2
6 Liston’s method of holding the knife in lithotomy. The cir- cumstance of all the artists giving the same attitude to the hand can be explained only on the hypothesis that each gave a a faithful representation. I trust that the facts mentioned above may clearly convince others that Professors Miller, Erichsen, and myself, have not been guilty of giving, in our works on Surgery, erroneous de- ’’ lineations of Mr. Liston’s method of holding the knife in litho- tomy. I regret that there should exist any want of unanimity of opinion amongst the admirers of Mr. Liston’s method of opera- ting in lithotomy; and, for my own part, I am particularly grieved to differ on this point from one so highly distinguished as Professor Fergusson, for whom I entertain sentiments of the greatest admiration and esteem. Aberdeen, December, 1856. A Mirror OF THE PRACTICE OF MEDICINE AND SURGERY IN THE HOSPITALS OF LONDON. LONDON HOSPITAL. DISARTICULATION OF THE HIP-JOINT IN A FEMALE, AGED FORTY, FOR MEDULLARY CANCER OF THE THIGH, COMMENCING EIGHT MONTHS BEFORE; PUNCTURE BY A TROCAR FIVE DAYS PRE- VIOUS TO THE OPERATION, GIVING EXIT TO THIRTY OUNCES OF BLOODY FLUID ; RECOVERY. (Under the care of Mr. CURLING. ) Nulla est alia pro certo noseendi via, nisi quam plurimas et morborum et dissecttomim historias, tam aliorum proprias, collectas habere et inter se comparare.—MoRGAGNI. De Sed. et Caus. Morb.lib. 14. Procemium. WITHIN the past nine months we have had the opportunity of witnessing on two occasions the operation of amputation at the hip-joint-the first by Mr. Curling, at the London Hos- pital, in March last ; the second by Mr. Hancock, at the Charing-cross Hospital, in October. Both have been perfectly successful in their results. Our readers are aware that this operation is seldom had recourse to in civil practice, as a glance I at our " Mirror" for some years past will show. It is more ’, frequently the task of the military surgeon to perform this li operation in the field, and generally under great disadvantages. Those surgeons who have studied this subject will probably re- collect that during the eventful days of June, 1S48, in the French capital, amputation at the hip-joint was performed four times; three with quickly fatal results; but the fourth I was successful; the patient-an insurgent at the Hopital St. ’I, Antoine under the care of M. Nelaton-lived four months; the , stump had perfectly healed, but death occurred from pneu- monia of the left lung, with ulcerations of the large bowel. ’’, This patient, from being an insurgent, was subject to visits ’, from the police, which to some extent must have influenced the result. * With the very large field of civil practice afforded by the London hospitals, the opportunities for witnessing this important procedure are comparatively limited; few surgeons therefore have the chance of performing it more than once during their active career, although it has been twice done by Mr. Liston, and also twice by Mr. Syme. In the cases in which it has been resorted to, it has been justified only under the most urgent circumstances; very few indeed would hazard it unless as a last resort; and when it is considered how exten- sive is the mutilation, it is gratifying to know that in its re- .sults there is not so great an amount of fatality as was believed but a short time back. The following extract from Erichsen’s " Science and Art of Surgery" will, we think, satisfactorily show this :- * See British American Journal of Medical and Physical Science, vol. iv., for 123 cases of Gun-shot Wounds, reported by Dr. Gibb, occurring in Paris in June,1848. " The result of amputation at the hip-joint has been investi- gated by Dr. Stephen Smith, of the United States; he has col- lected 98 cases in which this operation has been done, of which 56 died, and 42 were cured. With reference to the cause of amputation, it is stated that in 30 cases it was for injury; of these 18 died, and 12 were cured; whilst in 32 cases in which it was done for chronic disease, 16 died, and 16 were cured. It is a remarkable fact, according to Dr. Smith, that the mor- tality from this operation has been greatly less of late years than formerly ; this he attributes to the cases having been better selected, the operation more skilfully performed, and,, above all, to the employment of anaesthetics; indeed the em- ployment of chloroform must necessarily greatly diminish the risks of an operation such as this, in which the effect of a shock is much to be dreaded."