darken the blood by altering the form of the corpuscles, and partially dissolving the colouring matter; and that hematozine is black only in mass, and red when powdered, or when viewed in a small portion by transmitted light. My own observations are to the same effect generally. I found, after Nasse, Scherer, and Mulder, that agents, as pure water and carbonic acid, which darken the blood, make the corpuscles tumid or globular, and that florid arterial blood soon became dark coloured when kept in a jar, and remarkably so when putrefaction began; and the form of the red corpuscles was more or less altered, when the true bright vermillion hue of arterial blood could no longer be restored in it either by oxygen or neutral salts. The effect, too, of these salts in fresh blood is always to separate the corpuscles, and render them slightly thinner, smaller, or more compact, which oxygen produces also in a less degree; nor could I find that either neutral salts, sugar, or oxygen, would strike a scarlet colour with pure and nearly black hematozine.

But the valuable observations of Dr. Wells, published in the Philosophical Transactions of 1797, and strangely neglected, notwithstanding Dr. Davy's notice of them in 1838, are so conclusive on this subject, that much discussion might have been spared had Wells' paper not been forgotten. He obtained the same results, as those just mentioned, as to the action of air and neutral salts not brightening the colour of pure hematozinethat nitre does not change the colour of a solution of hematozine, and proved by an ingenious experiment that the opacity of blood, and the reflection of light from it, are increased by neutral salts; and observed that these salts and air-of course the oxygen-affect the blood, just as bright vermillion is produced from dark cinnabar by subjecting it to minute mechanical division. Thus, then, the result is, that it is not simply to chemical agency, but either to changes in the form of the corpuscles, or to their more or less state of aggregation, so as to dispose them either to reflect or to absorb more or less light, that the effect of many substances on the colour of the blood is owing; and we have already specially stated how neutral salts and oxygen act in this respect. Nor can we dismiss the observations of this eminent man, made upwards of sixty years since, without remarking the grievous injustice to him and to English science, by our translators and commentators adopting the sorry claim of very recent German genius to "the discovery that everything relating to the colour of the blood does not pertain to chemistry!"

If you look again at the diagrams you will see that the red corpuscles, when highly magnified and viewed by transmitted light, appear of a pale straw colour, and that they are of a deep red hue only when seen in mass, and are, consequently, more or less opaque. The extension or diffusion of their surface, and of the light through them, under the microscope, are just what might be expected from a consideration of chromatic laws. Hematozine only appears black in mass; in small transparent portions and in powder it is red. Now, it is well known that the more concentrated the colouring matter the darker it is, and the more diffused or diluted, cæteris paribus the lighter it becomes. The more, also, the colour is mixed with white or reflected light, and the purer the white ground on which the colour is spread, so much the brighter is the effect. Indeed, the great masters of colouring of the Venetian school practised their consummate art on these beautifully simple principles. The colours they used were transparent, not black; and darkness or blackness were produced rather by a concentration of colour than by a direct use of any black pigment.

Uses of the Red Corpuscles.-And now, having shown the difference of colour, and the cause of modifications or even cessation of that difference, between arterial and venous bloodto what agent the effect is owing, and how it is produced, we are prepared to enter on a further consideration of the functions of the red corpuscles. In a former lecture it was mentioned, incidentally, that the red corpuscles vivify the blood, and through it the animal frame; and this mainly by means of their function as carriers of oxygen. We now propose to adduce such evidence as may be sufficient to support this proposition, which will lead us, among other interesting questions, to a consideration of that of the source of animal heat; into which difficult subject, however, it is only intended at present to enter as far as may concern the immediate agency of the red corpuscles in this important process, and by way of illustrating their use in the animal economy, reserving some details for the next lecture.

