T R A N S A C T I O N S OF T H E U L S T E R M E D I C A L SOCIETY.

SESSION 1879-80.

President~PROFSSSOR DILL, ]~I.D. I-Ion. Secretary--WlLLIA~ WHITLA, M.D.

PROFESSOR DILL~ President, in the Chair.

Notes and Remarlcs on the Treatment of Three Cases of N~vus. By J. FAGAS, F.R.C.S.I.

CASE I . - - T h e child that has been shown to you this evening was the subject of a cellulo-cutaneous n~evus of the upper lip, extending nearly its whole length in the vertical direction and about half an inch in its trans- verse measurement. She was brought to me some time back for treat- ment. The first method I tried was the subcutaneous ligature. This did not succeed in destroying the growth. I then tried setons with very little better result; it remained stationary for a time, and seemed as if it were going to shrink. However, it soon began to enlarge again ; and the mother being most anxious that it should be removed, I proposed taking it away by the knife. This I did as follows : - - I passed two straight needles, armed with a double-wire suture, under the base of the turnout, at right angles to the long axis, and lying parallel to each other. A hare-lip pin was next passed under its base, in the line of its long axis. They were all made to enter the sound skin about a quarter of an inch outside the margin of the tumour, and were passed deeply, so as to be felt in contact with the mucous lining of the lip. The needles and pin being left in sltu, I threw a soft cotton thread round their exposed extremities ; and while an assistant pressed the blood out of the turnout, I gradually tightened the encircling ligature, and then tied it, leaving the tumour, that was isolated by the pins, quite bloodless. I next carefully dissected out the tumour, keeping my knife in the sound skin about two lines outside its margin, and deep enough to nearly expose the needles. I next pushed the needles through, and brought the edges of the wound together by the twlsted-wire suture. The hare-lip pin was withdrawn, and the encircling ligature dropped off. A pad of dry lint was placed on the wound, and strips of plaster brought over it, from cheek to cheek, to keep it in position. There was scarcely a drop of blood lost in the operation. For some reason or other the mother did not bring the child

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back to me for eight or ten days, and during that time the dressing was not removed. I found the parts in a very dirty state--the sutures had ulcerated through, and there was a granulating sore about a line and a half wide in the course of the wound. This healed up in a few days. I t is now about six weeks since I operated ; there is not a trace of the diseased structure, and the slight scar following the operation will, I believe, be scarcely perceptible in the course of time.

CXSE I I . - - T h e next case occurred to a child six months old, the tumour being of the same character as the one already described. I t was seated on the centre of the cheek, and was nearly the size of a shilling. This I treated as follows : - - I passed two hare-lip pins under its base, at right angles to one another, and threw a ligature round them, tying it tightly, thus cofnpletely strangulating the tumour. I did not see the case for six or seven ~'eeks after this, as the child lived some considerable distance in the country. The mother stated that in about a week the strangulated mass dropped off, leaving an ulcerated surface which was healed in about another week. For some short time before she called on me she noticed that when the child cried the place where the sore was became very red and somewhat swollen. When I saw it it had the appearance as if there was going to be a recurrence of muscular growth. Having protected the part around the cicatrix, I freely applied to it with a glass-brush a solution of sodium ethylate in pure alcohol (3 ij. of the former to 3 iij. of the latter). In a fortnight she called on me again, when I applied the solution a second time, and as I found it very much improved after the first application, I told her she might not call again if there was no appearance of the redness returning. I have not seen her since, so I suppose it has kept well.

CAsE III . ---The third case is one in which the tumour involved half the lower lip, the angle of the mouth, and the mucous membrane covering the gums on that side. This I treated by seton as follows : - - I got a large darning-needle armed with a very thick woollen thread. I passed this through the tumour, round its margin, a few lines from the healthy skin, after the manner of darning a stocking. I passed another seton through its centre in the same way. I then passed two or three through the thickness of the lip, and tied all the ends together and cut them off short. The setons were moved every day, and after a little, when free suppura- tion was established, and the threads became quite loose, I removed them and repeated the same process in fresh parts of the tumour. I may mention that I insisted that the parts should be kept very clean, by con- stant washing with linen rag.s saturated with a strong solution of chlorate of potassium. After the removal of the ~econd set of setons the tumour was very much reduced in size, and what was a soft, fluctuating mass had now a feeling of consolidation. I have not seen the child for the past

O

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two months, and if i t is not already cured, I feel certain a few more similar applications of the seton will make it all right.