-p. 76. In previous "Mirrors" we have placed upon record three in- stances of amputation at the hip-joint, to which we would especially beg to refer the reader; the first by Mr. Charles Guthrie, at the Westminster Hospital, for malignant disease of the femur, (THE LANCET, vol. i. 1853, p. 405;) the second by Mr. Adams, at the London Hospital, for a very extensive fibro-cystic tumour of the leg and thigh, (THE LANCET, vol. i. 1854, p. 442;) and the third by Mr. Erichsen, at University College, for a severe injury to the thigh from the passage of two loaded railway trucks over it, (THE LANCET, vol. i. 1855, p. 363.) In all these the result was fatal, Mr. Guthrie’s on the second day, Mr. Adams’ on the twelfth day, and Mr. Erichsen’s the same evening. A successful case of this opera- tion by Mr. Wigstrom, of the 14th Dragoons, at Lahore, appears in THE LANCET, vol. i. 1850, p. 411. In some remarks which we ventured to offer upon Mr. Guthrie’s case, we took occasion to glance at the history of the operation from the time of Morand in 1739 down to Mr. Sands Cox in 1845. We at the same time went over the principal facts bearing on this import- ant operation, which some of our readers will perhaps take the trouble of referring to, as on the present occasion we are pre- vented from dilating on the subject owing to the length of the cases. In Mr. Curling’s case, like that of his colleague Mr. Adams, the disease was manifested in the presence of a tumour of the thigh, of considerable size, which proved to be medullary.- cancer. It was punctured two days after admission, and about thirty ounces of fluid were evacuated, being principally blood, the first twenty ounces possessing a dark colour. Subsequently to this, the growth of the tumour rapidly increased, so that measures of an urgent character were demanded, and an anxious consultation with Mr. Luke, Mr. Adams, and other of his colleagues, resulted in the performance of disarticulation at the hip-joint. It will be observed that the anterior flap was not made first in the present instance, as the tumour would necessarily have been transfixed, and the operation thus rendered complicated and somewhat hazardous. The posterior flap was therefore first made, and then the anterior, whilst the femoral artery was carefully compressed in the groin, and very little blood was lost. The patient looked rather pale -ancl delicate for a few days afterwards, but owing to an otherwise good constitution, conjoined with extreme quiet and care in a small ward, the stump rapidly healed by first intention, and not a single untoward symptom showed itself. We had An opportunity several times of seeing Mr. Curling dress the stump, and were struck with the healthy condition of the patient, notwithstanding the loss of such an extensive part of her body. Her progress since leaving the hospital has been satisfactory, and no return of the disease has taken place, although there was an œdematous swelling of the other foot and leg, which has to some extent subsided. The evidence afforded by the naked eye, as well as the microscope, clearly pointed out the nature of the disease, but as there is no heredi- tary tendency, we will hope that its reappearance, should it occur, m; y be remote. Mary Ann G--, aged forty, married, residing at Speen, near Newbury, Berks; admitted March 4th, 1856. She states that her father and mother died from old age, being of the ages of eighty-five and eighty-four; she has been married many years, and has had five children. Her occnpation is that of a schoolmistress, and she has always had good health during the last twenty-four years; before that, she was rather delicate. She has only one sister, who is of sound constitution. About twenty-six years ago, the patient suffered from a contusion over the knee, and was cupped. She has had no illness since then until last August, when she first noticed a small lump upon the right thigh, which she thought to depend upon rheumatism, and various applications were made to it, but without any effect. The swelling continued steadily to enlarge, without

