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UNIVERSITY COLLEGE HOSPITAL.CLINICAL REMARKS

ON

CASES IN THE HOSPITAL.

RECENTLY DELIVERED BY

ROBERT LISTON, ESQ.

IRRITABLE BLADDER SIMULATING CALCULUS.

MR. LISTON proposed, he said, to make afew remarks upon cases that had presentedthemselves within the last two or threeweeks, and first upon that of a boy, who hadbeen lately admitted into the hospital, labour-ing under some symptoms of stone. He was seven or eight years of age, made water fre-quently, and apparently sufl’ered much painin doing so. It was naturally enoughthought by the gentleman under whose carethis patient had been that the symptomsarose from stone, and he had, by the intro-duction of a catheter, which had been fromtime to time required, almost satisfied him-self of its presence. An examination wasnow made, but no stone could be detected.As the sound, however, passed over thecoats of the distended bladder they werefound to be hardened and fasciculated, andgave a sensation to the hand as though theinstrument was passing over parchment orwet leather; a very curious sort of rub, onewould almost say grating sound, was ex-perienced in withdrawing the instrument.The boy had made water in great quantity,and all about the bed and spectators, butwith much straining, whilst preparationswere making for introducing the sound, yetthe curved part of the instrument moved

freely in the viscus. It was evidently over-distended, and incapable of expelling but alimited quantity of its contents. This was

proved, after a second examination with thesound, bv the introduction of a catheter.

It was not unlikely, Mr. Liston stated,that the distention of the bladder might haveoriginally arisen from the lodgment of a

small concretion in the neck of the viscus,which might have escaped in the intervalbetwixt the examination made out of doorsand in the hospital. This he was inclinedto believe from what he had known to occurin other cases. He referred to one publishedin his " Practical Surgery," and illustratedby a sketch of a most remarkable dilatationof the bladder, with large pouch in its fun-dus, great enlargement of the ureters andpelves of the kidneys. This patient, a boyof very tender years, had been sent from adistance to be cut for stone, which was re-ported to have been felt distinctly ; none,however, could be discovered upon carefuland repeated soundings by Mr. Liston. Theboy was in a very declining condition, anddied within a few weeks of his admissioninto the Edinburgh Hospital. There was

no stone in the bladder or in any of thepassages. Retention of urine in childrenarises more frequently from the passage ofsmall concretions than from any other cause.Mr. Liston in this case ordered half a drachmof the balsam of copaiba, with castor oil,every morning, for the purpose of clearing outthe bowels, for the removal of any irritatingmatters, worms, or sordes. He also directedthe house-surgeon to introduce the catheternight and morning. In a few days the

symptoms were much ameliorated; the boyhad regained full power over the bladder;all the symptoms abated, and he was soondischarged cured. Mr. Liston drew atten-tion to the necessity of carefully soundingfor stone and decidedly detecting its presencebefore proceeding to any operation whatever.Some surgeons (who ought to have knownbetter) had cut into the bladder, some ofthem over and over again, when there hadnever been any stone in it. The only test ofthe presence of calculus was the unequi-vocal striking of the sound upon the foreignbody.

TUMOUR OF THE MOUTH.-OPERATION.

Mr. Liston exhibited a tumour which hehad removed from the mouth in the courseof the preceding week. The growth wasawkwardly situated at the posterior part ofthe mouth, involving the gums and teeth onone side of the lower jaw. It was of a

homogeneous character, of about the struc-ture of the gums, not very vascular, andendued with but little sensibility, coveredby a prolongation of the lining membrane ofthe mouth, firm, and a slight noise washeard when it was under the knife. It ex-hibited no single character of malignancy.The situation of this tumour rendered the

operation of removal very difficult; it wassituated at the further extremity, and near theramus of the jaw, and was of considerablesize. In these cases it was desirable to

operate without external incisions, to avoiddeforming the features, though such incisionsdiminished greatly the difficulty of the opera-tion. It might generally be done by firstcutting away part of the tumour, extractingany teeth connected with the growth, andcutting out a portion of the alveolar pro-cesses by means of the cross-cutting pliers.It was attempted in this instance, but it wasto be feared, from the restlessness of the

patient during the operation, that the com-plete removal of the parts involved had beenfrustrated, and possibly further proceedingsmight be necessary.Tumours of this description were met with

in various parts of the mouth; they wereoften connected with the body of the underjaw, sometimes affecting the gum or socketof only one tooth, sometimes of two or more.They were of various sizes, and generallyprojected outwards; in the present case thegrowth was inwards. They were sometimes

