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oer. Persons become cachectio, and enfeebled as the disease advances, as its result, not as its cause.
In most of the patients, an unhealthy state of the skin prevailed, and there were few cases in which some complication was not observed, arising from disturbances of the respiratory or circulatory organs, varix, varicose ulcers, chronic gastro-hepatitis, pellagra, &c. After a while, the gland* in the vicinity enlarge, and it is of importance to determine whether their increase be merely sympathetic or symptomatic of invasion of the disease. In the former case, a single gland only usually becomes enlarged, being of recent origin, round or oval in form, moveable, and liable to spontaneous changes in size; it is painful and tender to the touch, the skin being warmer than usual, and in some cases slightly reddened. In symptomatic enlargement, two or more glands are almost always affected, large and indurated lymphatic cords stretching between them, and often down the side of the neck. After a while, the glands may acquire a large size, assuming an irregular form, becoming more or less fixed nt their base, being slightly moveable, and not undergoing spontaneous change in size.
Before proceeding to the operation, M. Kiberi submits his patients to hygienic and medical treatment calculated to relieve any complication or subdue any inflammatory aetion that may be present. Some cases of cancroid would indeed be cured by such procedures, had the patient sufficient patience to await the result. Believing the employment of caustics mischievous in almost all other forms of cancer, M. Riberi regards them as of great utility in epithelial cancer, especially of the face, when the base is small enough to admit of its entire destruction. But as the tissue of the lip is very soft and yielding, and cancer soon sends widely-spread roots into it, and as patients usually do not apply until the lesion has thus become extensive, the employment of caustics is not admissible. Moreover, considerable deformity may result from its application, and an aggravation of the disease may be produced when the whole has not been extirpated. The operation with the v incision, having its base towards the labial edge, and conjoined when necessary with cheiloplasty, is that to which Professor Riberi gives the decided preference. He enters into considerable details upon this part of the subject, for which we have not space. Whatever form of the operation be adopted, he insists upon the necessity of removing during its performance all glands that may bo symptomatically affected.
Of 78 persons operated upon, 73 left the Clinic cured; some of these, however, returned at the end of more or less long periods suffering from other cancerous diseases, 2 succumbed to a reproduction of the disease while in the Olinio, and 3 died after the operation from causes not connected with it. The following are the conclusions drawn from a consideration of the cases of the 81 patients:—1. The disease almost always commences as epithelial caucer or epithelioma of the skin or mucous surface of the lip, spreading thence to the parenchyma, and very rarely begins in this last, extending thence to the surfaces. 2. The skin is almost always primarily affected, and only in some rare instances by morbid diffusion from the mucous surface. 3. Although very frequently unaffected at first, the mucous membrane becomes almost always implicated in the course of the disease. 4. The cellular tissue of the parenchyma is always simultaneously affected, as are very frequently the mucous and sebaceous crypts, to the great number of which in the lips Benjamin Bell attributed the frequency of labial cancer. 5. The muscular tissue is sometimes unaffected, sometimes participates slightly in the disease, and in some cases is so involved as to become entirely destroyed. 6. Whatever our nosological distinctions may be in respect to the species of cancer, Nature shows how ill— founded they are, by exhibiting more than one of these together; but facial cancers are those in which this junotion is seldomest observed.
VI. On the Union of Wounds by Collodion. By M. Goyband. (Gazette Medioale, 1858,
Nos. 49 and 60.)
M. Goyrand observes that collodion intended to act as an agglutinative agent should possess the consistence of a very thick syrup. The following formula furnishes such a collodion: Snip. ethor. at 60°, hundred parts; pyroxiline, eight parts; and alcohol at 36°, five parts. Collodion so prepared is very adhesive, drying into a thin transparent pellicle, only capable of being removed by means of ether. It possesses, however, but little extensibility, and if applied to parts liable to change in volume it cracks. When, therefore, it is required as an impermeable covering for parts whioh are inflamed or menaced with inflammation, its elasticity should be increased by the addition of a little castor oil or turpentine. This elastic oollodion should not be employed as an agglutinative agent.
