

THE first ordinary meeting of this Society was held onTuesday last, Mr. M. Berkeley Hill, Vice-President, in thechair. The attention of the meeting was drawn to the im-proved lighting and ventilation of the Society’s rooms. Acopy of the new volume of the Transactions was laid on thetable for inspection.Mr. MORRANT BAKER and Mr. A. A. BowLBY read a con-

joint paper on Diffuse Lipoma, of which the following is anabstract :-The term "diffuse lipoma" is applied by theauthors to certain cases in which there is a great increaseof the subcutaneous fat, without any distinct boundary orcapsule, such as is usual in the more common forms oflipoma. These growths are usually symmetrical, and aremost common behind the ears, over the mastoid processes(not extending above the superior curved line of the

occipital bone in the nape of the neck), and in the sub-maxillary regions. The same tendency to the developmentof fat is in many of the cases observed also in the arms andforearms, the scrotum, and the abdominal wall. Theauthors have observed and record thirteen cases, andrefer to others already published. A point to whichattention is directed is the fact that these fatty massesare prone to develop in the regions occupied by lym-phatic glands. Whether these latter are ever involved inthe growth, the writers are not in a position to state.All the cases hitherto observed have been males, the agesvarying from twenty-nine to sixty-three years, the majorityof the patients being from thirty-five to forty-five years ofage at the time the tumour commenced to grow. None ofthe patients have been exceptionally stout men. Some ofthem have been healthy and strong; others have sufferedfrom phthisis, albuminuria, and other wasting diseases. Allthe swellings observed appear to have a similar structure,being composed simply of adipose tissue. With regard tothe anatomical position of the swellings, the writers givereason for believing that they are situated in the subcuta-neous cellular tissue. The manner in which the growths arelimited in the various regions in which they are found isdiscussed. The development of these tumours is somewhatrapid. The rate of growth, however, varies much in in-dividual cases. Another noticeable fact is that in some in-stances the swelling varies in size from time to time. Ofthis fact several of the patients were very certain, and in somecases the authors were able to verify this statement. Whetherthe tumours ever entirely disappear in the absence of anywast-ing disease cannot certainly be affirmed. The only circum-stance which seems to give any clue to a cause is (so far as thewriters have been able to observe) the fact that, with one ortwo possible exceptions, the patients have been hard drinkers,Beyond the discomfort produced by the deformity, no symp-toms specially referable to the fatty tumours have beenobserved. Internal remedies have apparently little or noeffect. In one or two cases, however, the administration ofarsenic with steel seemed slightly beneficial. In accordancewith Brodie’s suggestion, the writers have tried the effect ofliq. potassse, but have not hitherto found it beneficial inreducing the size of the growths. They have administeredthe above-mentioned drugs, as well as iodide of potassiumand mercury, in several cases for some months. Severaltypical living specimens of the disease were exhibited.-Dr. CREIGHTON said that he was reminded of a casethat Mr. Henry Morris had related to him. There was adiffuse infiltration of the submaxillary region extendingfrom ear to ear; it was of scirrhous hardness. He thought- that a sclerosis of the fatty tissue would account for this

induration. He admitted there was no evidence of sclerosisin any of the cases that the authors had exhibited.—Mr. H.MoRRiS said that the case to which Dr. Creighton had re-ferred was one of diffuse cancer, and very different fromdiffuse lipoma, of which he had seen three cases. Recur-rence took place in two cases; in one of these there wascancer of the tongue which extended into the floor of themouth, and then involved the glands beneath the jaw. Afterthis time the lipoma softened and suppurated. In anothercase that occurred, also in a man, there was a large pendulousmass hanging from the abdomen, almost to the knees. Somechest and vesical disease were present, and the lipomabecame severely inflamed and suppurated, so that enormousquantities of mixed discharge came from it. In a third casethat he had seen, Sir William Mac Cormac’s observation wasborne out. There was an enormous tumour of the scalp,which became inflamed and looked like a huge sebaceouscyst; it was, however, a large fatty tumour, situatedbeneath the aponeurosis of the scalp, and it had causedsome depression of the bone, except at its margin, wherethe bone was "heaped up."—Mr. H. T. BUTLIN had seen

