NOTES ON SOME SURGICAL CASES. By Subgeon D. G.
CRAWFORD, m.b., i.m.s., Surgeon, Saran. The cases which aie the subject of the following notes, have been operated upon in stations widely scattered over the whole province of Civil
Bengal, Mymensingh, Champarun, Bakerganj, Darjeeling, Midnapur, Puruia, and Saran.
The first series comprises several cases of for large malignant tumours, epithelioma of the lower jaw (two); of the tongue and floor of the mouth ; of the eye-ball; of the penis (two); and one of melanotic sarcoma of the orbit. Of the seven cases, two died within 24 hours, aud the other five recovered for the time being, though one at least died some nine months later, probably of recurrence of the growth. In the Indian Medical Gazette for March 1887 I published notes of some similar operations for malignant tumours, viz., two cases of excision of the upper jaw for sarcoma, and one of excision of the One of the two former rectum for epithelioma. cases died, also within 24 hours ; the other two recovered. In my small experience of operations for large malignant, tumours, all cases which have not died within the first 24 hours, chiefly from shock, have recovered for the time being. The next two cases are those of tumours, not important in themselves, but somewhat singular Then follow a case of removal of in character. the whole clavicle, aud one of repair of a perineal fistula. The next are five cases of stone, a selection from a number of cases of lithotomy (as well as a few of litholapaxy)} which I have performed. The first two are given simply as a contrast, both in the manner in which the operation was performed, and in its result. Each of the other three cases is distinguished by some peculiarity. In two at least of the five cases litliolapaxy would have been a better operation, but in neither case were the crushing instruments availFew charitable dispensaries in the provable. ince possess these instruments. Out of seven districts in which I have served, Chapra dispensary is the only hospital in which I have seen a set of litliolapaxy instruments, and here they have only been procured a few months ago. Indeed, there are few dispensaries which can afford to a set of these pay the very high price which All or nearly all hospitals instruments costs. could profitably expend much more money than can possibly be found for their maintenance. And while this is the case, and while stone is not a common disease in most parts of the province, such money as can be budgeted for the support
operation
Oct.
CRAWFORD'S NOTES ON SOME SURGICAL CASES.
1892.]
be laid out in other ways with greater benefit greater number of patients. This of course is not to disparage the operation of litholapaxy. It is now an accepted fact that in most cases of stone in the bladder it is a better operation than lithotomy. But considering the cost of the instruments, and the liability of the aspirator bag to get out of order in the damp climate of Bengal, most hospitals in this province simply cannot afford to purchase them. The last three cases of elephantiasis of the genitals, are also a selection from a much larger number of cases, which are peculiar, in that in all three the penis was the chief seat of the disease ; the scrotum, contrary to what we commonly see, being little affected. Cass No. 1.?Melanotic sarcoma of orbit.?? Maghu Shaikh, Musalman male child, aged 2|years, of Gargha, Mymensingh thana, was brought to Mymensingh dispensary on 8th June 1887, suffering from a melanotic sarcoma of the right orbit, said to have been of two months' growth. The tumour protruding from the orbit a was sloughy fungating mass about the size of a large orange, or about one-fourth the size of the child's head, which bled copiously when At the urgent request of the parents handled. the tumour was removed. First a ligature was slipped round it, and pressed down to as near its base as the fingers could reach; it was then drawn tight, and the tumour was cut off above The base of the tumour was then it. gradually separated from the eye-lids and the walls of the orbit, as well as from the orbital fissure. It appeared to be completely removed, but it is probable that its remotest roots came from inside the skull, and were not got away. There was little bleediug. The orbit was plugged with lint, and a pad and bandage applied. The wound healed rapidly by granulation, and the boy was discharged "cured" on 18th June. Remarks.?Although to the sense of touch it appeared that the whole of the tumour had been removed, there is little doubt, I am afraid, that a tumour of this sort would almost certainly recur, and the prognosis as regards duration of life was extremely bad. It was worth while, however, to perform the operation, as it relieved the child of a prominent and iusightly tumour, which bled freely at the slightest touch, and might have proved immediately dangerous to life by hemorrhage. In this connection, it was remarkable that there was hardly any haemorrhage during the operation. There was of course an off-chance of a permanent cure. I left the station soon after, and heard no more of the case. There were no signs of recurrence before the patient left hospital. Case No. 2.?Epithelioma of tongue and floor of mouth.? Sharupullah, Musalman male, aged 35, of Jhalukati, came to Barisal dispensary on 9th March 1889. He said that he had first of
a
hospital,
can
to a
Xj
j
I noticed
295