Any v«ry superficial breach of surface may be united by means of collodion. It is a bad plan, however, to apply it upon strips of linen, which conceal the wound from the surgeon and render the exact apposition of its edges doubtful. The edges should be brought into perfeet contact, and kept somewhat pressed together by the fmgers of an assistant; the part being well dried, a thick layer of collodion is then applied by means of a pencil, and is extended for some little distance beyond the edges of the wound, the contact of the parts Wing maintained by the assistant until the pellicle has dried. This answers admirably in clean wounds comprising only a portion of the thickness of the skin, such as the small cuts on the hands and face, which if neglected give rise to much inconvenience by inflaming and suppurating. The ordinary plasters uot only conceal the condition of the wound, but become detached by washing, while the collodion does not separate until healing is effected.
This simple procedure is insufficient when there is a tendency to separation in the wound, and when there is a considerable loss of substance. Strips of adhesive plaster often hold such wounds in only imperfect apposition, and make insufficient or irregular traction; while when union by the second intention is only possible, they impede the flow of the discharge. In such cases M. Goyrand makes a frequent use of what he calls the dry collodion suture. Two strips of linen are prepared, being somewhat longer than the wound itself, and broad in proportion as it is deep. These are soaked in collodion, and fastened parallel to the two sides of the wound, at some millimetres from its edges. To these strips, and perpendicular to their direction and to that of the wound, are stuck by one of their outer extremities some narrow, thin, and very supple ribbons, forming part with the linen strips, Hiitil the edges of the wound are reached. The ribbons vary in number according to the length of the wound, and their free ends being placed opposite each other, may be tied together in pairs. This tying draws together the linen strips, and consequently the edges of the wound, which can then be brought together with as much exactitude and pressure as may be deemed desirable. This mode of uniting the deeper wouuds possesses many advantages. It maintains the parts in exact apposition unattainable by plasters, is applicable to wounds taking any direction, and admits of the consentaneous employment of irrigation if required. Vidal's pretty little instruments, the serres-fines suitable enough for a superficial wound, only bring the edges of the surface of a deep wound in contact, and they cannot be kept on more than twenty-four hours without risking the production of small eschars. The collodion, acting over large surfaces, brings into contact not only the edges of the incision, but also the subcutaneous bleeding surfaces. It has the advantage over the ordinary suture of being painless, of remaining in situ as long as required, and of allowing of the wound being easily re-opened on account of secondary haemorrhage.
M. Goyrand has no intention of indiscriminately recommending the substitution of collodion for other means of securing union, but claims for it admission into practice concurrently with them. He states his practice in the matter as follows:—1. When I have good collodion at my disposal, I always employ a layer of it to unite very superficial clean cuts, to -which gummed plasters are usually applied. 2. When the wound comprises all the thickness of the dermis, its edges being clean, easily approximated, and not likely to become displaced, I often employ the serres-fines, which allow of very exact adaptation, and are very easily applied. 3. No uniting means is comparable to the serres-fines, when the object is to bring together the edges of a wound involving very thin and very moveable skin, and when one edge of the wound is formed by delicate skin and the other by a mucous membrane. Thus, I consider them preferable to any other means for fixing the dap in certain anaplastic operations of the face, and for uniting the wound made by circumcision or castration. The difficulty of obtaining an immediate union of a large wound of the scrotum by means of plasters, or even by the interrupted suture, is well known. A rolling of the edges of the incision takes place, bringing the epidermic surface into contact with the deeper seated .parts, and union never takes place without suppuration. The serres-fin€s, on the contrary, maintain the edges of the wound in exact contact, and usually lead to union by the first intention. 4. Adhesive strips may be advantageously employed in wouuds comprising the entire thickness of the skin, or even when the subcutaneous fatty tissue is divided, providing their direction is longitudinal I especially employ them when I think that the compression they exert may prove of utility. 5. When the wound, though simple, is transverse, and does not seem to be able to be united throughout its depth by means of serres-fines, I obtain the best effects from the dry collodion suture. 6. This suture is the sole means by which we can, through an energetic .and sustained action, keep together the edges of a large wound accompanied by loss of substance, whether our object be to secure complete contact, or to change the ronnd form of the wound, so unfavourable to cicatrization, into an elongated elliptical form. 7.1 know of no means comparable to the dry suture in the case where, during the production of secondary union, it is desired to keep for a long period parts in contact whose adhesion to eooh other it is sought to obtain. 8. Finally, I am certain that no means can replace the twisted suture in hare-lip operation, or the deeply-acting sutures which are employed in uniting penetrating wounds of the abdomen and the pored edges of a ruptured perineum.