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Liston’s method of holding the knife in lithotomy. The cir-cumstance of all the artists giving the same attitude to thehand can be explained only on the hypothesis that each gave a afaithful representation.

I trust that the facts mentioned above may clearly convinceothers that Professors Miller, Erichsen, and myself, have notbeen guilty of giving, in our works on Surgery, erroneous de-

’’

lineations of Mr. Liston’s method of holding the knife in litho-tomy.

I regret that there should exist any want of unanimity ofopinion amongst the admirers of Mr. Liston’s method of opera-ting in lithotomy; and, for my own part, I am particularlygrieved to differ on this point from one so highly distinguishedas Professor Fergusson, for whom I entertain sentiments of thegreatest admiration and esteem.

Aberdeen, December, 1856.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

LONDON HOSPITAL.

DISARTICULATION OF THE HIP-JOINT IN A FEMALE, AGED FORTY,FOR MEDULLARY CANCER OF THE THIGH, COMMENCING EIGHTMONTHS BEFORE; PUNCTURE BY A TROCAR FIVE DAYS PRE-VIOUS TO THE OPERATION, GIVING EXIT TO THIRTY OUNCESOF BLOODY FLUID ; RECOVERY.

(Under the care of Mr. CURLING. )

Nulla est alia pro certo noseendi via, nisi quam plurimas et morborumet dissecttomim historias, tam aliorum proprias, collectas habere et interse comparare.—MoRGAGNI. De Sed. et Caus. Morb.lib. 14. Procemium.

WITHIN the past nine months we have had the opportunityof witnessing on two occasions the operation of amputation atthe hip-joint-the first by Mr. Curling, at the London Hos-pital, in March last ; the second by Mr. Hancock, at theCharing-cross Hospital, in October. Both have been perfectlysuccessful in their results. Our readers are aware that this

operation is seldom had recourse to in civil practice, as a glance Iat our " Mirror" for some years past will show. It is more ’,frequently the task of the military surgeon to perform this lioperation in the field, and generally under great disadvantages. Those surgeons who have studied this subject will probably re-collect that during the eventful days of June, 1S48, in theFrench capital, amputation at the hip-joint was performedfour times; three with quickly fatal results; but the fourth I

was successful; the patient-an insurgent at the Hopital St. ’I,Antoine under the care of M. Nelaton-lived four months; the ,stump had perfectly healed, but death occurred from pneu- monia of the left lung, with ulcerations of the large bowel. ’’,This patient, from being an insurgent, was subject to visits ’,from the police, which to some extent must have influencedthe result. * With the very large field of civil practice affordedby the London hospitals, the opportunities for witnessing thisimportant procedure are comparatively limited; few surgeonstherefore have the chance of performing it more than once

during their active career, although it has been twice done byMr. Liston, and also twice by Mr. Syme. In the cases in

which it has been resorted to, it has been justified only underthe most urgent circumstances; very few indeed would hazardit unless as a last resort; and when it is considered how exten-sive is the mutilation, it is gratifying to know that in its re-.sults there is not so great an amount of fatality as was believedbut a short time back. The following extract from Erichsen’s" Science and Art of Surgery" will, we think, satisfactorily showthis :-

* See British American Journal of Medical and Physical Science, vol. iv., for123 cases of Gun-shot Wounds, reported by Dr. Gibb, occurring in Paris inJune,1848.

" The result of amputation at the hip-joint has been investi-gated by Dr. Stephen Smith, of the United States; he has col-lected 98 cases in which this operation has been done, of which56 died, and 42 were cured. With reference to the cause ofamputation, it is stated that in 30 cases it was for injury; ofthese 18 died, and 12 were cured; whilst in 32 cases in whichit was done for chronic disease, 16 died, and 16 were cured.It is a remarkable fact, according to Dr. Smith, that the mor-tality from this operation has been greatly less of late yearsthan formerly ; this he attributes to the cases having beenbetter selected, the operation more skilfully performed, and,,above all, to the employment of anaesthetics; indeed the em-ployment of chloroform must necessarily greatly diminish therisks of an operation such as this, in which the effect of a shockis much to be dreaded."-p. 76.