in the right submaxillary reand six mouths before, gion previously had noticed a lump ou the right side of the tongue. His present condition was as follows : a
a
tumour
year
There was an epitheliomatous tumour, involving the right submaxillary gland, which was as large as a small lemon, the right side of the
floor of the mouth, and the anterior half of the right side of the tongue. It had not yet becrun to ulcerate. On the following day the tumour was removed. A gag was inserted, much trouble being given by spasmodic closure of the jaws, a thread was even when under chloroform, and put through the tongue, by which it was drawn outside the mouth. The tongue was split down the middle, and the anterior half of the right side was ligatured and cut off behind the tumour. The glaud and right side of the right floor of the mouth were removed through a subinches long. The margins mental incision, of the excised parts of the tongue and of the floor of the mouth were quite soft and free from disease. There was considerable hemorrhage, about 16 oz. of blood, by guess, being lost. The wound was sprinkled with iodoform, and strips of lint inserted into it. At 4 P. M., some six hours after the operation, the patient got up and tried to leave the ward iu a semi-delirious state. The pulse was then about 150, and very thready. He never thoroughly recovered from the operation, and died the next mortiincr at 7-30 A. m. Remarks.?Considering the extent of the disease, it would perhaps have been wiser to have left this case aloue. The fact that ulceration had not yet begun, however, encouraged me to hope that the tumoitr might be successfully removed. The dispensary did not possess an ecraseur, with which the operation might have been carried out with less hasmorrhage. Death was probably due partly to shock and partly to haemorrhage. There was no bleeding, except some ooziug, small in quantity, after the operation had been completed. The result of course must have been fatal before very long, if the tumour had not been touched. Case No. 3.?Epithelioma of lower jaiv.? G-obindo, Hindu female, aged 40. of Muradia, Backerganj thana, came to Barisal dispensary on 3rd May 1889, suffering from an epithelioma of the left lower jaw, which extended from the second bicuspid tooth to the angle of the jaw, much of which was absorbed, and also implicated the internal surface of the left cheek. She was unable to give the duration of the disThe tumour was removed the same ease. day. An incision was made, beginning over the condyle of the jaw, passing under its angle, then forward, and up over the chin to a point half an inch above the tip of the chin. The symphysis was sawn through, and the condyle disarticulated by twisting, in which process the
"submaxillary
\)
296
INDIAN MEDICAL GAZETTE.
internal
\J
maxillary artery ligatured. The gap
gave way, and was at was stuffed with carbolized lint, and the edges of the incision stitched. On the 4th, 5th, and 6th May her temperature fluctuated between 99 and 101*6; after the 6th it never rose above normal. The two ends of the incision healed by first intention, She but the middle third failed to uuite. swallowed milk the day after the operation, and on the 14th May took solid food. On 15th May the portion of the wound still unShe abhealed was clean and doing well. sconded during the following night. Remarks.?This case was unsatisfactory, in that the patient left the hospital before the cure was complete. The unhealed wound could procured by a small plastic operahave been bably tion, but the patient departed suddenly, without She any previous intimation of her intentions. of the result the with satisfied operaappeared There was considerable probability of tion. recurrence, but in the meantime she had been relieved of a malignant tumour. I never heard of the case again. Case No. 4.?Epithelioma of eye-ball.?Sursuni, Hindu female child, aged 8 years, of Purnia, was brought to the Purnia dispensary on 11th March 1890, with the following historv. She had suffered for a year past from hemicrania and blindness of the right eye, which had been ulcerating for about a month past. The right orbit was entirely occupied by a fungating epitheliomatous tumour, the size of a lemon, protruding from the orbit, and widely separating the eye-lids, not adherent, but freely moveable by the ocular muscles, in concert with the left eye. The tumour was at once removed under chloroform, the whole of the eve-ball being excised. Its posterior surface appeared healthy. The wound healed by granulation, and the patient was discharged "cured"on 29th March 1890. On 23rd May the same patient was brought back again with a tumour, the size of a lemon, springing from the left orbit. I at first supposed it to be a recurrence of the epithelioma previously removed, but on removal, which was done at once under chloroform, it was found to be a sebaceous cyst, growing from a fatty base, with no sign of malignancy. She had slight fever, the highest temperature being 101 for two days, after which it remained normal. The wound granulated healthily, and she was again discharged "cured" on 8th June 1890. In December 1890, I made enquiries about the child, and was informed that it had recently died of " fever and pain in the eye." Remarks.?This case was curious, the excision of a malignant tumour in one orbit being followed so soon by the growth of an apparently non-malignant tumour of the other orbit. From the very vague after-history, I should suppose
once
that
[Oct.