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lobulated, sometimes quite smooth, and un-attended by any pain or discharge. Mr. J.Bell had described a tumour situated inthese parts, of a soft, spongy, and cancerouscharacter, not at all allied to the cases underconsideration, and of very uncommon occur-rence. Mr. L. had been occasionally con-sulted in such cases, but they were moreallied to malignant ulcers, with soft andspongy swelling surrounding them, than to

tumours, properly speaking. In such casesremoval would be useless, excepting in thevery earliest stages. Epulis, the diseaseexhibited in the preparation, was of a

benign character, as far as any disease couldbe called benign, and when completely re-

moved would not be re-produced again, eitherin the part operated upon or in any other.It was necessary to know from whence thedisease had its origin, in order for its com-

plete removal. It was sometimes dependentupon decayed teeth, sometimes it sprungfrom the aveoli, and sometimes from the jawitself. It grew from the gums, the perio-steum of the socket, or the periosteum ofthe tooth. Mr. L. related the case of a boywho had a tumour of this kind attached toone of the bicuspides ; a tooth was removedfor the purpose of taking away a part of thealveolar processes to which the tumour wassupposed to be connected ; the tumour wasfound attached to the neck of the tooth, andcame away with it, rendering further inter-ference unnecessarv. The case did well.All sorts of caustics had been used to

destroy the tnmour ; it had been cut awayrepeatedly, but all in vain. These tumourswere often large, but were generally easy ofremoval. It was sometimes necessary toremove the tooth and a portion of the alveolus.No further treatment was required; cicatri-sation took place, and a cure was the result.Occasionally, however, operations at theback of the mouth were attended with diffi-culty, particularly when the disease had itsorigin low in the jaw, or involved its base.It might be necessary in some cases to care-fully examine the jaw, and even to removea portion of it through its entire thickness.He related the case of a boy, ten or twelveyears of age, who had a large tumour of the ’’

lower jaw. In this case it was thoughtthat possibly a portion of the jaw might re-quire to be removed, and an incision of thecheek was accordingly made. It was found,however, that the base of the jaw was un-affected. The tumour was detached withthe alveolus on each side of it, which wasthen cut out with pliers. The remainingportion contained the permanent teeth, thetops of which had been partly exposed inthe operation. These teeth eventually cameforward and became serviceable.

TUMOUR OCCUPYING THE POPLITEAL SPACE.

The subject of this case was a boy tenyears of age. A tumour was noticed at the

posterior part of the thigh when he was- about two years of age; as this continuedi to increase in size, it was explored by agroove needle, but nothing escaped. Atthis time there appeared to be evident fluc-tation and pulsation. A variety of meanswere employed for its dispersion, such asblisters, the use of setons, &c., but these pro-duced no change in it ; it still increased in

size, and on admission into the hospital itoccupied all the popliteal space, and it feltfully as large as a goose’s egg. On exa-mination, the tumour had a soft, doughy

feel, almost amounting to a sense of fluctua-tion. It was evidently deeply-seated underthe fascia of the ham. By flexing the legupon the thigh, so as to relax the ham-stringmuscles, the tumour could be lifted up,together with the other structures of theregion ; its borders, however, could not bedistinctly denned, nor could it be isolatedfrom the adjacent tissues. The elasticity ofthe tumour was such as to resemble thefluctuation of fluid, and to lead many to con-

sider it a collection of matter-a chronicabscess. The duration of the disease, thefact of its having been explored withoutescape of pus, and a seton having been keptin it for some time without reducing the bulk,forbade this idea, nor did they afford better

grounds for suspecting the existence of

aneurism, of which the only symptom thathad ever existed was a degree of pulsationin the tumour. This did not now exist, andthe youthfulness of the patient rendered theexistence of such disease improbable. Satis-fied that it was a new and solid growth, Mr.Liston determined on removing it.

It was thought advisable to explore it inthe first instance, a narrow bistoury was ac-cordingly thrust into it, turned upon its axis,and partly withdrawn. This was followedby an uninterrupted stream of blood of adarkish hue. On attempting to move thepoint of the knife about in the tumour no

cavity could be detected, and it was thoughtprobable that some vein had been woundedby the puncture. When the bistoury waspushed into another part of the tumour nofluid escaped from the puncture so made.A free incision was now made over thetumour and the fascia divided; the resultoffered little encouragement to proceedingwith the operation, for the tumour had ap-parently shrunk away to nothing, andappeared covered on every aspect by muscle.It was soon discovered that the growth wassituated in the substance of the semi-mem-branosus ; this muscle was accordingly cutinto, and the tumour, which was imbeddedin it, dissected out. It was closely connectedwith the popliteal nerve, which, with thelarge vessels of this region, was exposedduring the dissection. On cutting into thetumour, which was covered by muscle andvery dense fatty matter, a large and beautifulmass of erectile tissue was exposed to view,

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and the haemorrhage, the pulsation in the

early stage of the disease, its gradual in-crease in size, and its shrinking away onbeing handled, were now all sufficiently ex.plained.