a case in a woman aged about thirty; at least therewas the same kind of enlargement, and extended downinto the neck. He had benefited the case by largedoses of liq. potassae. He did not remember the habitsof this patient.-Mr. DAVIES COLLEY had seen a case

of diffuse lipoma in a woman aged thirty ; it was

situated over the trapezius, and he had removed itwithout seeing any of the muscular fibres. Other cases ofdiffuse lipoma he had seen in infants, which tumours wereprobably of congenital origin; they grew between themuscles and beneath the fascia. He had been under theimpression that Brodie’s cases were examples of di6semi-nated lipomata.—Mr. F. B. JESSETT has seen a diffuselipoma in the person of a gentleman who had been a totalabstainer for many years, and had never been more than a

moderate drinkerof alcoholic liquors.—Mr.MoRRANT BAKER,in reply, said that ordinary lipomata were liable to cal-careous hardening, but, with the exception of a heaping upof bone about the base of some of the diffuse lipomata, hedid not know of an induration like that referred to byDr. Creighton. He did not remember any case in whichsuppuration occurred, and he considered that there was notendency in such tumours to suppurate. It was strangethat the disease had not been met with by him or Mr. Bowlbyin females. Alcoholism seemed to be the only antecedent thatappeared to have a causative relation to the disease.

Mr. RIVING1’ON read a paper on a case of Ligature of theLeft Common Carotid Artery, wounded by a fish-bone thathad penetrated the pharynx. The patient, aged nine, wasadmitted into the London Hospital, under the care of Dr.Sutton, on Nov. 14th, 1882. Six days before he had swalloweda plaice-bone. At the hospital a probang was passed, and hewas sent home; not being relieved, he came back to thehospital and was taken in. His symptoms were pyrexia,stiffness of the neck, oedema of the upper eyelids, profusesalivation, and a small tender lump on the left side, oppositethe cricoid cartilage. Pulse 120; temperature 101.3°; re-

spiration 22. He could not swallow solid food, and was verydrowsy. He had two attacks of haemorrhage from themouth on the 17th and profuse haemorrhage on the 19th.Mr. Rivington was sent for, and, diagnosing wound of theleft carotid artery from penetration of the fish-bone, cutdown and tied the artery above and below the seat of injury.The operation was difficult, owing especially to inflammatoryadhesions and uniform staining of all the structures, includingnerves and bloodvessels, with effused blood. The pneumo-gastric was adherent to the artery for about two inches, and,being in front of the artery and undistinguishable, wasnecessarily included in the ligature. The fish-bone wasfound in the centre of a clot. The patient lived ten daysafter the operation, dying from abscess of the brain on theleft side, which had probably commenced to form before theoperation. Remarks were made on the salient features ofthe case, and the mischief which was often wrought by theincautious passage of bougies and probangs in these cases.In an appendix to the paper there was given an abstract of44 cases of wounds of bloodvessels by foreign bodies intro-duced through the mouth. These included wounds of thefollowing vessels: thoracic aorta, 22; carotids, 12; abnor-mal right subclavian, 1 ; pulmonary artery, 1; azygos vein,1; heart and right coronary vein, 1 : vena cava, 3 ; inferiorthyroid, 3. Comparison of these cases with one another,and the author’s case, necessarily suggested a variety of con-