1892.
third tumour, malignant again, had apin one of the orbits. It was unfortunate that the case was not again brought for examination, if not for treatment. I saw a somewhat similar case in Purnia in 1891, when a female child of three or four years old was brought with an ulcerating epitheliomatous tumour of one eye, great bulging of the second eye, and a large flat epithelioma, covering almost the whole of the front of the right forearm, and implicating both radius and ulna. Of course nothing could be done for such a case ; extirpation of one eye-ball and amputation of one arm would have been necessary at once, followed probably by extirpation of the other eye-ball, and still further recurrence later on. Case No. 5.?Epithelioma of penis.?Dhoni Lai, Hindu male, aged 40, of Malora, Purnia, Purnia dispensary on 14th December came to 1891, with epithelioma of the penis, said to be of two years' standing. He had presented himself for treatment at least ouce before at the disThe pensary, but had then declined operation. same day amputation of the penis was performed under chloroform, one inch below the glans. The urethra was separated, brought out through an incision in the middle line below the scrotum, The cut short, its end slit, and stitched there. were separated, ligatured, and cavernosa corpora The top of the penis was sewn up; a divided. silver S-shaped catheter tied into the bladder, and the wound dressed with a pad and T bandage. His temperature that evening was 101*3, and from the 15th to 18th December it fluctuOn the 18th an abscess, ated from 100 to 102. which had formed on the left side of the scrotum, was opened, the incision being continued into the lower wound. On the same day the ligatures from the ends of the corpora cavernosa came away. From the 19th December the temperature remained normal. On 28th January 1892 he the penis being healed, was cured, discharged and the lower wound represented by a small slit, which answered its purpose as an exit for urine. Remarks.?This was a simple case, the disease not being far advanced, in spite of its long duration. The only untoward event was the formation of a small abscess in the scrotum. Case No. 6.?Epithelioma of penis.?Jalim Ahir, Hindu male, 60 years, of Satwa, Baniapur, Sarun, came to Chapra dispensary on 22nd May 1892, with epithelioma of the penis, said The penis was conto be of a year's duration. verted into a cauliflower mass, rounded, and as large as a large orange, extending down to the pubes; there were two indistinct furrows round it, one at the root, the other apparently below the glans, though the glans could hardly be distinguished from the rest of the penis. On 24th May, under chloroform, the penis was amputated. The corpora cavernosa were ligatured together below the tumour, not being separable. a
peared
Oct.
1892.]
CRAWFORD'S NOTES ON SOME SURGICAL CASES.
was some difficulty in gettiug a sufficient stump for the ligatures to catch on below the disease. The urethra was separated and brought out through a buttonhole incision below the scrotum, to the edges of which it was stitched, and a gum elastic catheter was tied into the bladder. This catheter was withdrawn next day, urine passing freely alongside it, as well as through it. The temperature on the evening of the day of operation rose to 103, which gradually sank to normal by the 27th May. There was nothing noteworthy about the further progress of the case, except that some long strings of slough came away through the lower wound four days after the operation. The patient left hospital on 16th June practically cured, a small flat ulcer still remaining unhealed on the stump, whence the penis had been removed. Remarks.?This case was not so simple as the preceding one, the disease being much further advanced, in spite of its alleged shorter duration and consequently less easy to remove, as well as more likely to recur. In neither case were the inguinal glands at all affected. Case No. 7.?Epithelioma of lower lip and jaw.?Dwarka Tewari, Hindu male, 55 years, of Chapra, came to Chapra dispensary on 6th April 1892, with an epithelioma of the lower lip. The tumour, which was as large as a cricket ball and much ulcerated, sprang from the lower lip, somewhat to the right of the middle line, and had affected the body of the lower jaw on both The tumour was said to be of eight sides. months' duration, and caused great pain. On 9th April it was removed under chloroform, the body of the lower jaw being sawn through an The right inch in front of both the angles. submaxillary gland which was affected was also excised. The edges of the wound were brought together as far as possible. The patient never thoroughly recovered consciousness, and died of shock two hours after the completion of the operation. There had been very little bleeding during the operation. Remarks.?In this case the disease was very much advanced, in spite of its alleged comparatively short duration, and it would perhaps have been wiser to let it alone. Still, it was not beyond hope that operation might completely remove the disease, the pain suffered was great and the end necessarily fatal in any case, facts which were sufficient, I think, to
There
1
?
the operation. Case No. 8.?Angioma of chin.?Babar Jan, Musalman male, of Sealganj, Kewari, came 10th September 1889, to Barisal dispensary on with a soft flabby, indistinctly lobulated tumour, covering the whole chin, from the lower lip downwards, and hanging down for about 1| inches below the point of the chin. This tuIt had mour, he said, had existed from birth. been cauterized over almost its whole surface,
justify
297
and the'skill was adherent to it throughout. To the touch it had the doughy consistence of an angioma, but no pulsation could be felt in it; and on thrusting a trocar into it, 110 blood It was removed, under chloroform, flowed. the same day, by an elliptical incision 011 eacli side, and was found to consist of very vascular fatty tissue. Next day there was great swelling of the lower lip, which had almost entirely subsided by the 14th September, when he absconded, the stitches being still in the wound. He returned on 29th September, with the wound healed up. There was then 110 sign of tumour hanging below the chin, but some swelling of the lower lip remained at the upper end of the incision. He expressed himself as satisfied with the result, aud declined further interference.