There are few subjects in surgery that present a greater variety in their treatment than n,evus. There" are advocates for the knife, the ligature, injections, caustics, cautery, electrolysis, vaccination, seton, and scarification, and the modifications of each o~ these methods are too numerous to mention.

I have given you in a very unfinished way the notes of a few cases that occurred lately in my practice. A few points in the treatment I may now briefly consider. In the first case I used the subcutaneous l igature ineffectually. I have used the subcutaneous ligature a great many times, and the conclusion I have come to regarding i t is t h i s - - tha t it scarcely ever, if ever, accomplishes the end i t is mean~ f o r - - t h a t is, the cutting off of the blood-supply to the tumour and the subsequent strangulation of it. I t partakes, to my mind, more of the character of a seton, that for a few hours modifies the vascular supply, and if any good should follow its application, it is due, I believe, more to its action as a seton than a ligature.

The ligature, to be effectual, must occlude all channels by which blood can get to the tumour, and this can only be effectually done by including in it all the surrounding tissue, as I practised in the second case ~ have described.

The method of removing n~evus by the kniffe has been practised by a great many surgeons-- the objection to it being the danger likely to arise from hmmorrhage. The bloodless method I have described is a modifica- tion of that practised by Scale and Buchanan and recommended by Davy. I t is, to my mind, a very simple and effectual way of getting r id of the deformity with the least amount of suffering and in the shortest time, and one not at all likely to be followed by a return of the disease.

I mentioned in the report of my second case that there was a tendency to return of the disease in the cicatrix, and that i t was cured by the application of the ~4 sodium ethylate." We are indebted to Dr. Richard- son for the introduction of this powerful caustic+ which will, I believe, take the place of all the others that have been used in the treatment of this affection. I t has been found very successful by those who have used it in the treatment of small nmvi, and many large ones that resisted other modes short of excision. My own experience of i t is limited to this part icular case, and would not warrant me in drawing any general conclusions.

In large venous n~evi involving tissue to the amount described in Case I I I . , the seton is, I believe, the safest and best means of treatment. I ts use in the manner I have described is, I think, the surest way of obliterating the tumour. I t acts in a twofold w a y - - i t s zigzag course obstructing the circulation to a certain degree, while its presence, causing inflammation and suppuration in the tumour, leads to its consolidation.

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DR. H).RKI~ thought that the operations as performed by Dr. Fagan were successful, but in eases like these he found it impossible to lay down any fixed rule, as every case had to be treated upon its merits.

Da. DEr~PS~r pointed out in one of the patients the great resemblance between the scar and that seen in haxe-lip, and accounted for this by the direction in which the suture was introduced.

DR. I~I'KEowrr dissented from Dr. Fagan's practice of sending a patient home until he had seen the final effects of his own operation. He showed many possible ways in which the treatment might be entirely useless for want of a proper adjustment at the proper moment long after the operation. Hence he did not approve of the subcutaneous ligature. He often thought that a surgeon's responsibility commenced after the operation was finished.

~Exhibition of Splint. MR. F A G ~ exhibited a splint~he contrived for extension of the wrist

in acute diseases of that joint, a description and woodcut of which can be seen in the Report of the Transactions of the British Medical Asso- ciation aV the Cork Meeting in 1879.

Two Cases of Lithotrity. Dm WHITLA exhibited two calculi which he removed, and gave a short

account of. the cases. The first was from a girl of six years, who pre- sented herself at the Ulster Hospital for complete incontinence of urine of two years' duration. On an examination under chloroform, he found a large stone; and though his intention at the time was only to make a diagnosis, he was tempted to operate on the spot. The" urethra, which just admitted a probe, was dilated by a pair of fine dressing forceps, and the stone easily caught, but extraction was impossible owing to its size and shape, without destruction of the soft parts. I t was oblong, and lay with the great diameter across the bladder. A stout pair of necrosis .forceps were introduced, the stone caught in the middle of its length and broken in two. Each piece was found to be too large for removal, and a further application of the forceps crushed them into the fragments which they saw in tl:e specimen before the Society. These were removed with some trouble, and by their size an idea of the dilatability of the urethra might be learned. One was as large as a bean. The passage was dilated during the extraction so much that he easily introduced his little finger and explored the bladder thoroughly. He expected that a good time would be required before the canal would resume its tone again~ but he was astonished to find that the little patient was able to keep her urine for two and a haft hours after the operation, and continued to improve rapidly, leaving hospital in about a week per- fectly well. The stone was phosphatic, and weighed nearly half an

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ounc% and before removal seemed to entirely fill the bladder, which had contracted round it~ the urine as it was carried by the ureters dribbling continually away. More than a year had passed and she was now in perfect health~ and had no inconvenience whatever.