In previous "Mirrors" we have placed upon record three in-stances of amputation at the hip-joint, to which we wouldespecially beg to refer the reader; the first by Mr. CharlesGuthrie, at the Westminster Hospital, for malignant disease ofthe femur, (THE LANCET, vol. i. 1853, p. 405;) the second byMr. Adams, at the London Hospital, for a very extensivefibro-cystic tumour of the leg and thigh, (THE LANCET, vol. i.1854, p. 442;) and the third by Mr. Erichsen, at UniversityCollege, for a severe injury to the thigh from the passage oftwo loaded railway trucks over it, (THE LANCET, vol. i. 1855,p. 363.) In all these the result was fatal, Mr. Guthrie’s onthe second day, Mr. Adams’ on the twelfth day, and Mr.Erichsen’s the same evening. A successful case of this opera-tion by Mr. Wigstrom, of the 14th Dragoons, at Lahore, appearsin THE LANCET, vol. i. 1850, p. 411. In some remarks whichwe ventured to offer upon Mr. Guthrie’s case, we took occasionto glance at the history of the operation from the time ofMorand in 1739 down to Mr. Sands Cox in 1845. We at thesame time went over the principal facts bearing on this import-ant operation, which some of our readers will perhaps take thetrouble of referring to, as on the present occasion we are pre-vented from dilating on the subject owing to the length of thecases.

In Mr. Curling’s case, like that of his colleague Mr. Adams,the disease was manifested in the presence of a tumour of thethigh, of considerable size, which proved to be medullary.-cancer. It was punctured two days after admission, and aboutthirty ounces of fluid were evacuated, being principally blood,the first twenty ounces possessing a dark colour. Subsequentlyto this, the growth of the tumour rapidly increased, so thatmeasures of an urgent character were demanded, and ananxious consultation with Mr. Luke, Mr. Adams, and other ofhis colleagues, resulted in the performance of disarticulation atthe hip-joint. It will be observed that the anterior flap wasnot made first in the present instance, as the tumour wouldnecessarily have been transfixed, and the operation thusrendered complicated and somewhat hazardous. The posteriorflap was therefore first made, and then the anterior, whilst thefemoral artery was carefully compressed in the groin, and verylittle blood was lost. The patient looked rather pale -ancldelicate for a few days afterwards, but owing to an otherwisegood constitution, conjoined with extreme quiet and care in asmall ward, the stump rapidly healed by first intention, andnot a single untoward symptom showed itself. We had Anopportunity several times of seeing Mr. Curling dress the

stump, and were struck with the healthy condition of thepatient, notwithstanding the loss of such an extensive part ofher body. Her progress since leaving the hospital has beensatisfactory, and no return of the disease has taken place,although there was an œdematous swelling of the other footand leg, which has to some extent subsided. The evidenceafforded by the naked eye, as well as the microscope, clearlypointed out the nature of the disease, but as there is no heredi-tary tendency, we will hope that its reappearance, should itoccur, m; y be remote.Mary Ann G--, aged forty, married, residing at Speen,

near Newbury, Berks; admitted March 4th, 1856. She statesthat her father and mother died from old age, being of theages of eighty-five and eighty-four; she has been married manyyears, and has had five children. Her occnpation is that of aschoolmistress, and she has always had good health during thelast twenty-four years; before that, she was rather delicate.She has only one sister, who is of sound constitution. Abouttwenty-six years ago, the patient suffered from a contusion overthe knee, and was cupped. She has had no illness since thenuntil last August, when she first noticed a small lump upon theright thigh, which she thought to depend upon rheumatism,and various applications were made to it, but without anyeffect. The swelling continued steadily to enlarge, without