Remarks.?This rather curious
case was protumour, the vascularity of which had been for the most part destroyed by repeated cauterization. It is the only case of I v/ the kind which I have seen. Case No. 9.?Fibroma of eye.?Constable Bisendeo Sing, Hindu male, aged 25, of the Purnia Police, came to Purnia dispensary on 26th January 1892, complaining of a tumour on the right eye. He stated that the tumour had first appeared a year and-a-half previously as a small red spot, and had gradually grown to its present size. It had once been cut off by a native hakim, but had speedily grown again. It was now pyramidal in shape, soft, the base the size of a sixpence, aud about half au inch high. It was freely moveable, and covered the left half of the right cornea, and as much of the sclerotic to the inner side of the It appeared to be a fibroma. It was cornea. cut off with a cataract knife the same day under chloroform, the tumour being shaved off level with the surface of the eye-ball and its base touched with nitrate of silver. About half a drachm of blood was lost when cutting it off. It grew from the corneo-sclerotic junction, by a broad pedicle. The patient was discharged cured on 5th February, only a white spot remaining at the corneo-sclerotic junction. I saw There were 110 signs him again on 9th March. of recurrence up to that date. Remarks.?This was a rather curious case. I had never seen a similar tumour, and could find no mention of a tumour of the kind in any of any books, either of surgery or of ophthalmology. It showed 110 appearance of malignancy, but apparently had recurred once after removal. The former removal, however, may have been not free enough. Case No. 10. Necrosis of clavicle.?Grurubhanjan, Musalman male, 9 years, of Manihnri,
bably
an
angiomatous
Purnia,
was brought to Motihari dispensary on February 1891, with a siuus over the inner end of the lett clavicle. Under chloroform, three
3rd
39
/
INDIAN MEDICAL GAZETTE.
298
[Oct.
1892.
of dead bone, eacli over an inch long, to Brigade-Surgeon (now Surgeon-Colonel) J. Gr. removed. He left hospital on 8th Febru- Pilcher, the then Civil Surgeon of Darjeeling, for leave to operate on this case ; also for the ary. On 21st February he was brought.back to the operation. again, with an abscess over the middle of the patient's history subsequent left clavicle, on opening which bare bone was I left Darjeeling the next day, aud so only saw felt. On the same day, under chloroform, an the patient once after the operation on the incision was made from the sternoclavicular following morning. D articulation outwards, and the whole clavicle, be continued.) To ( all of which was necrosed, was with some difficulty manipulated out with the fingers. A drainage tube was inserted along the whole length of the bone, and. the wound stitched and dressed. His temperature rose in the evening to 105 ; it remained high until the 24th, and there was an evening rise up till the 28th, on which He was again brought he was taken home. day back for inspection on 14th March. The wound He had was now a narrow superficial ulcer. in shoulder the of motion every joint perfect direction, and a strong grip with the hand. On 18th March seven skin grafts were applied, and He did not return again. he was taken home. Remarks.?Though the cure was not quite complete when he was last seen, an ulcer still remaining, I think there is no doubt that this case resulted in a perfect cure. Indeed, as far as the mobility and strength of the affected limb go, the cure was complete when he left hospital for the second time. Case No. 11. Wound of perinatum with perineal fistula.?Chotu Lai IJpadhia, Hindu male, 13 years, of Elam, Nipal, was gored in the perinasum by a bull in August 1888, the injury being followed by suppuration and perineal fistula. On 17th November 1888 he was admitted to Darjeeling dispensary, with a fistula, rather to the left of the middle line, 1^ iuches in front of anus. A small catheter could be passed through this fistula into the bladder. A catheter could be passed down the urethra, as far as the perinteum, within an inch of the fistula, but rather to the right of the middle line. On 21st November 1888, the following operation was performed under chloroform. The meatus was incised, a staff passed down the urethra into the perinaeum, and an incision Thence the incision was prolonged made on it. backwards into the urethra behind the fistula. A soft catheter was passed into the bladder and tied in. The new wound was stitched up, but the The bladder was washed old fistula left open. out through the catheter, which was kept in for three days. Afterwards the urethra, during the of the case, was gradually course subsequent dilated up to No. 12. Urine came through the penis for the first time on 1st January 1889, and the whole of the urine was passed through the penis for the first time on 31st January. He was discharged cured, with the fistula quite healed, on 18th February 1889. Remarks.?This case was more successful than I ventured to hope when I first saw it, the i result being exceedingly good. I am indebted 1
fragments were
O
?
