P A R T IIL

~ A L F - Y E A R L Y R E P O R T S . . . . . ~ . . . . . . . .

R E P O R T ON S U R G E R Y .

By WILLIAM THOMSOn, A.B., M.D., F.R.C.S. ; Surgeon to the Richmond, Whitworth, and Hardwicke Hospitals; and Member of the Surgical Court of Examiners, Royal College of Surgeons.

EXCISION" OF BOTI-I HIP-JOI:NTS.

AT the Clinical Society of London (Brit. Med. Jour., Dec. 20, 1879), Mr. J . Croft read a paper in which he gave details of a case of excision of both hip-joints in a child aged four years. Disease had existed for two years, and there was marked contraction of both limbs, with abscesses. The left joint was excised antiseptically on the 17th May, and the right was similarly treated in three weeks afterwards. The wounds healed in a few weeks. The epiphysls was found separated a~ the epiphysal line from the neck of the bone. On the left side its upper surface was for the most part bare, and small pieces of dead bone were adhering to it, and its under-surface was irregular where it had separated from the epiphysal cartilage. The trochanteric epiphysis was left attached to its muscles. Mr. Croft urged the value of operating early before the third stage had advanced; the value of operating anti- septically; the value of removing the parts freely; the value of leaving the great trochanter attached to the muscles which were fixed to it. Mr. J . Hutchinson remarked that in his experience separation of the epiphysis had been seen in only four or five cases. Mr. Marsh said that out of some 120 cases of excision at the Children's and St. Bartholomew's Hospital he could only point to six or seven entirely good results.

CHOLECYSTOTOMY.

Mr. Lawson Tait (Brit. Med. Jour., Nov. 15, 1879) reports a successful case of this operation. I t was first suggested by Dr. Handfield Jones in cases of threatened death from impacted gall- stone ; and the operation was first performed by Marion Sims, but unsuccessfully (Dublin Journ. of Medical Science, July, 1878, p. 35).

Report on Surgery. 135

Mr. Tait's patient had been married eighteen years, had borne six children, an& menstruation was normal and health good till the summer of 1878. At that time she had spasmodic pains in the right side, aggravated by walking and lifting slight weights. A swelling, noticed in September, slowly increased; and during last winter pain became more intense and she presented a cachectic appearance, suffering from incessant headache, sickness, and obstinate constipation. The seat of pain was over the right kidney, where there was a heart-shaped tumour, firm and elastic without fluctua- tion, tender to the touch, and movable to each side. The urine gave only negative results. After consultation with Dr. Edgington on August 23rd, the abdomen was opened in the middle llne to the extent of four inches. The turnout was found to be a distended gall-bladder containing a white starchy-looking fluid and two large gall-stones, one lying loose, and the other impacted in the entrance of the duct, and adherent to the mucous surface. The latter was removed by being carefully broken up. The stone and frag- ments weighed 6"11 grammes (94"3 grains). The wound in the gall-bladder was stitched to the upper end of the wound in the abdominal walls by continuous sutures ; the aperture into the bladder was left open, and the rest of the abdominal opening was closed in the usual way. The operation was performed antiseptically under ether. The patient rallied completely in a few hours, and the dressings of the wound were found stained with healthy bile. The flow of bile from the wound continued till September 3rd. The wound was completely healed on September 9th, when the patient began to take solid food,-the diet having up to that time been restricted to milk and beeF-tea. On the 30th she went home quite restored to health. A temperature-chart indicated the evenness and the rapidity of the recovery. An entire absence of symptoms of gall-stone rendered an accurate diagnosis impossible, but this was of less importance, as the improvements in abdominal surgery made an early exploratory incision for ascertaining the true nature of the disease feasible.

T H E T R E A T M E N T OF BURNS AND ULCERS.

Mr. J. Duncan (Brit. Med. Jour., Oct. 18, 1879) draws attention to the healing of burns and ulcers by the union of granulations. In a case of extensive burn he adopted the following plan : - -

" Having washed the sore carefully with boracic lotion, I operated under the spray, because, after the parts are drawn together, the

13 6 Report on Surgery.

wound ceases to be a superficial ulcer. I then entered the needle two inches from the sore, and brought it out at the margin, entered it again at the opposite margin, and brought it out two inches off. W h e n the sutures had been drawn tight upon the buttons (of the largest size), the sore, originally three inches in diameter, was reduced to a line three inches long. I t was then dressed with carbolised gauze. The dressings were changed on the fourth day, and, on the ninth, I removed the buttons, the sore being healed with the exception of little marks where the silver wire passing from the buttons had slightly cut the skin.

