No. 1660.

JUNE 23, 1855.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

GUY’S HOSPITAL.

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborumet disgectionum historias, tam aliorum proprias, collectas habere et interse comparare.-MORGAGNI. De Sed. et Caus. Morb. lib. 14. Prooemium.

REMARKABLE CASE OF CONGENITAL ABSENCE OF STERNUM;THE MOVEMENTS OF THE HEART VISIBLE.

AN instance of congenital fissure, or the absence of the ster-num, in a young man, a foreigner, excited very considerableattention this week at the above hospital. We have seldom,if ever, seen a case of such intense interest, in a physiologicalpoint of view, as connected with the very vexed question ofthe sounds of the heart. The region of the sternum, in thisindividual, is, in fact, quite open, and displays under theskin the particular movements of the pericardium and heart.This fault of conformation interferes rather singularly with theactions usually ascribed to the sterno-hyoid and sterno-thyroidmuscles, which are entirely absent at the right side, and veryimperfectly developed at the left. The sterno-cleido-mastoidmuscles, curiously enough, in their movements, extensivelyinfluence the neck, without a trace of sternal attachment;and in fact, when forced inspiration is tried, it is quiteremarkable how the chest is expanded by these muscles,,and the trapezius at each side, the diaphragm and the heartnot seeming to be much affected, while the lungs, or what maybe conceived to be a mass of pleura, mediastinum, and lung,being forced out, fills up the front of the neck. Theman is now twenty-five years of age, and enjoys apparentlygood health. He has been examined by Skoda, Rokitansky,Bouillaud, Bernard, Piorry, Malgaigne, and some others onthe continent, and has excited no ordinary speculation as tothe sounds of the heart. He has been at Guy’s Hospital, underthe observation of Dr. Wilks, Dr. Pavy, Dr. Addison; at St.Thomas’s Hospital under that of Mr. Simon, Dr. Peacock, &c.;at King’s College Hospital under that of Dr. Todd, &c. We havebeen particularly struck, at a hasty glance of the case, by the’beautiful vermicular movement of the heart, by which theright auricle is filled with blood; for it does not appear to bethe aorta which is under the skin, as at first suspected, but an’oblong tumour covered with pericardium, the pulsations ofwhich are not exactly synchronous with the pulse at the wrist,though it requires considerable care to detect the difference-more especially if the young man, the subject of the malfor-mation is tired by too much examination of the parts. This

oblong tumour is most probably the right auricle, dilatingand contracting in a peculiar vermicular way sixty or

seventy times in a minute, and being about the size of twolarge thumbs of an adult, but made once and a-half as largeby the young man " holding his breath," and thus allowingthe auricle to be engorged. The diastole and systole are alter-nate, but not of that steam-engine piston character, up anddown, as is usually thought; the period of the dilatation is longerthan that of the contraction of the tumour or auricle; the dila-tation is however rapid, with an apparent tilt of the heart for-ward, immediately followed by a peculiar vermicular collapse, oremptying of the tumour, impeded only by "holding the breath,"or offering an obstacle to the blood going to the lungs. Thesevarious points are clear, and what, theoretically, might beexpected. Not so, however, the relation of the sounds of theheart to the movements of systole and diastole; on which it iscurious to perceive (looking through the note-book the youngman takes with him) that all the first observers in Europe seem IIto have had peculiar and not very harmonizing opinions, from ’,those offered by Rokitansky, Skoda, Bouillaud, Hamernik, Be-clard, &c., down to the plessimetric crudities of Piorry, andthe fancies of some American friends. The second sound is,perhaps, more marked than the first. It is difficult to arriveat any certainty on this and other points, however, as at Guy’sHospital, on Tuesday last, every pupil in the theatre seemedanxious about some one other particular point, no littleconfusion necessarily ensuing. The two sounds are about equalin duration and force, but passing obliquely towards the base