CRAWFORD, m.b., i.m.s., Surgeon, Saran. The cases which aie the subject of the following notes, have been operated upon in stations widely scattered over the whole province of Civil
Bengal, Mymensingh, Champarun, Bakerganj, Darjeeling, Midnapur, Puruia, and Saran.
The first series comprises several cases of for large malignant tumours, epithelioma of the lower jaw (two); of the tongue and floor of the mouth ; of the eye-ball; of the penis (two); and one of melanotic sarcoma of the orbit. Of the seven cases, two died within 24 hours, aud the other five recovered for the time being, though one at least died some nine months later, probably of recurrence of the growth. In the Indian Medical Gazette for March 1887 I published notes of some similar operations for malignant tumours, viz., two cases of excision of the upper jaw for sarcoma, and one of excision of the One of the two former rectum for epithelioma. cases died, also within 24 hours ; the other two recovered. In my small experience of operations for large malignant, tumours, all cases which have not died within the first 24 hours, chiefly from shock, have recovered for the time being. The next two cases are those of tumours, not important in themselves, but somewhat singular Then follow a case of removal of in character. the whole clavicle, aud one of repair of a perineal fistula. The next are five cases of stone, a selection from a number of cases of lithotomy (as well as a few of litholapaxy)} which I have performed. The first two are given simply as a contrast, both in the manner in which the operation was performed, and in its result. Each of the other three cases is distinguished by some peculiarity. In two at least of the five cases litliolapaxy would have been a better operation, but in neither case were the crushing instruments availFew charitable dispensaries in the provable. ince possess these instruments. Out of seven districts in which I have served, Chapra dispensary is the only hospital in which I have seen a set of litliolapaxy instruments, and here they have only been procured a few months ago. Indeed, there are few dispensaries which can afford to a set of these pay the very high price which All or nearly all hospitals instruments costs. could profitably expend much more money than can possibly be found for their maintenance. And while this is the case, and while stone is not a common disease in most parts of the province, such money as can be budgeted for the support
operation
Oct.
CRAWFORD'S NOTES ON SOME SURGICAL CASES.
1892.]
be laid out in other ways with greater benefit greater number of patients. This of course is not to disparage the operation of litholapaxy. It is now an accepted fact that in most cases of stone in the bladder it is a better operation than lithotomy. But considering the cost of the instruments, and the liability of the aspirator bag to get out of order in the damp climate of Bengal, most hospitals in this province simply cannot afford to purchase them. The last three cases of elephantiasis of the genitals, are also a selection from a much larger number of cases, which are peculiar, in that in all three the penis was the chief seat of the disease ; the scrotum, contrary to what we commonly see, being little affected. Cass No. 1.?Melanotic sarcoma of orbit.?? Maghu Shaikh, Musalman male child, aged 2|years, of Gargha, Mymensingh thana, was brought to Mymensingh dispensary on 8th June 1887, suffering from a melanotic sarcoma of the right orbit, said to have been of two months' growth. The tumour protruding from the orbit a was sloughy fungating mass about the size of a large orange, or about one-fourth the size of the child's head, which bled copiously when At the urgent request of the parents handled. the tumour was removed. First a ligature was slipped round it, and pressed down to as near its base as the fingers could reach; it was then drawn tight, and the tumour was cut off above The base of the tumour was then it. gradually separated from the eye-lids and the walls of the orbit, as well as from the orbital fissure. It appeared to be completely removed, but it is probable that its remotest roots came from inside the skull, and were not got away. There was little bleediug. The orbit was plugged with lint, and a pad and bandage applied. The wound healed rapidly by granulation, and the boy was discharged "cured" on 18th June. Remarks.?Although to the sense of touch it appeared that the whole of the tumour had been removed, there is little doubt, I am afraid, that a tumour of this sort would almost certainly recur, and the prognosis as regards duration of life was extremely bad. It was worth while, however, to perform the operation, as it relieved the child of a prominent and iusightly tumour, which bled freely at the slightest touch, and might have proved immediately dangerous to life by hemorrhage. In this connection, it was remarkable that there was hardly any haemorrhage during the operation. There was of course an off-chance of a permanent cure. I left the station soon after, and heard no more of the case. There were no signs of recurrence before the patient left hospital. Case No. 2.?Epithelioma of tongue and floor of mouth.? Sharupullah, Musalman male, aged 35, of Jhalukati, came to Barisal dispensary on 9th March 1889. He said that he had first of
a
hospital,
can
to a
Xj
j
I noticed
295