Page 2: ROYAL MEDICAL AND CHIRURGICAL SOCIETY

806

siderations, the most important being those which bore upondiagnosis and treatment. For diagnosis there were the.history of a foreign body having been swallowed; the per-sistence of pain, referred to one spot; dysphagia, especiallyinability to swallow solids; pytalism; failure of the foreignbody to pass per anum or from the mouth; recurringexpectorations or vomitings of blood; passage of bloodby stool, and fainting fits. In the neck there would belocal evidence of inflammation, swelling, and tenderness.For treatment, improved illumination of the pharynxand cesophagus and extraction of the foreign body withforceps, regulation of diet, exhibition of demulcents, andthe cautious use of the expanding probang were mentioned.In some cases the question of cesophagotomy must be con-sidered, and, in all cases, as life was soon endangered by theoccurrence of haemorrhage, prompt surgical assistance wasimperative.-Mr. BERKELEY HILL said the paper was oneof considerable interest.-Mr. MORRANT BAKER said that atobacco-pipe was occasionally thrust into the mouth andpenetrated a large vessel in the throat, and so led to severeand even fatal haemorrhage. He briefly related a case of thekind that was recorded in the St. Bartholomew’s HospitalReports. The diagnosis of these cases was sometimes verydifficult from the history being overlooked.—Surgeon-MajorBLACK narrated the case of a soldier who had swallowed afish-bone. The probang was used, and after many weeks thebone was disentangled; it had probably been entangled inan abscess.-Mr. A. A. BOWLBY mentioned a case that wasrecorded in the catalogue of the museum of St. Bartholomew’sHospital. A probang was passed to get out the fish-bone ;the throat felt much worse after this had been done; thesame evening some blood was vomited; the next day bloodwas passed from the bowel, and the man died. The bonehad entered the front part of the arch of the aorta near theleft subclavian artery.-Mr. RIVINGTON briefly replied.

CLINICAL SOCIETY OF LONDON.

Cholecystotomy.— FebriLe Epidemic Illness at a School.AN ordinary meeting of this Society was held on the

23rd inst., Mr. Morrant Baker, Vice-President, in the chair.Mr. A. W. MATO ROBSON read notes of two successful

cases of Cholecystotomy. He said that, after the interestingpaper by Mr. Lawson Tait on the Surgical Treatment ofGall-stones, in THE LANCET of Aug. 29th and Sept. 5th, 1885,with the reports of his cases previously published, and afterthe paper by Musser and Keen in the American Journal ofMedical Science, in which thirty-five cases of cholecystotomyare reported (of which ten were fatal), the record of his twosuccessful cases would seem to be almost unnecessary if thesubject were not still sub judice, and did not present manyinteresting physiological and pathological questions not yetsettled, and which every case fully reported might dosomething to elucidate. But his apology must be a

paragraph taken from Sir Spencer Wells’s work, "Uterineand other Abdominal Tumours," 1885, p. 203, where he says:"What we need is further experience and an accurate recordof all cases." In the first case Mr. Robson was consulted inJune, 1884, by Mrs. B--, aged thirty-three, on account ofa tumour the size of a hen’s egg, which caused draggingpain and uneasiness, but there had never been any jaundice.It was then diagnosed as a distended gall-bladder, butconsent to operate was not obtained until June 21st, 1885,when, the tumour having greatly increased in size, withaugmentation of the discomfort, cholecystotomy was per-formed, and eight facetted gall-stones were removed fromthe cystic duct. They varied from the size of a pea to thatof a large bean, and were of a dark brown colour. The gall-bladder contained nearly half a pint of clear watery fluid,which was removed by an aspirator before the cyst wasopened. Peritoneum was then sutured to peritoneum, andmucous membrane to skin, and the rest of the wound wasclosed by catgut sutures, a drainage-tube being inserted intothe gall-bladder. Recovery was uninterrupted, unionoccurring by first intention, the patient being able to

go for a drive on the seventeenth day. A minute fistularemained in September, just capable of admitting a smallprobe. It discharged a little thin mucus, but gave ncinconvenience. The patient was feeling well in ever)respect, having gained in strength and weight. The secondcase was that of a German governess aged twenty-two, whc