of the heart. The second sound (shall we call it valvular?) ismore marked over the pulmonary artery, and to the ear evenmore superficial than that of the aorta. There did not seemto us any doubt that the impulse of the heart or tumour coin-cided exactly, not with the pulse at the wrist, as a ventri-cular phenomenon, but rather with the emptying of the sub-cutaneous tumour or auricle. We thought we could detectthe systole of the right ventricle, agreeing with the phenomena,of the opposite ventricle and pulse; a very appreciable in-

terval, it must be remembered, existing between the latter andthe exposed right auricle.The movement of the tumour is very marked, as already

stated, especially on forced expiration, or ’’ holding thebreath." It (the tumour) sometimes appears fluttering or in-complete in its contractions or movements, pointing still fur-ther to its auricular character. The shock or impulse, so mucha matter of controversy at the British Association and elsewhere,would appear to arise from the diastole of the ventricle, andnot the systole as usually believed. The second sound of theheart is, however, not so well cleared up by the case as thefirst sound. The second sound is now universally consideredto be caused by the click of the valves, as suggested to us byDr. Sieveking, who also examined the case this week. Thisfact is arrived at, of course, from pathological indications. Itwill be found interesting to confine the observations made onthis young man (E. A. Groux) as much as possible to the FIRSTsound, due so much to the impulse or shock of the heart, andsynchronous contraction of both ventricles.We hope to have a further and better opportunity of ex-

amining the case next week with Dr. Todd, Mr. Paget, Dr.Carpenter, or Dr. Bence Jones, as the subject of the case hasbeen a little of a "lion," in the physiological way, at thevarious hospitals. There is a model in the museum of the

London Hospital exhibiting a similar anomality of structure.

ST. BARTHOLOMEW’S HOSPITAL.OPERATION FOR HERNIA WITHOUT OPENING THE SAC.

(Under the care of Mr. LLOYD.)AMONGST the less important but not less practical cases we

have seen at St. Bartholomew’s Hospital within the last fewdays, have been two instances of hernia under Mr. Lloyd, inone of which the intestine was returned into the abdomen bythe steady and careful application of ice; while in the other acure was effected by the operation at the external inguinalring, without opening the sac. Mr. Lloyd, with the late Mr.Aston Key, was amongst the first, if not the first, who broughtprominently forward the operation without opening the sac-amode of procedure which he informed his class he has hadreason to be every year more and more satisfied with. Veryconsiderable difference of opinion exists in hospitals even yeton this point, some surgeons conceiving that the risk is toogreat where strangulation has existed for some time; but thereply to this, Mr. Lloyd states, is to operate early, chloroform,he alleges, being much more valuable, as allaying the appre-hensions and fears of the patient, than even as acting liketobacco or opium specifically on the seat of stricture itself.The experience of Guy’s Hospital, indeed, would go to show

that chloroform, the warm-bath, purgatives, &c., are all far in-ferior in value to a full dose of opium, and that in a vast pro-portion of cases the inflammation or irritation brought on bythe excessive use, or rather abuse, of the taxis must be subduedbefore the patient can be thought out of danger. Two caseslately examined at Guy’s by Mr. Birkett fully corroborated these

I views as held by Mr. Lloyd, Mr. Stanley, and Mr. Lawrence,at St. Bartholomew’s. One was a case of hernia (femoral),strangulated seventy-eight hours, and a similar case (alsofemoral), strangulated only ten hours and a half; yet the latterwas quite gangrenous, probably from the excessive use of thetaxis; while the former, over three days in a state of strangu-lation, was very little, if at all, changed. We do not givethese cases to uphold any particular doctrine as to the value ofthis or that operation-Petit’s, for instance-but as the passingimpressions of some of our best everyday working surgeons inthe largest fields of operative experience in London. All suchcases suggest caution in the use of the taxis, as well as a clearermode of reasoning, lest we should confuse two things argumen-tatively dissimilar-gangrene from the taxis, which may beavoided; and gangrene from a tight stricture, which may arisefrom the disease not being detected at all. We cannot either

fairly compare the older statistics of all the milder cases of thelast century before the discovery of chloroform with the returnsof very bad hospital cases since that epoch, now operated onwithout opening the sac.

624

UNIVERSITY COLLEGE HOSPITAL.

ATHEROMATOUS TUMOURS OF THE SCALP-EVULSION.