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any pain. She stated that a fortnight before her admission,the surgeon under whose care she was plunged a groovedneedle into the tumour, and drew off about a cupful of blood. IUpon examination, a tumour of considerable size was found tooccupy the upper part of the thigh, chiefly in front and towardsthe outside, extending nearly as high up as the groin. It hadan elastic, fluctuating feel, was tender, and the seat of somepain. She was put upon generous diet and wine, and orderedtonic medicines, with half a grain of morphine every night.Two days after admission, Mr. Curling introduced a trocar

at the outer part of the tumour, and about thirty ounces ofbloody fluid Bowed freely. The first twenty ounces were quitedark-coloured, but the last ten which escaped were Of1 a brightcolour. Both coagulated on standing. The tumour felt lesstense and uneasy after the puncture, but soon regained itsformer size, and during the three following days it rapidly in-creased. Her general health was now also very visibly de-clining.Mr. Curling therefore, in consultation with his colleagues,

decided that nothing short of amputation at the hip-jointwould be of any service. The operation of disarticulation wasthen performed on the llth of March, when the patient wasunder the influence of chloroform. The posterior flap wasmade first, and three or four small vessels were secured; andthen the anterior flap, the femoral artery being compressed inthe groin. Not more than four or five ounces of blood werelost altogether. It was quite evident that the operation couldnot have been done by transfixion, because the knife wouldhave penetrated the tumour and divided it in two, which was.obviated by performing the operation as described.

She was then ordered a draught of spirits of sulphuric ether,aromatic spirits of ammonia, and tincture of opium, of eachhalf a drachm, in an ounce of camphor mixture, to be taken im-mediately ; four ounces of wine, milk diet, beef-tea, and twoeggs. -Half-past Nine P.M.: Slept two hours and a half, andwas doing well.Without giving the details from day to day, it is sufficient

to mention that she continued to progress most favourably; thestump healed very quickly by the first intention, the mainligature came away at the usual time, she was discharged fromhospital, and went down to Ramsgate.Examination of the tumour showed it to be pear-shalped, the

’base being superior. It was bounded on the inside by the adductormuscles and femoral canal, and on the outside it invaded thevastus externus muscle, which was extended over the growth.It rested on the outer part of the femur, and extended, closeto the bone, as high as the great trochanter. There was nodistinct capsule, only a slight condensation of the parts imme-diately surrounding the tumour. It was composed of massesof brain-like matter, intermingled with large coagula, chiefly:towards the lower part, and a number of imperfect cysts, someof considerable size, containing a bloody fluid. The outer andfront surface of the upper portion of the middle third of thefemur, for about three inches-the part upon which the tumourrested-was very vascular, rough, and granular, and abradedto such an extent as to destroy the rounded outline of the bone.The tumour exhibited the microscopical elements of encephaloidcancer, and some of the masses were undergoing fatty de-generation.

This patient left Ramsgate able to walk on crutches, and re-turned to her duties as a schoolmistress. An oedematousswelling has since occurred in the other foot and leg. InNovember, when seen by Mr. Curling, this swelling had par-tially subsided. He examined the chest, abdomen, and groin,but had not been able to detect any tumour, or to discover anyglandular swelling indicative of a return of the disease.

ST. THOMAS’S HOSPITAL.

STONE IN THE BLADDER OF A MAN AGED SIXTY; LITHOTOMY;EXTRACTION OF A URO-PHOSPHATIC CALCULUS THE SIZE OF A

HAZEL-NUT; DEATH FROM PERFORATION OF THE STOMACH.

(Under the care of Mr. SIMON.)THE patient who was the subject of the following case was

long a sufferer from irritable bladder, which most probablygave rise to the formation of a stone, although bloody urinewas a marked symptom before its nucleus was formed. In the

history there are no symptoms referable to the kidneys, andthese organs were found healthy after death. This conditionof the bladder, in an irritable constitution, will account for theextreme restlessness after the operation, which was increasedby the presence of an ulcer of the stomach, which was not sus-pected during life, and which, now that the powers of vitality

became lessened, went on to perforation, and so destroyed life.An interesting point in the case, taken with the presence of

this lesion, is the pain of the abdomen before the operation,localised in the epigastrium after it, but masked by sufferingelsewhere. We have no doubt but that this poor man had longbeen suffering from a small gastric ulcer, which took on in-creased action after being operated upon. The notes of thiscase were kindly furnished us by Mr. Ord, the surgical registrarto the hospital.

