Art. X.?NOTES ON ASYLUM SURGERY. BY ROBERT
LAWSON, M.B., Pathologist and Assistant Medical Officer, West Riding Lunatic Asylum.
During the past month two surgical cases have occurred in the West Riding Asylum which are, in certain respects, instructive
and interesting. The first was the removal of a darning needle from the abdominal parietes of a female patient, and the second the excision of a large mammary tumour of fibro-cystia/ structure. The patient in the first case was admitted in March last. She suffered from simple melancholia, and had made repeated attempts to cut her throat. She was depressed on account of business embarrassments into which her husband had fallen,, and had excessive feelings of regret for having taken a small sum of money from his till, for the use of her own sister. Her delusion was that if she were out of the way there would be nothing to prevent her husband's prosperity. When admitted she was low-spirited, owing to a vague feeling that everythingwas going wrong. She had a recent incision on the left side of the neck. Her physical health was fair, and she appeared to be at the menopause. In a month she was so much improved that she was employed in the kitchen, but had again to be sent to the wards on account of the occurrence of a certain amount of depression. In June she was much depressed, and showed great listlessness and want of appetite. She retained the obscure delusions which she had manifested on admission; and after a visit from her husband appears to have become much On the 18th of August she worse than she had formerly been. complained of pain in the left hypochondriac region, and on examination it was found that some sharp body was pointing underneath the skin at that part. On' cutting down upon the spot a needle, measuring 3f inches in length and one-eighth of an inch thick, was readily removed. She stated that during the period of depression which has just been noted she swallowed a darning needle, a large piece of glass, and a portion of a bent knitting needle, in the expectation that they would occlude the windpipe and cause suffocation. The nurse remembered that at the time referred to the patient was refusing her food, but that the refusal appeared to arise more from defect of appetite or suicidal intent than on account of pain during or after swallowing. The patient herself observed that for
NOTES ON ASYLUM SURGERY.
hours after swallowing the needle there was of obstruction in the throat, followed by a strange sensation at the pit of the stomach which she described as a hungry feeling. This feeling also disappeared, and was followed by pain in the left side, which was increased by movement, and especially prevented her raising herself up when she had lain down in bed. When removed the needle presented appearances which led to the conclusion that it had passed through the cardiac end of the stomach wall and found its way directly into the abdominal parietes. The point was but little eroded, while the metal surrounding the eye was on one side completely eaten away, evidently on account of prolonged exposure to the action of gastric juice. This roughening of the posterior part of the needle caused a considerable amount of laceration during removal, but the small aperture closed in two or three days, and no threatenings of peritonitis were ever observed. The needle did not smell of fsecal matter, and had no trace of digestion products on its roughened surface, so that the natural conclusion is that the needle had been lying entirely in the abdominal parietes for a considerable time. The patient in the second case was also admitted in March 1875, and presented symptoms of subacute mania. She was a criminal, and at the expiry of her sentence was certified for admission into the asylum. She had numerous delusions and hallucinations, and was said to be at times violent. On examination it was found that she was exceedingly irrational and incoherent, morose and suspicious. She refused her food, and had to be fed with the stomach tube. She had hallucinations of hearing during the time of examination, and imagined that she heard the voice of a distant friend. A large fibro-cystic tumour was found to occupy the place of the left breast. It There was no rewas not adherent to the subjacent textures. traction of the nipple, no enlargement of axillary glands, and The only discomfort caused by the tumour was a no pain. of weight. sense The patient was somewhat sallow dragging She stated that the tumour had been growing and very thin. for about three years, but her evidence was not reliable. In a week after admission the patient was somewhat better and had begun to take her food. In a month it was noted that she was losing flesh and that the tumour was undergoing no change. On August 18th a special examination was made, and it was determined that, as she was gradually becoming weaker, and as the growth was very rapidly increasing in size, it would be necessary to remove it. Before removal it measured at the base, which was the The skin smallest part of it, 12\ inches in circumference. a
NOTES ON ASYLUM SUEGEEY.
the upper surface was very tensely stretched, that on The larger flap was conseunder surface was flaccid. quently taken from below by means of a modified circular incision. There was a considerable amount of adhesion between the peripheral part of the tumour and the subcutaneous On the under textures. The skin was exceedingly attenuated. surface the growth was not to any extent adherent, but the pecOn removal, the growth, toral muscle was much atrophied. including the fluid which escaped from cut cysts, was found to In form it was lobulated, weigh rather more than 61bs. and on section exceedingly tough. Owing to the mental condition of the patient, it was impossible to employ the antiseptic system completely, but the skin surrounding the tumour was widely cleaned with carbolic lotion; the instruments, ligatures, &c. were steeped in carbolic oil, and the cavity left by enucleation of the tumour was thoroughly drenched with a solution of carbolic acid of the strength of 1 to 20. The incision was dressed with carbolic oil of the same strength ; and though the patient was so restless that two nurses were sometimes required to restrain her, the wound almost entirely healed by first intention. Around one ligature there was found at one or two dressings a small quantity of pus, and only at the extremities of the incision, where space was left for the draining away of discharge, was the healing action accomplished by granulations. From the date of the operation her appetite has increased, her pulse has gradually gained strength, and her mental condition has undergone at least temporary improvement. She has become more manageable, but is exceedingly mischievous. On the day after the operation she made several attempts to get out of bed, for the sake of annoying the attendants; yet, notwithstanding the disadvantages resulting from her frolicsomeness of disposition and her great prostration previous to the operation, the healing of the wound has advanced in every particular in the most advantageous manner possible. Perhaps it is not too much to say that this result is in no small measure due to 'the protection afforded by the use of a rough and ready form of the antiseptic system of treatment. On microscopic examination the structure of the tumour was found to be made up of bundles of white fibres along with spindle-shaped cells. The fluid in the cysts was sero-purulent in character. over