(Under the care of Mr. ERICHSEN.)MR. ERICHSEN made some very useful clinical remarks, one

day last week, previous to an operation of removing a series ofsebaceous growths from under the skin of the head, in a youngwoman who had been some weeks under treatment. Thesurgical class were particularly struck with the microscopiccharacters of these tumours and their contents, appearancesso nearly allied to those of the disease termed " mol-luscum" (ante, page 289), or enlarged sebaceous follicles inother parts of the body. Mr. Erichsen confined his remarksto those found on the head, or in the hairy scalp, varying often,as in the present case, from the size of a pea to that of a wal-nut, and essentially consisting of a diseased sebaceous follicle,lined inside by tesselated epithelium, and containing ordinaryatheromatous matter, so like scraped Parmesan cheese, or" pap" of bread, as the term atheroma itself signifies. Largequantities of cholesterine were also observable, as well as adarkish-coloured fluid in the older ones-a sign, Mr. Erichsenremarked, of disintegration not unfrequently followed byulceration. This sort of bad fungous ulcer on the head may bereadily mistaken, when seen for the first time, for a malignantgrowth, if care be not taken to inquire into the history of thecase, or other " wens" not looked for. The mode of removalof these tumours before ulcerating is very simple. A singleincision is made across the wen or cyst, and then, with a

strong drag of a forceps, a sort of evulsion is practised, theentire growth coming out like an almond from its husk orshell. They are found also under the eyelid, and are madeworse by any practice but one-namely, passing a small probethrough them on the conjunctival surface, and stirring up thecontents with the probe dipped in nitric acid. As a matter ofminor surgery, a sort of study of

" common things," too often

neglected in practice, Mr. Erichsen showed how the tumourswere removed, by practising evulsion on five or six in as manyminutes.

LONDON HOSPITAL.

MAMMARY GLANDULAR TUMOUR OF THREE AND A HALF YEARS’DEVELOPMENT IN THE REGION OF THE LEFT MAMMA.

(Under the care of Mr. ADAMS and Mr. WARD.)Two cases of diseased breast operated on during the present

month-one of scirrhus, by Mr. Lawrence, at St. Bartholo-mew’s; the second adenoid, by Mr. Ward, at the LondonHospital-presented some features of practical interest. One,a very small tumour, required the removal of the entire breast;the second, a very large tumour, left the true gland tissueuntouched. The difficulty of diagnosis in chronic mammarygrowths is very considerable, nor are we quite sure that half adozen different names given to one and the same form ofdisease have tended to clear up the subject.

Irregular development or evolution of the female breast atthe time of puberty, it need hardly be observed, gives rise tomany changes of a hypertrophic or atrophic character in thisgland and surrounding parts; one of the latter, probably, isthe adenoid growth removed by Mr. Ward in the presentinstance, and so well described by Birkett under one name,by Paget, Rokitanski, and Müller under three others. Thescirrhous disease, on the other hand, removed by Mr. Lawrence,is unfortunately too familiar to the surgeon, and clearlyallied to the age of decline or climacteric decay in the femalesystem.The proper tissue of the mammary gland itself, as well as

the surrounding cellular membrane, fat, and dermis textures,may be each or all involved in these changes; but there arefew cases in hospital or private practice which require nicerdiscrimination in deciding on operating, and giving " thereason why." The several names by which this form ofmammary tumour is known rather tend to mislead and puzzlethe student than satisfy his mind. The later views of Roki-tansky, for instance, who has given considerable attention tothe subject, differ from those of Mr. Paget, who looks uponsuch products, we need scarcely remark, as cystic growths,like Sir Astley Cooper; while Rokitansky and Paget, again,differ from Birkett, who looks upon them as "adenoid," origi-nating in a specific blastema effused into the natural areolartissue of the mammary gland. Rokitansky has detected anacinus-like growth as determining the tumour, and, he believes,repeating one element of the gland itself. This tumour is con-sidered by him not to be encysted; yet in Mr. Ward’s case the

new growth " peeled out" of a dense fascia-like process, like acystic production.True cysts, according to the accurate Vienna, observer, are