VII. On the Treatment of Wounds and Ulcere by Ventilation. By Professor Bouisson. (Gazette MeMicale, 1858, Nos. 44, 45, 48, 47, and 48.)
Superficial wounds in animals become rapidly desiccated, and cicatrization is performed in the most favourable manner under the crust so formed. The idea occurred to Professor Bouisson of endeavouring to imitate this procedure by inducing the desiccation of wounds and nlcers through the employment of ventilation. Cicatrization might naturally be expected to take place more rapidly and more favourably under the protective crust so formed, than when the open surface continued exposed to the air and other sources of irritation.
The trial of the plan was commenced at the St. Eloi, Montpellier, in March, 1857. It was applied to various examples of recent and old wounds, local ulcers, solutions of continuity after operations, &c., these altogether amounting to above twenty in number. We can refer only to some of the details given by the author. The first case was a large ulcer of the leg of many years' standing, characterized by the usual obstinacy of the malady. Four times in the twenty-four hours a sharp ourrent of air was propelled over its surface during a quarter of an hour, the common bellows being the instrument and the patient the operator. By the very next day a crust had commenced forming, and by persistence for several days in the ventilation it was rendered thicker and thicker. At the end of about a fortnight the crust was detached by means of a bath, and the sore was found much reduced in size and of a very healthy aspect. A reproduction of the crust by renewed ventilation still further reduced its size; and had the patient not become content with the benefit received, complete cicatrization would have followed. More rapid success attended the employment of the means in more recent cases; thus, a small wound in the leg was healed in eight days, and even extensive wounds, after injury or operation, were more rapidly healed than by any of the ordinary procedures. Generally speaking, however, the procedure could not be adopted at once as most of the patients admitted having some complication, this required removal before the production of cicatrization could he attempted. The immediate effect of its employment was the production of a sense of coolness, while the pain became moderated and the surface of the wound paler, as if under the action of an astringent. The crust increased in thickness and tenacity in proportion to the duration and force of the ventilation, and after some days assumed a horn-like texture—the discharge, if still abundant, escaping somewhere at its detached circumference. The crust takes no part in the cicatricial process which i« going on beneath it, but acts simply as a natural protective dressing. When, however, the wound is small, nninflamed, and exempt from purulent secretion, the evaporation induced dries up the plastic lymph itself, reducing it to its organizable portion. The crust, in this case, becomes confounded with the cicatrix itself, which, forming rapidly, fills up the interval between the edges of the wound, and calls to mind what takes place in union by the first intention.
M. Bouisson believes that other therapeutical effects are also derivable from the plan, and enumerates these under the several titles of sedative, astringent, siccative, and antiseptic action. Into his account of these we have not space to enter, and merely add the general conclusions of his essay:—1. Ventilation of wounds and ulcers is of utility as a curative agent in a very great number of cases. 2. It induces healing by desiccating exposed surfaces, covering them with a crust formed of the residue of the co-effused liquids. 3. This crust acts by isolating the wound from the contact of the air, and by favouring a simpler and more regular mode of cicatrization than that which takes place in exposed wounds, the dressing of which frequently destroys the cicatrix while in process of formation. 4. Subcrustaceous cicatrization bears the same relation to open wounds, that subcutaneous cicatrization does to closed wounds. 8. Ventilated wounds and ulcers cicatrize more rapidly and with fewer primary or consecutive accidents than do wounds dressed with fatty bodies or other medicinal topical applications. 6. Ventilation develops effects which are exhibited by local refrigeration, antiphlogistic and astringent action, desiccation of the wound, together with its isolation and occlusion, and its preservation from the septic action of pus. 7. It may be performed by the ordinary bellows or any other apparatus. It should be continued for a quarter of an hour, and repeated several times a-day. 8. It is*pplicable to old or recent, to small or large wounds, to ulcers, burns, &c. It may also be preceded by other means of general treatment, or employed as adjuvatory to these. 9. It presents several indirect advantages, especially ecouomy and simplification of dressing, and the maintenance of greater cleanliness.