The history in connexion with the second specimen was interesting. A stout healthy gentleman, about thir ty-eight years of age, had suffered from severe painof a paroxysmal character in the left hypochondriac region~ which was supposed to be of splenic origin by his medical attendant. He lived in England. He had several attacks of this kind~ the last being about eighteen months since. About two months ago he received a letter from this patient describing most accurately the symptoms from which he was then suffering--symptoms evidently caused by stone. He wrote to him to that effect, and advised him to travel at once to London and see an hospital surgeon there ; but forty-eight hours afterwards the patient walked into his study after crossing the Channel. He passed the small sound~ which the members would see was a slight modification of Sir Henry Thompson's curve~ and detected a small stone~ which the patient affirmed gave an audible note. Upon the second day after this, Dr. Wheeler having administered chloroform~ he passed Weiss'~ smallest size lithotrite, caught the stone and crushed i t three times~ the operation last ing about a minute and a h a l l No irri tat ion of any kind followed. As Dr. Workman~ who watched the cas% remarked~ there was not a trace of blood to be seen in the urine after this crushing. He bore the chloroform so badly that upon the next operation forty-eight hours afterwards~ assisted by Dr. O'Neil~ he passed in the lithotrite and only caught two small fragments which he reduced to powder, and washed the bladder out with Clover's apparatus. F rom thence the convalescence was very rapid. He was put afterwards under ether~ and very carefully examined by himself and others, and subsequently by Professor Gordon~ and no trace of stone was found. The fragments~ they would observ% were all sharp and angular~ and composed of oxalate of lime. The stone was very minute; all that could be collected amounted to not quite 22 grains, which he was certain was at least two-thirds of its entire weight. Though so small~ probably not larger than a pea, its presence caused most excruciating agony for more than a year~ preventing to some extent the patient, who was the owner of some coal mines~ from pursuing his business. F rom the shape of the fragments they would see that the particles of the stone were united at angles to each other~ giving i t an almost spinous structure. Pain very much subsided after the first sitting~ and entirely disappeared after the second. Upon the eighth day the patient walked several miles with complete freedom~ which had not been his experience for more than a year before. Dr. Whi t la then referred at some length to Bigelow's operation~ which, he thought, m~rked a new era in the treatment of stone, l i e was satisfied that a

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few angular fragments in the bladder were far more dangerous than the prolonged contact of polished steel instruments in careful hands. He showed the great advantages that arise from using a small sound with a sharp curve~ and believed that he could not have detected the small stone with the large old-fashloned sound 9 while he thought he could not pass in the small one without striking it. He exhibited a small metal bougie which he had made for the treatment of fine strictures, its novelty being its peculiar curve~ which was hardly perceptibl% it being almost straight. Over a year has now elapsed (while going to press)~ and the patient has never once had a return of his old pain.

DR. WHEELER said he had the opportunity of witnessing the opera- tion which was followed by so successful a wind-up~ and he must say that he thought it would have been painless without the chloroform. He was surprised that the patient felt so relieved after the sittiug~ as he stated to him he felt no inconvenience whatever. He spoke about the difference between the treatment of stone now and what i t was in his student days~ when li thotri ty was almost unknown.

DR. J. W. BaOWN~ said he decidedly was in favour of a clean cut for stone. He detailed several cases upon which he had operated~ and he could recall one in which he was now certain had he performed lithotomy he would have had a very different result. Both the eases before the Society he thought very successful.

Dry. O'NEILL described the steps of the operation~ as he had seen the patient~ and he now understood what he had read in Sir Henry Thompson's book about detecting a stone not bigger than a pea and crushing i t at once. The operation was performed without any diitlculty~ and what convinced him of the great advantage of l i thotri ty was that he saw that there was not a trace of blood on the instrument or afterwards, and he could not see how in such a case coming before any surgeon again there could be a word spoken in favour of cutting.

PROFESSOR DILL, in thanking Dr. Whit la for his specimens~ com- mented at length about the different operations for stone~ and expressing himself confident that every year the cutting operation would become rarer and rarer~ as diagnosis became easier~ because stones would now be detected when they were small and crushed without danger. Both the cases were to him of great interest. He had not seen Bigelow's operation~ but he could see it was based upon rational grounds.