was admitted under the care of Dr. Churton in February,1885. There was vomiting, a history of prolonged constipa-tion, and a tumour in the position of the hepatic flexure ofthe colon, the size of which was unaffected by largeinjections. It being then suspected that the tumour wasa distended gall-bladder, the patient was transferred toMr. Robson, who performed cholecystotomy, remoiingnumerous small white calculi and eight ounces of clearfluid. The steps of the operation were exactly the same-as in the first case, and in both the finger was passedinside the peritoneum, along the cystic duct, in order to besure that no calculi were left to cause a block in the passage.After the operation the vomiting absolutely ceased andrecovery was uninterrupted, the pulse and temperaturebeing normal throughout, and the wound healing byfirst intention. The fistula discharged a clear mucous fluidfor a time, but on September 15th had completely closed.It, however, reopened in October, and discharged the samekind of fluid again, the patient experiencing no discomfortor pain, and feeling absolutely well in every respect.In the operations, which were performed antiseptically.pains were taken to stitch peritoneum to peritoneum, andmucous membrane to skin, great care being exercised inprotecting the peritoneal cavity from the intrusion of anyof the contents of the tumour. In the after-progress, thedischarge of clear fluid free from bile, and the length of timeelapsing in the second case before the fistula closed, soon,.however, to reopen (the fistula in the first case never havingclosed), indicated that the cystic duct remained blocked inboth, but there being no jaundice and no illness, the commonducts were evidently patent; moreover, since the fingerintroduced into the peritoneum and passed along the cysticduct failed to discover any perceptible enlargement, and a.

probe passed as far as it would go failed to feel any hardbody, the only conclusion Mr. Robson could come to was thatin these cases there was organic stricture of the ductus.cysticus. He raised the question, Is there organic strictureof the cystic duct in both cases, or is the obstruction due toother concretion which careful probing and intra-peritonealdigital exploration failed to discover ? If he thought therewere calculi causing obstruction he would not hesitate tadvise laparotomy as a preliminary to cholelithotrity; but ifthere were stricture, as he believed, then he would he,,zi-tate to advise another operation, since, if the stricture were

dilated, contraction would be likely to recur, again givingrise to a tumour requiring further treatment. Another ques-tion arose, Would cholelythectomy have been in these casesa better operation? Sir Spencer Wells seemed rather to inclineto this extreme measure in preference to cholecystotomy, butin the record of published cases the mortality was so great,that unless he saw a better way of doing it he should cer-tainly hesitate to recommend it. However, if he ever had toperform cholelythectomy, he should, if possible, completelydraw out the gall-bladder, bringing the duct into the woundjust as Mr. Thornton did the ureter in abdominal nephrec-tomy, this being more likely to prevent the entrance offoreign matter into the peritoneum. If he had thought thatdilatation would have done any gond, he would have passedin bougies from the outside through the fistula ; but this hefelt would have been attended with risk, as it would be veryeasy to push a bougie through the thin wall of the duct, andsuch a proceeding would, he feared, lead to fatal results.Mr. Robson remarked on the clinical importance of the fluid.He thought that the secretion had some antiseptic property.This had been confirmed by his colleague, Professor de BurghilBirch, who had also found it to contain a milk-curdlingferment and another ferment having a marked diastaticaction on starch. He remarked that in THE LANCET frrSept. 5th, 1885, p. 424, Mr. Tait says: " In cases wherepatients suffer from numerous gall-stones, the gall-bladeris never distended"; and again on the same page, "whenwe operate therefore, in cases of small numerous gall-stones, we flnd them lying in bile, the gall-bladder to

a large extent contriving to perform its functions." Thecases he had just reported must therefore come underan entirely different category. He had another case :’.’

present under observation, that of a middle-aged gentlemenof temperate habits, which he thought resembled the casereferred to in the paragraph quoted, in whom, after repeat=attacks and "spasms," usually coming on in the night, ’.

unaccompanied by jaundice, he found a tumour in the rightlumbar region, about the size of a swan’s egg, which per-sisted for several weeks and then disappeared, after ’."’.

attack of pain lasting about three hours. He reported


Recommended