Erectile tumours seemed sometimes to be

composed chiefly of venous branches, andwere allied to varix. In such cases theywere of slow growth, and threw out, whenpunctured, dark-coloured blood in consider-able quantity, but not impetuously. Some-times the arterial capillaries seemed to havemore to do in the formation of the disease.These tumoursoccasionally pulsated strongly,and were attended with a peculiar whizzingnoise; when cut into, blood was poured outrapidly, and to an alarming extent. Theirinternal structure resembled closely, in factcould often not be distinguished, as in thepresent instance, from the natural erectiletissue.

It was very unusual to find erectile tissuedeeply seated, and still more uncommon tofind it in the substance of a muscle and, in-deed, it was very uncommon to find musclesin any way diseased. These tumours werevery frequently found in subcutaneous cellu-lar tissue, involving also the skin itself,specimens of which were to be seen in themuseum of the college.

In alluding to the. rarity of any patholo.gical changes taking place in muscles, Mr.Liston related a case in which he had foundit necessary to remove the sterno-cleido-mastoid muscle of one side, involved in asarcomatous tumour,-a dissection so diffi-cult, from the great number of importantparts amongst which it was to be effected,as to make him think he should hesitatebefore repeating such an operation. In con-

sequence of the long continuance of thisdisease the neighbouring blood-vessels were Igreatly enlarged; one vessel, just above the ithyroid cartilage, bled so freely, and was somuch retracted, that to secure it with theforceps was impossible. In this dilemma atenaculum was passed through the thyro-hyoid membrane, underneath the vessel,some threads wound round it, and the pointof the instrument then cut off and left in thewound ; it effectually controlled the bleeding,and came away in the course of a few days,and all did well. Gentlemen who would beoperating surgeons must be prepared forthese pinches; it was not all smooth-sailing,nor could it be said when an operation wascommenced what might occur in its progress,or what shifts might be necessary to gothrough with it successfully. Erectiletumours were generally to be removed byligatures, the great hasmorrhage that followedwounds of them rendered the cutting of themout very dangerous. The operation of re-moval by ligature was often enough seen inthe practice of this hospital, and was gene..rally very successful. In the museum of thecollege was to be seen a very fine cast of a

subcutaneous erectile tumour in the peri-neum which had been removed by thismeans; they were of very frequent occur-rence, and in every part of the body. Erec-tile tumours very rarely or never occurred inbones. Both British and foreign patholo-gists were continually confounding malig-nant disease of the cancellated texture ofbones with this affection. In the FrenchDictionary of Medicine, in a paper on thesubject, the writer, after cautioning againstthis error, himself falls into the same mis-take. The cancellated texture of the headsof bones was often enough the seat of ma)ig -nant disease ; the veins became enlarged,deposits of cancerous matter took place ; thewhole normal structure was destroyed. Theperiosteum became thickened; the end of thebone enlarged to various sizes, sometimesvery large. These tumours proceeded on toulceration ; they threw out fungi, and mightbleed profusely sometimes, but they were al-together another thing from erectile tumours.Mr. L. had seen a case in which a manof about forty years of age had had abscessof the lower end of the femur, from whichfollowed exfoliations of bone ; these weredischarged through some ulcerations whichhad taken place in the ham. After their dis-charge the ulcers cicatrised and all appearedto be doing well. Sometime after a small fun-gus protruded in the situation of the cicatrix,and bled rather freely ; for some time thehaemorrhage was easily arrested by bandages ;however, it continued to increase, and on one

occasion had bled so profusely that it was foundnecessary to apply a tourniquet, and thena second. All was in vain, and the patientwas nearly moribund from loss of blood ; inthese circumstances nothing remained but toamputate the limb, which was accordinglydone, and the issue was successful. On ex-amining the end of the femur the cancellatedtexture was found dilated, full of cells con-taining a bloody lardaceous matter, with

enlarged veins, &c.; at the back of thefemur was an opening through which pro-truded a small fungus, that which, presentingthrough the integuments, had given rise tothe alarming haemorrhage.

MALIGNANT TUMOUR OF THE HIP.

Mr. Liston then exhibited an immensemalignant tumour which he had recentlyobtained at the post-mortem examination ofa patient. It was connected with the osilium, from which it had grown, projectinginto the pelvis, where it was covered by theiliacus muscle, and outwardly over the dor-sum of the ilium. The subject of it was agentleman of about sixty ; it had beengrowing some years, had increased veryrapidly, and was attributed to a blowreceived by a fall on the hip. Many sur-geons had seen the case, and several hadconsidered the disease aneurismal, from thefact that during its progress pulsation had

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existed in it, and a bruit had been heard.These were of frequent occurrence in suchtumours, and were to be accounted for bythe increased size of the vessels going to orcontained in the diseased tissue. Some ofthese cases had been treated as aneurism.Mr. L. related one in which the commoniliac artery had been tied; so far as theoperation was concerned, the patient didwell. The tumour, however, did not decreasemuch, and ultimately the patient perished ;and examination after death showed whatthe true state of the case had been.