in the right submaxillary reand six mouths before, gion previously had noticed a lump ou the right side of the tongue. His present condition was as follows : a
a
tumour
year
There was an epitheliomatous tumour, involving the right submaxillary gland, which was as large as a small lemon, the right side of the
floor of the mouth, and the anterior half of the right side of the tongue. It had not yet becrun to ulcerate. On the following day the tumour was removed. A gag was inserted, much trouble being given by spasmodic closure of the jaws, a thread was even when under chloroform, and put through the tongue, by which it was drawn outside the mouth. The tongue was split down the middle, and the anterior half of the right side was ligatured and cut off behind the tumour. The glaud and right side of the right floor of the mouth were removed through a subinches long. The margins mental incision, of the excised parts of the tongue and of the floor of the mouth were quite soft and free from disease. There was considerable hemorrhage, about 16 oz. of blood, by guess, being lost. The wound was sprinkled with iodoform, and strips of lint inserted into it. At 4 P. M., some six hours after the operation, the patient got up and tried to leave the ward iu a semi-delirious state. The pulse was then about 150, and very thready. He never thoroughly recovered from the operation, and died the next mortiincr at 7-30 A. m. Remarks.?Considering the extent of the disease, it would perhaps have been wiser to have left this case aloue. The fact that ulceration had not yet begun, however, encouraged me to hope that the tumoitr might be successfully removed. The dispensary did not possess an ecraseur, with which the operation might have been carried out with less hasmorrhage. Death was probably due partly to shock and partly to haemorrhage. There was no bleeding, except some ooziug, small in quantity, after the operation had been completed. The result of course must have been fatal before very long, if the tumour had not been touched. Case No. 3.?Epithelioma of lower jaiv.? G-obindo, Hindu female, aged 40. of Muradia, Backerganj thana, came to Barisal dispensary on 3rd May 1889, suffering from an epithelioma of the left lower jaw, which extended from the second bicuspid tooth to the angle of the jaw, much of which was absorbed, and also implicated the internal surface of the left cheek. She was unable to give the duration of the disThe tumour was removed the same ease. day. An incision was made, beginning over the condyle of the jaw, passing under its angle, then forward, and up over the chin to a point half an inch above the tip of the chin. The symphysis was sawn through, and the condyle disarticulated by twisting, in which process the
"submaxillary
\)
296
INDIAN MEDICAL GAZETTE.
internal
\J
maxillary artery ligatured. The gap
gave way, and was at was stuffed with carbolized lint, and the edges of the incision stitched. On the 4th, 5th, and 6th May her temperature fluctuated between 99 and 101*6; after the 6th it never rose above normal. The two ends of the incision healed by first intention, She but the middle third failed to uuite. swallowed milk the day after the operation, and on the 14th May took solid food. On 15th May the portion of the wound still unShe abhealed was clean and doing well. sconded during the following night. Remarks.?This case was unsatisfactory, in that the patient left the hospital before the cure was complete. The unhealed wound could procured by a small plastic operahave been bably tion, but the patient departed suddenly, without She any previous intimation of her intentions. of the result the with satisfied operaappeared There was considerable probability of tion. recurrence, but in the meantime she had been relieved of a malignant tumour. I never heard of the case again. Case No. 4.?Epithelioma of eye-ball.?Sursuni, Hindu female child, aged 8 years, of Purnia, was brought to the Purnia dispensary on 11th March 1890, with the following historv. She had suffered for a year past from hemicrania and blindness of the right eye, which had been ulcerating for about a month past. The right orbit was entirely occupied by a fungating epitheliomatous tumour, the size of a lemon, protruding from the orbit, and widely separating the eye-lids, not adherent, but freely moveable by the ocular muscles, in concert with the left eye. The tumour was at once removed under chloroform, the whole of the eve-ball being excised. Its posterior surface appeared healthy. The wound healed by granulation, and the patient was discharged "cured"on 29th March 1890. On 23rd May the same patient was brought back again with a tumour, the size of a lemon, springing from the left orbit. I at first supposed it to be a recurrence of the epithelioma previously removed, but on removal, which was done at once under chloroform, it was found to be a sebaceous cyst, growing from a fatty base, with no sign of malignancy. She had slight fever, the highest temperature being 101 for two days, after which it remained normal. The wound granulated healthily, and she was again discharged "cured" on 8th June 1890. In December 1890, I made enquiries about the child, and was informed that it had recently died of " fever and pain in the eye." Remarks.?This case was curious, the excision of a malignant tumour in one orbit being followed so soon by the growth of an apparently non-malignant tumour of the other orbit. From the very vague after-history, I should suppose
once
that
[Oct.