only developed through the dilatation of the said gland oradenoid structure, the-so to call them-" dendritic" or

adenoid excrescences in the cysts of the cysto-sarcomatoustumour not being outgrowths from the internal blastema orcyst membrane to the outside, but products from the outsideinto the cyst of the matrix, still invested inside with the

primitive cyst membrane, and internal epithelium. All patho-logists, as Mr. Ward observed, agree as to their non-malignantcharacter; yet as tumours, from the inconvenience attendingthem, and the facilities afforded by chloroform, it is alwaysbetter to have removed.We find these non-malignant growths also, it must not be

forgotten, putting on some of the characters of growths of anopposite kind. We do not speak now of the genuine hydatidcyst, with its echinococcus, also found in the female breast,fibrous or other products, &c., but of the chronic mammarytumour, which, under the hands of the pathologist, has assumedsuch a multiplicity of names. This in hospital wards isoften found in some measure simulating malignant growths,springing up quickly in the unmarried female, at the age ofthirty or later; yet, unlike cancer, sometimes, according toRokitansky, disappearing as fast under treatment. Thesepoints are all practically important. In the present instance,Mr. Ward pointed out that the case was under observation fora very long period, yet we could not notice that treatment hadhad any effect. Such tumours, it may be useful to add, are almostalways without pain, yet they are occasionally met with in prac-tice excessively painful, as described by Sir Astley Cooper. Thisis now for the first time known to be a " neuromatous" condi-tion of the nerves of the part, and best treated on that indica-tion. It will be well also to keep in mind that the chronicmammary tumour, if neglected, may ulcerate, and at a hastyglance be mistaken for more serious disease. The ulcerationof an " adenoid" growth will differ very materially from thatof a cancerous breast; for while one may be got to heal, themost marked, indeed, we had almost said, the one constantand only unvarying, condition of the other is never to heal.True cancer also usually arises as a tumour, like adenoid; but,as well dwelt on by Birkett, the question of age alone, whetherthe female is within the epoch of active menstruation or pastthe age of forty-five, will correct the first impression as tomalignancy and almost alone decide the question. The re-currence of the chronic mammary tumour or cystic sarcoma hebelieves also must not be taken as a sign of malignancy, butrather as a mark of a constitutional error of nutrition, or ofplastic force, to be corrected by constitutional remedies. Per-

haps we might say, finally, that the appearance of milk, ormilk-like fluid, in the nipple of enlarged mammary tumours isof some value as a test of the disease being of a benign cha-racter, though some, with rather finely-drawn distinctions,doubt this point.

Eliza D-, aged twenty-four, housemaid, came under thecare of Mr. Ward, as an out-patient, two or three months ago.The region of the left mamma was considerably larger thanthe right, the mammary integument smooth and unaffected,and at the inner part of the gland itself a tumour could be.detected, about the size of a small pear. It was harder andless elastic than the mammary gland, and somewhat nodu-lated on the surface; and careful examination indicated thatthough in contact with the inner part of the mammary gland,it was not connected with it by a similar development of struc-ture. The patient stated that the growth had been in pro-gress for more than three years; that she could trace its pre-sence to no local injury, that it pained her occasionally, andthe only inconvenience she experienced was from a sense ofweight, and a constitutional uneasiness. She had been regularup to the time of her application at the hospital, shortly afterwhich the menstrual discharge ceased. The patient had beenunder the care of two or three medical gentlemen, who hadprescribed tonics, and local applications of mercurial ointmentand iodine, with and without mechanical support. She wasadmitted into the hospital; and during eight weeks prior tothe operation, the swelling had advanced much in its originalsize, the mammary gland had become displaced somewhat tothe outside, and became in closer relation to the tumour. Witha knowledge, however, of the previous local conditions, themorbid growth, notwithstanding that it had increased to aboutthree times the volume it had when the young woman first ap-plied as an out-patient, could be made out as unconnected struc-turally with the breast, although in its progress of growth ithad insinuated itself, as it were, behind the true gland. Mr.Ward removed the tumour on the 25th of May. An elliptical