William P-, aged sixty, a porter, admitted into Isaac’sward September 30th, 1856. He had generally enjoyed goodhealth up to ten years ago, when one day, on passing urine,he found the stream suddenly stop. He never rememberspassing gravel; his water has been often thick, with a densesediment, often bloody. He has had instruments passed forthe last eight or nine years. He was in this hospital on accountof the bladder symptoms about two years ago. Instrumentswere then passed, and, temporary relief being afforded, he wasdischarged. After going out, he became worse than ever; painover the whole abdomen, bad appetite, and want of sleep, allpreventing him from doing any work since January last. Onthe day of admission, he was taken into William’s ward, underthe care of Mr. Simon, who was attending to Mr. Mackmurdo’spatients. He complained of much pain in the abdomen. Theurine deposited a thick sediment of phosphates and mucus, andwas alkaline. Full diet.

Oct. 7th.-He was sounded by Mr. Simon, who discovereda stone in the bladder.

11th.—He was brought into the theatre, and, chloroformbeing administered, Mr. Simon performed lithotomy, cuttinginto the bladder by a nearly transverse cut, rather further backthan usual, and using a broad knife. Only a small notch was.made in the prostate, and the opening was enlarged with thefinger. The staff was a very large one, greatly curved, andwith a large lateral groove. Owing to the great depth of theperinæum, there was at first some difficulty in reaching thestone. It was at last removed by a very long pair of forceps,and the patient, who had lost very little blood, was removed.to bed. The stone appeared to be originally uric acid covered,over with phosphates; was about the size of a small walnut,,and flattened. In the evening, when the patient was movingsomewhat impatiently in bed, hæmorrhage occurred from a.

superficial vessel in the wound, which was stepped almost im-mediately by torsion. A watch was maintained till the follow-ing day, and pressure by the finger was (unnecessarily) appliedfrom time to time. He was in a very nervous state, and attimes quite unruly. There was some bleeding from the pros-tate into the bladder, and a clot was discharged with the firsturine. To have six ounces of brandy and one-third of a grain.of muriate of morphia, at once.12th.-He did not sleep during the night. This morning he’

feels pretty comfortable. A pain in his stomach, of which he;complained yesterday, has been relieved by the stone poultice.-He is very feeble and nervous. His face is pallid and anxious.,There is no return of the haemorrhage; tongue a little furred..To have beef-tea, eggs, and milk diet.13th.--W’ound looks healthy. He has slept a little better,,

and feels pretty easy. The urine scalds him as it comes away.To have three ounces of wine.

16th.-Sleeps better. Has been much purged; his appetiteis pretty good, and his mind seems in a healthier state, thoughhe is still very nervous. The urine all passes by the wound,,which looks healthy. Compound rhubarb pill five grains to-night.18th.-Bad night’s rest; bowels relieved many times. Urine

comes by the wound, causing scalding. Brown fur on tongue;,thirsty; appetite bad and capricious. No headache; skincool; pulse 100, soft and compressible.20th.-Not so well; laboured respiration; tongue has a white

fur, dry, red at edges; pulse 84, soft. Dozes much, but not longat a time. Wound inactive; no headache ; pallid; restlessin mind and body; takes food pretty well; refuses meat.,Brandy and arrowroot, extra beef-tea. His diarrhoea was re-lieved yesterday by an astringent mixture.22nd.-Complains of great pain, caused by the passage of the

urine through the wound. Tongue coated with a thick whitefur, dry, thirsty; very weak; continually complaining; pulse90, small; face pallid; eyes sunken; bowels relaxed; irritableto an excess. To have twenty minims of dilute nitric acid inwater three times a day.

24th.—Sleeps very badly; very irritable; tongue moist,rather coa-ted. Several small abscesses on the arms and otherplaces, which were opened by iSr. Simon. Appetite better;pulse 84, feeble; diarrhoea, cough, and expectoration.