1892.
third tumour, malignant again, had apin one of the orbits. It was unfortunate that the case was not again brought for examination, if not for treatment. I saw a somewhat similar case in Purnia in 1891, when a female child of three or four years old was brought with an ulcerating epitheliomatous tumour of one eye, great bulging of the second eye, and a large flat epithelioma, covering almost the whole of the front of the right forearm, and implicating both radius and ulna. Of course nothing could be done for such a case ; extirpation of one eye-ball and amputation of one arm would have been necessary at once, followed probably by extirpation of the other eye-ball, and still further recurrence later on. Case No. 5.?Epithelioma of penis.?Dhoni Lai, Hindu male, aged 40, of Malora, Purnia, Purnia dispensary on 14th December came to 1891, with epithelioma of the penis, said to be of two years' standing. He had presented himself for treatment at least ouce before at the disThe pensary, but had then declined operation. same day amputation of the penis was performed under chloroform, one inch below the glans. The urethra was separated, brought out through an incision in the middle line below the scrotum, The cut short, its end slit, and stitched there. were separated, ligatured, and cavernosa corpora The top of the penis was sewn up; a divided. silver S-shaped catheter tied into the bladder, and the wound dressed with a pad and T bandage. His temperature that evening was 101*3, and from the 15th to 18th December it fluctuOn the 18th an abscess, ated from 100 to 102. which had formed on the left side of the scrotum, was opened, the incision being continued into the lower wound. On the same day the ligatures from the ends of the corpora cavernosa came away. From the 19th December the temperature remained normal. On 28th January 1892 he the penis being healed, was cured, discharged and the lower wound represented by a small slit, which answered its purpose as an exit for urine. Remarks.?This was a simple case, the disease not being far advanced, in spite of its long duration. The only untoward event was the formation of a small abscess in the scrotum. Case No. 6.?Epithelioma of penis.?Jalim Ahir, Hindu male, 60 years, of Satwa, Baniapur, Sarun, came to Chapra dispensary on 22nd May 1892, with epithelioma of the penis, said The penis was conto be of a year's duration. verted into a cauliflower mass, rounded, and as large as a large orange, extending down to the pubes; there were two indistinct furrows round it, one at the root, the other apparently below the glans, though the glans could hardly be distinguished from the rest of the penis. On 24th May, under chloroform, the penis was amputated. The corpora cavernosa were ligatured together below the tumour, not being separable. a
peared
Oct.
1892.]
CRAWFORD'S NOTES ON SOME SURGICAL CASES.
was some difficulty in gettiug a sufficient stump for the ligatures to catch on below the disease. The urethra was separated and brought out through a buttonhole incision below the scrotum, to the edges of which it was stitched, and a gum elastic catheter was tied into the bladder. This catheter was withdrawn next day, urine passing freely alongside it, as well as through it. The temperature on the evening of the day of operation rose to 103, which gradually sank to normal by the 27th May. There was nothing noteworthy about the further progress of the case, except that some long strings of slough came away through the lower wound four days after the operation. The patient left hospital on 16th June practically cured, a small flat ulcer still remaining unhealed on the stump, whence the penis had been removed. Remarks.?This case was not so simple as the preceding one, the disease being much further advanced, in spite of its alleged shorter duration and consequently less easy to remove, as well as more likely to recur. In neither case were the inguinal glands at all affected. Case No. 7.?Epithelioma of lower lip and jaw.?Dwarka Tewari, Hindu male, 55 years, of Chapra, came to Chapra dispensary on 6th April 1892, with an epithelioma of the lower lip. The tumour, which was as large as a cricket ball and much ulcerated, sprang from the lower lip, somewhat to the right of the middle line, and had affected the body of the lower jaw on both The tumour was said to be of eight sides. months' duration, and caused great pain. On 9th April it was removed under chloroform, the body of the lower jaw being sawn through an The right inch in front of both the angles. submaxillary gland which was affected was also excised. The edges of the wound were brought together as far as possible. The patient never thoroughly recovered consciousness, and died of shock two hours after the completion of the operation. There had been very little bleeding during the operation. Remarks.?In this case the disease was very much advanced, in spite of its alleged comparatively short duration, and it would perhaps have been wiser to let it alone. Still, it was not beyond hope that operation might completely remove the disease, the pain suffered was great and the end necessarily fatal in any case, facts which were sufficient, I think, to
There
1
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the operation. Case No. 8.?Angioma of chin.?Babar Jan, Musalman male, of Sealganj, Kewari, came 10th September 1889, to Barisal dispensary on with a soft flabby, indistinctly lobulated tumour, covering the whole chin, from the lower lip downwards, and hanging down for about 1| inches below the point of the chin. This tuIt had mour, he said, had existed from birth. been cauterized over almost its whole surface,
justify
297
and the'skill was adherent to it throughout. To the touch it had the doughy consistence of an angioma, but no pulsation could be felt in it; and on thrusting a trocar into it, 110 blood It was removed, under chloroform, flowed. the same day, by an elliptical incision 011 eacli side, and was found to consist of very vascular fatty tissue. Next day there was great swelling of the lower lip, which had almost entirely subsided by the 14th September, when he absconded, the stitches being still in the wound. He returned on 29th September, with the wound healed up. There was then 110 sign of tumour hanging below the chin, but some swelling of the lower lip remained at the upper end of the incision. He expressed himself as satisfied with the result, aud declined further interference.