"Encouraged by this success, I now attacked the second sore, which is situated on the shoulder. I t was two inches and a half in diameter, besides new cicatrix about half an inch wide. One or two lessons were taught us by this operation. I folded up the wound wi th my finger and thumb, and then passed a suture deeply under it, and drew it t ightly over two large buttons. On removing the manual pressure, it was at once evident to you that this method was not nearly so effectual as the one previously described, in which the skin only on each side was involved in the suture. The folded-up sides of the sore, instead of lying in contact, formed a deep hollow--assumed a V-shape. To remedy this, I passed sutures above and below by the former method, and so succeeded in bring- ing about exact apposition. Thinking that by the first suture the tension must have been greatly relaxed, I used very small buttons for the upper one.

" ] t has not been found necessary to change the dressing till now, the seventh day after the operation, and you see the result. The upper suture has cut itself out and is lying quite loose. The part of the wound where it .was inserted has diminished in breadth by half an inch, but the line which the wire has cut has been added to it. Where the lowest large buttons were applied, the burn is healed, and opposite the central deep suture it is reduced to half an inch in breadth. W e have therefore gained much ground, but not nearly so much as in the former remarkably successful operation, and, I think, entirely because the manner of performance was less efficient. I have treated in the same way, and with perfect success, two other ulcers of smaller size than these, one of a syphilitic character on the forearm, the other a strumous sore on the neck.

" I t is evident that a method which shortens the healing of a wound by weeks, as in the case you have before you, is of the greatest possible value, and I believe that it may also present

l~eport on Surge~ T. 137

other advantages--in burns, for example, it may sometimes be used to prevent contraction by approximating the margins in a direction which will not be injurious. The mere diminution in the amount of cicatrix is in itself a benefit."

THE TREATMENT OF GOITRE.

In Langenbech's Archly (Band 24, Heft 1), Dr. W~lfler, in speaking of the treatment of goltre with subcutaneous injec- tions of iodine, says that favourable results have been obtained both in cases of simple hyperplasia, and of colloid degenera- tion. He illustrates his statement by a few cases from Billroth's clinic, and an experiment on a dog made by himself. The lobes of the thyroid gland of the dog had respectively attained the size of a goose's egg, and the author made ten injections of iodine into one of the lobes. The dog was killed at the end of a month, when the portion of the goltre into which the injections had been made was found to have dwindled down to the size of a man's thumb; it consisted of connective tissue which no longer contained any colloid liquid. The peripherie part of the injected goltre pre- sented the same appearance as the lobe which had remained untouched ; it consisted of large meshes of connective tissue, which contained colloid fluid. There were no traces of inflammation or hmmorrhage following the injection of iodine. Several strumous cysts were treated in a different manner ; one cyst with thin walls was absorbed after injections of iodine; two other cysts resisted this treatment. In two cases Billroth drained strumous cysts with antiseptic pre- cautions. In one of these cases, the cure was speedily effeeted; in the other, the cyst was not wholly absorbed, as there were cal- careous deposits in its walls. The sac was then opened and the con- lents removed, after which the patient, a woman aged seventy-two, recovered. The author thinks that tapping the cyst and putting in a drainage tube ought to be done in cases where a cyst does not collapse immediately after being tapped, or in old people where the injection of iodine might be succeeded by a too strong reaction, b u t where extirpation of the goltre might prove fatal. In the course of the last year, Billroth has extirpated goitres in seven cases under antiseptic precautions, the results having each time been very favourable. In one of these cases the patient was suffering from malignant cystous papilloma; in another case the struma was of carcinomatous nature. All the wounds healed by first intention.-- London Med. Rec, Oct., 1879.

138 Report on Surgery.

S U B P E R I O S T E A L E X T I R P A T I O N O F T H E E N T I R E S C A P U L A ;

C O M P L E T E R E G E N E R A T I O N .