CASE OF DISEASED KNEE-JOINT.

Mr. Liston then made some remarks on acase of diseased knee-joint, for which ampu-tation of the thigh had recently been per-formed. Showing a cast of the diseasedjoint, he stated that the subject of the opera-tion was a little girl, who had been sufferingfor some years from the disease. The castexhibited great mischief in the joint, the

cavity of which was full of pus ; the ligamen-tous tissue was nearly destroyed ; the syno-vial membrane in a soft pulpy condition, thearticulating surfaces of the bones deprivedof cartilage by ulceration ; a large cavityfilled with pus in the head of the tibia, withother abscesses of the soft parts. Thesecases were attended with great impair-ment of the health ; patients became hectic,lost flesh, and suffered from great pain, fever,night-sweats, and diarrhoea. Such had beenthe patient’s condition in the present instance,and the only chance of benefit offered wasthe removal of the disease by amputation.This was generally followed by immediateimprovement of the health, as in the presentinstance, and life was thereby prolongedwith a very fair recovery of health for manyyears, and not unfrequently there was noreturn of the disease at all; in other casesthe result was not so favourable. In somefew of these cases recovery took place with-out operation; the disease gradually sub-sided where the constitution bore up againstits effects, and the parts being kept in per-fect rest, and other means used to keep thegeneral health good, anchylosis took placebetween the articulating extremities of thebones; but even when this occurred, thejoint, of course, remained stiff and immove-able.STRANGULATED HERNIA.-OPERATION.-DEATH.

Another interesting case had recently oc-curred, but with unfavourable result. A

man, about forty years of age, had been

operated on for strangulated inguinal herniaa few days before. Hernia had existed for

twenty years, but had always been reducible.The patient had worn a truss, but havingrecently broken it, had been using anotherwhich was old, and did not completely keepback the bowel. In consequence, duringsome exertion, it had come down, and everymeans had been resorted to in vain to return

it, both before and after his admission intothe hospital. There was little tenderness ofthe tumour, and the only bad symptom wasvomiting of stercoraceous matter. The stran-gulation had existed about forty hours. Theoperation of cutting down on the bowel andreturning, it was had recourse to, and effectedwithout difficulty, and for four and twentyhours the patient had gone on without anunfavourable symptom. A great deal offlatus had been expelled from the bowels,which had also been relieved by stool once; nomedicine had been given. Suddenly a

violent diarrhoea came on, which could notbe arrested. The patient was much debili.tated by it, and whilst sitting up in his bedsuddenly fell back and expired. An ititer-mission in the pulse had been noticed onhis admission into the hospital, and had beenobserved at different times before by his medi-cal attendant. An examination of the bodywas made after death, when nothing could bediscovered to account for it. There wasscarcely a trace of peritoneal inflammation ;the part of the bowel which had been stran-gulated was but little injured ; in the heartnothing abnormal was discovered, but a

slight dilatation of the left ventricle ; thelungs were pretty thickly studded with

tubercles, and contained also some cavities.Indications of the existence of tubercular

phthisis had been observed for some years,but neither could the state of the lungs, theheart, or the bowels, account for the suddenand unlooked for fatal termination of the case.

ASPHYXIA.-THE FORAMEN OVALE.-Atthe meeting of the Westminster Medical

Society, on Dec. 17th last, Mr. Snow de-tailed three cases of partial asphyxia in new-born infants and young children, who gotover the first shock of the condition, buteventually perished without any obviouscause. In the only instance he had examinedafter death, the signs presented were pre-cisely similar to those observed in an adult,although the foramen ovaie was still patent.The patient in that case was newly-born,the case was a footling one, and the head wasdetained only a minute in the passage. Thechild recovered from the first effects of theasphyxia, but perished in a few hours after-wards, without any obvious cause. On thesame occasion Mr. H. J. Johnson relatedthe case of a woman who was admitted intoSt. George’s Hospital with intractableulceration of the leg. Her complexion wasremarkably dingy, but not at all cerulean.She died of erysipelas. On examination ofthe body the foramen ovale was found so

patent that two fingers could be passed fromone auricle to the other. The heart waslarge, flabby, and somewhat dilated. He

thought an open condition of the foramenovale of no serious consequence, unless ac-

companied by some malformation. In thiscase there was no symptom of its being open,