Remarks.?This rather curious
case was protumour, the vascularity of which had been for the most part destroyed by repeated cauterization. It is the only case of I v/ the kind which I have seen. Case No. 9.?Fibroma of eye.?Constable Bisendeo Sing, Hindu male, aged 25, of the Purnia Police, came to Purnia dispensary on 26th January 1892, complaining of a tumour on the right eye. He stated that the tumour had first appeared a year and-a-half previously as a small red spot, and had gradually grown to its present size. It had once been cut off by a native hakim, but had speedily grown again. It was now pyramidal in shape, soft, the base the size of a sixpence, aud about half au inch high. It was freely moveable, and covered the left half of the right cornea, and as much of the sclerotic to the inner side of the It appeared to be a fibroma. It was cornea. cut off with a cataract knife the same day under chloroform, the tumour being shaved off level with the surface of the eye-ball and its base touched with nitrate of silver. About half a drachm of blood was lost when cutting it off. It grew from the corneo-sclerotic junction, by a broad pedicle. The patient was discharged cured on 5th February, only a white spot remaining at the corneo-sclerotic junction. I saw There were 110 signs him again on 9th March. of recurrence up to that date. Remarks.?This was a rather curious case. I had never seen a similar tumour, and could find no mention of a tumour of the kind in any of any books, either of surgery or of ophthalmology. It showed 110 appearance of malignancy, but apparently had recurred once after removal. The former removal, however, may have been not free enough. Case No. 10. Necrosis of clavicle.?Grurubhanjan, Musalman male, 9 years, of Manihnri,
bably
an
angiomatous
Purnia,
was brought to Motihari dispensary on February 1891, with a siuus over the inner end of the lett clavicle. Under chloroform, three
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INDIAN MEDICAL GAZETTE.
298
[Oct.
1892.
of dead bone, eacli over an inch long, to Brigade-Surgeon (now Surgeon-Colonel) J. Gr. removed. He left hospital on 8th Febru- Pilcher, the then Civil Surgeon of Darjeeling, for leave to operate on this case ; also for the ary. On 21st February he was brought.back to the operation. again, with an abscess over the middle of the patient's history subsequent left clavicle, on opening which bare bone was I left Darjeeling the next day, aud so only saw felt. On the same day, under chloroform, an the patient once after the operation on the incision was made from the sternoclavicular following morning. D articulation outwards, and the whole clavicle, be continued.) To ( all of which was necrosed, was with some difficulty manipulated out with the fingers. A drainage tube was inserted along the whole length of the bone, and. the wound stitched and dressed. His temperature rose in the evening to 105 ; it remained high until the 24th, and there was an evening rise up till the 28th, on which He was again brought he was taken home. day back for inspection on 14th March. The wound He had was now a narrow superficial ulcer. in shoulder the of motion every joint perfect direction, and a strong grip with the hand. On 18th March seven skin grafts were applied, and He did not return again. he was taken home. Remarks.?Though the cure was not quite complete when he was last seen, an ulcer still remaining, I think there is no doubt that this case resulted in a perfect cure. Indeed, as far as the mobility and strength of the affected limb go, the cure was complete when he left hospital for the second time. Case No. 11. Wound of perinatum with perineal fistula.?Chotu Lai IJpadhia, Hindu male, 13 years, of Elam, Nipal, was gored in the perinasum by a bull in August 1888, the injury being followed by suppuration and perineal fistula. On 17th November 1888 he was admitted to Darjeeling dispensary, with a fistula, rather to the left of the middle line, 1^ iuches in front of anus. A small catheter could be passed through this fistula into the bladder. A catheter could be passed down the urethra, as far as the perinteum, within an inch of the fistula, but rather to the right of the middle line. On 21st November 1888, the following operation was performed under chloroform. The meatus was incised, a staff passed down the urethra into the perinaeum, and an incision Thence the incision was prolonged made on it. backwards into the urethra behind the fistula. A soft catheter was passed into the bladder and tied in. The new wound was stitched up, but the The bladder was washed old fistula left open. out through the catheter, which was kept in for three days. Afterwards the urethra, during the of the case, was gradually course subsequent dilated up to No. 12. Urine came through the penis for the first time on 1st January 1889, and the whole of the urine was passed through the penis for the first time on 31st January. He was discharged cured, with the fistula quite healed, on 18th February 1889. Remarks.?This case was more successful than I ventured to hope when I first saw it, the i result being exceedingly good. I am indebted 1
fragments were
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