Dr. Johann Mikullcz, assistant in Billroth's clinic at Vienna, narrates a case in which the entire scapula was successfully extir- pated subperiosteally, and was subsequently regenerated.--(Lan- genbeck's Archly far klin. Chirurgie, 24 Band, erstes Heft, 1879). The patient was a girl aged nine years, who had been for some time under treatment as an out-patient. In 1876 she was suffering from synovitis of ' the right knee-joint, and as abscesses followed, and the parts were disorganised, an excision was performed in July, 1877. Some sinuses remained, discharging thin pus, but in 1878 she complained of pain in the region of the right shoulder. There was severe fever, and the patient rapidly became anaemic and emaciated. An abscess was discovered in the supra-spinous fossa, and this was opened under antiseptic precautions. As bar as the finger could reach the scapula was found to be stripped of periosteum and bathed in pus; so that Billroth determined to lay bare the bone to the extent that it was diseased. The periosteum was entirely separated from the bone; it was only adherent to the edges, especially at the inferior angle and the aeromion and coracoid processes. By means of a raspatorium its slight attachments to the two last-named were easily broken, and the scapula was thus altogether loosened from its perlosteal covering. At the coracoid and the acromion processes only were the bone ibrceps necessary. The point of the former was left behind, and with that exeeptiolt the whole of the scapula was removed. The antiseptic dressings were laid aside after fourteen days, the deeper parts being all closed. With the exception of two or three evenings after the operation there was no appearance of fever, and on the tenth day she was able to leave bed. Later on a periosteal abscess formed on the left tibia, and was opened, but the patient was discharged in August well. When she again presented herself in the middle of October the right scapula was regenerated in its whole extent, and only in form was it inferior to the normal condition. The regene- rated scapula was smaller; the inner edge measured 10'5 against 12 ctm. of the opposite side, the outer 10 against 13 ctm., and the greatest width 7 against 8"75 etm. In contrast to the smaller superficies of the bone, it could be clearly felt that the regenerated shoulder-blade was, especially at the edges, considerably thicker than at the left. The lower angle was turned somewhat outwards;

Report on Surgery. 139

the spine was normally developed in its inner half, but in the outer part it was very slender; the coraeoid process was scarcely smaller, and was firmly joined to the body of the scapula. The acromion was regenerated as an independent piece of bone, the periosteum having been divided at the time of the operation. With regard to the shoulder-joint passive motions were possible in all directions. The extent of rotation and elevation amounted almost to a right angle, the amount of forward and backward motion being nearly 60 degrees. I t is not unlikely that a perfect joint surface with a cartilaginous covering had been newly formed on the scapula. The possibility of the formation of a perfect joint after resection is sufficiently proved by the writings of Luecke, Czerny, Ollier, and others. The active movements in the joint itself were somewhat limited, since the patient in all the greater extensions moved the scapula also. In spite of this the function of the arm was very satisfactory; the patient could execute all normal movements, but the complete elevation of the arm was difficult, and only a right angle was reached. The muscles of the whole extremity were strong, and not weaker than on the left side, except the supra- and infra-spinous, which were somewhat atrophied. The conditions had not altered ten months afterwards.

The number of subperiosteal, partial, and total resections of the scapula appears to be comparatively small, the inflammatory diseases of' the bone only seldom presenting the indications for this opera- tion. Of 56 cases collected and reported by Rogers in 1868, caries or necrosis gave an indication for resection of the scapula only eight times.--(Schmidt's Jal~sb., Bd. 144, S. 194). Bardelcben enumerates 26 cases of total extirpation of the bone with preser- vation of the arm, but of these there are only three which were operated on because of caries or necrosis.--(Lehrbuch der Chirurgie und Operationslehre, 7 Aufl, 4 Bd., S. 668). Heyfclder described the first in 1857. The patient was weak and died of py~emia. In a second case by Jones (1858) a girl fifteen years old recovered, but no mention is made of regeneration of the scapula. L inha r t describes a third case in 1870 (Com. der Chirurg. Operationslehre, 1, S. 464). I t was a case of total necrosis in a boy aged eleven. The periosteum and the cartilage were completely left behind, and there resulted a total regeneration of the bone. I t is interesting that the scapula is the bone which has shown itself in experiments upon animals to be particularly suited for proof of the capacity of regeneration in a high degree.