VITL Loss of the Teitiele consequent upon Scarifying the Scrotum. By M. Dejiarcjuay. (Bulletin de Therapeutique, tome lv., p. 549.)
Long since M. Velpeau recommended the little operation of scarifying the scrotum in cases of gonorrhoea! orchitis; and its practice is usually followed by very advantageous results, especially when it gives issue to a notable quantity of citron-coloured fluid accumulated in the tunica vaginalis. M. Vidal went much further than this, by opening in painful orchitis the tnnica albuginea itself, an operation he declared to be without inconvenience, ami one which he performed himself more than four hundred times. M. Demarquay for some years past has not had recourse to this practice; and he does not even employ scarification of the scrotnm unless there be fluid in the tnnica vaginalis, fearing injury to the gland itself. Having seen an account of a case by M. Montanier, in which severe hwmorrhage followed scarification, he determined to make known four instances which oame under his own notice, in which still graver consequences ensued.
The two first cases occurred in persons between fifty and sixty years of age, in whom orchitis coming on during the treatment of stricture, scarifications had been resorted to. They only came under M. Demarquay's notice when the testicles were in part gone, s[ierinatio filaments being found every morning in the dressings. The patients were cured, but the testes were lost. In the third case, in a man forty-six years of age, intense orchitis came on during treatment of stricture; and after various means had been tried in vain, scarifications were resorted to, and gave rise to a tolerable flow of blood. No great amendment resulting, the author was called in next day. All the apertures were closed but one, the edges of which were everted. Presently a plug of greyish matter, at first no larger than a millet-seed, but gradually increasing to the size of a cherry, projected. It proved to be the testicular substance, infiltrated with a little pus; and gradually the whole of the testicle was in this way discharged. The fourth case occurred in a young man, under the same circumstances, but here the loss of the testis was only partial. It may be supposed that these are mere coincidences, being really examples of inflammation of the testis terminating in suppuration. Such termination is, however, very rare, as the experience of MM. Ricord and Monod sntficiently prove.
The less liability to such an occurrence in gonorrheal orchitis, as compared with orchitis connected with disease of the genito-urinary apparatus, may be thus explained. In gonorrhoea, it is the epididymis which becomes especially seized with inflammation, this being propagated to the envelopes of the testis, and sometimes to the organ itself, and to the tunics vaginalis. Fluid then distends the latter, and great relief may follow the discharge of this by punctures. But in orchitis symptomatic of disease of the urinary organs, it is generally the testis that is affected, and the same abundant effusion into the vaginalis does not take place. Scarification may here easily attain the secretory organ itself, and ill effects will the more readily follow in consequence of the economy being already under the influence of the original disease.
IX. Six Caset of tuceeuful Operation for Congenital Cataract in one Family. By Dr. 'wilLiams. (Boston Medical and Surgical Journal, vol. lix., p. 149.
These cases occurred in a German family living at Boston, the mother and four children suffering from cataract in both eyes. The mother was not aware of any cases having occurred among her eight brothers and sisters or other relatives, and she has two other children who exhibit no traces of cataract. In her the opacity of each lens was greatest at the centre, the margin being comparatively clear, so that in a moderate light she could see enough to perform her household duties in an imperfect manner. The capsules, as also in the children, were transparent. In all the children, opacities, consisting in dots of various sizes and occupying different planes, occupied nearly the entire field of vision; and in a bright light, reflections from crystals of cholesterine were plainly seen. In a bright light the children were nearly blind, and their sight was never suflicient to allow of their learning to read or to get their livelihood. Six operations were performed on the same day upon three of the children, aged seventeen, twelve, and ten respectively, the lens and capsule being freely divided by a needle introduced through the sclerotic. Sparkling reflections from cholesterine were distinctly seen in the posterior chamber. It was several months before the pupils all became clear, and in the youngest girl one of the eyes had to be operated upon a second time. The children now have perfect vision, and with the aid of cataract glasses will be able to follow any occupation. The eyes 6f the mother, and of the other child, aged two years, have not yet been operated upon, the woman still feeling too timid. Dr. Williams knows of another family, presenting no less than teven cases, others of the family being free from disease. Some of the eyes had been operated upon, but with imperfect success, portions of the capsule left behind having become tough.
[In the January number of the 'North American Medico-Chirnrgical Review,' is a very interesting case of congenital cataract, related by Dr. Rohrer of Philadelphia. The patient had been totally blind for sixteen years, and continued in the enjoyment of unimpaired vision at a period of twenty-one years after the performance of the operations.]
X. On the Operation for Hernia in Children. By Dr. Ravoth.
Dr. Ravoth communicates an interesting case of inguinal hernia occurring in a male child, fourteen months old. Observed soon after birth, a truss had not been applied to it until the child was six months old, and this, owing to the frequent projection of the large hernia, seems to have been ill-fitting. When the child was seen by the author, incarceration of the hernia had taken place during forty-eight hours. The scrotum was distended with a tumour as large as a man's fist, haviug very much the appearance of a hydrocele. As repeated attempts with the taxis, under chloroform, were found useless, the operation was at once resorted to. In order to avoid loss of blood, two small arteries, which were divided while laying the sao bare, were at once tied. The parts were replaced without opening the sac, and the wound was simply dressed, a little pad of charpie being laid over the inguinal canal. Chloroform was employed during the operation, and frequently since during the dressing of the wound, on account of the child's cries—the hernia then very easily redescending. In about three weeks the wound had oicatrised, and a properly fitting trass was after a while well borne.
In reference to the history of this case, the question may be asked, when is the most suitable time for the application of a truss in infants? Most practitioners say not before the sixth month, and some even not before the twelfth. This advice is grounded upon the great sensibility of the child's skin, the necessity of great cleanliness, the rapid growth of the child rendering a frequent change of the truss necessary, the rarity of strangulation in childhood, and the frequency with which a spontaneous cnre is brought about in congenital hernia. Although these reasons may have their weight in particular cases, the author does not consider that they have validity enough to raise this practice into a general rule. On the contrary, he believes that the truss should be applied at the earliest possible period, and chiefly because the partial or total protrusion of the hernia gives rise to much abdominal pain and gastric disturbances, oausing crying and restlessness, and impeding development. The hernia, too, increases in size, and the abdominal ring in width, so that the tumour is retained with more and more difficulty, and a radical cure, which at this early age may usually be expected from a well-fitted truss, becomes more unlikely to happen. The pressure from the large pad and strong spring, too, now required, will not be borne by the child's delicate skin. Finally, there is the danger of strangulation, which at this early age is not always easily detected, and the operation for the relief of which is one of great danger.
The successful issue of the present case is chiefly attributed by Dr. Ravoth to three circumstances—viz., the promptitude with which the operation was performed; the executing this without opening the sac, and dilating the ring with a blunt hook in place of a cutting instrument. This child had rejected all food during twelve hours, and had been deprived of refreshing sleep during forty-eight hour3; and had a further delay taken place from the use of baths, clysters, ,fcc., the issne would probably have been different. Moreover, the hernia had not suffered from excessive employment of the taxis, and chloroform was resorted to during its application. After repeating the well-known arguments in favour of not opening the sac, Dr. Ravoth observes that in children this should never be opened when there is any possibility of avoiding it, and especially in the case of large hernias, where repeated protrusion may be produced by the child's cries and movements before the healing is accomplished. In the present instance the hernia was very large, containing the caecum and processus vermiformis. The old practice, now almost forgotten, of attempting to dilate the aperture without the use of a cutting instrument should, when practicable, be preferred. As far as the author is aware, there are about thirty cases on record in which the operation for hernia has been performed on infants and young children; and of the seventeen operations of which the issue is given, nine terminated in death.