In the course of this inquiry we cannot fail to be impressed

with a strong sense of the vast importance of these corpuscles, small and insignificant as they might appear to the uninquiring mind; and that, so far from being only microscopic curiosities, as they were too often regarded about the time when my researches concerning them were commenced, they are, in the vertebrate sub kingdom, endowed with special functions, absolutely essential to the existence of the animal, from man downwards, throughout the whole classes, orders, and species, to one or more of the lowest fishes, as Amphioxus, where the necessity for the red corpuscles would appear to cease among Vertebrata. So that, without the red corpuscles we could neither live nor breathe, nor move, nor have our being; and even a slight change in their texture, or an alteration in their proportion relatively to the other proximate constituents of the blood, may be the cause of disease or death. And this consideration might suggest an inquiry as to what variation in this proportion may be consistent with health in the two sexes of the human species, and in the inferior animals; but our present purpose is not to treat of pathology. The red corpuscles would appear to be connected with nutrition, and with the maintenance of the action or excitability of parts. The muscles lose their power of motion when the current of arterial blood is cut off from them, as was long since observed by Stenson, and confirmed by subsequent experimenters. After tying the aorta or the iliac artery in dogs, I have frequently seen, as no doubt Sir Astley Cooper and others had done before, more or less paralysis of the hind limbs, which diminished as the collateral circulation became established; and this in cases where there was no sufficient injury of the nerves to account for the diminished power of motion. But until recently we had no demonstration of the manner in which the influence of the arterial blood is exerted. That the red corpuscles vivify the blood and the parts to which they are carried by virtue of the oxygen which they convey, has often been supposed, believed, or stated; but the proof, and that proof so legitimately carried out as to command the merit of discovery, is due to the researches of Dr. Brown-Séquard. Now, suppose either man or brute animal, dead and stiff, cold, the post-mortem rigidity so fully established that the muscles are no longer capable of being affected by any kind of stimulus previously known to affect them until they had become stiffened after death, such as mechanical, chemical, or galvanic action; in short, having lost all remains of vital endowment and returned to mere dead matter. Suppose, then, the discovery of an agent capable of so far reanimating this dead and stiff body-this stark cadaver -as to revive the muscles, restoring their flexibility and their susceptibility to stimuli, and it might seem that we were asking for the supposition of a modern miracle! Yet the red corpuscles, charged with oxygen, really constitute this marvellous agent; and we well know how in the living body they are incessantly supplied with oxygen from the atmospheric air during their circulation through the lungs, and how intimately this process is connected with the breathing function. Here is one of the experiments, to which these remarks are the prelude:-A mixture of red corpuscles and serum, charged with oxygen, was injected into the radial artery of a man, after cadaveric rigidity, when the injected blood, which, of course, had been made scarlet by the oxygen, returned blackened through the veins, while the irritability and flexibility of the muscles were restored! And that this wonderful effect was produced by the red corpuscles is fairly inferred from the facts, that no fibrin was injected, and that trials with serum alone produced only negative results. Nay, it was further found that the integrity of the red corpuscles is necessary to the success of the experiment, since corpuscles altered by incipient putrefaction or otherwise, will not carry the oxygen like the regular fresh corpuscles, as already described when treating of the colour of the blood.

And I may add, that the oxygen was carried alone by the red corpuscles may be as surely concluded from Dr. Davy's experiments, published many years since, from which it results that healthy serum, though capable of absorbing more than its own bulk of carbonic acid gas, is nearly, or quite, incapable of absorbing oxygen gas; and that venous blood will absorb more oxygen than arterial blood, as might be expected from the corpuscles of the arterial blood already containing oxygen, to be given out or enter into combinations according to the wants of the economy, before the conversion of the florid arterial blood into the dark venous blood. In his experiments, Dr. Davy used the same kind of apparatus as had before been employed by Dr.

Christison, the eminent chemist of Edinburgh, in a similar inquiry. Dr. Davy experimented on blood deprived of its fibrin, and he always found that, when the remaining mixture of red corpuscles and serum was agitated, either with atmospheric air or with pure oxygen gas, there was a marked diminution of the volume of air, most in venous, and least in arterial blood. The air which disappeared from absorption by the blood was oxygen only; and that this is absorbed simply by the red corpuscles is to be inferred from the very curious and important fact already mentioned, that serum is scarcely capable of absorbing this gas. When ten cubic inches of the venous blood of the sheep were agitated with common air, there was an absorption of one cubic inch of the air; and arterial blood, similarly treated, absorbed from 3 to 4 of a cubic inch. The venous blood, agitated with pure oxygen, absorbed 1.25 cubic inch. It is remarkable that there was no evolution of carbonic acid; but it might have been formed and held by the serum. We shall have to recur to these experiments in connexion with respiration. For the present they are merely cited as proofs that the red corpuscles, and not the serum or liquor sanguinous, are the absorbers and carriers of oxygen. It is no part of our purpose now to enter at length into an inquiry as to the potent agency of this element. We have simply to represent the great importance of the red corpuscles as the distributors of it throughout the animal frame, confining our attention to some of the most obvious effects of the oxygen thus dealt out wherever the red corpuscles of the arterial blood may penetrate. Nor can we, even thus limited, avoid being reminded of the mistake of our illustrious Hunter, in attaching such comparatively little importance to the red corpuscles. He seems, indeed, almost to have taken a dislike to them, a feeling in which he was followed by some other eminent physiologists.

Now, while the experiments already alluded to lead to the conclusion, that certain secretions are increased under the influence of blood charged with carbonic acid, and that the superoxygenation of the blood may diminish or suspend the secretions, the inference results that there can be no nutrition in vertebrates without a sufficiency of oxygen. It appears, also, that the properties which the blood possesses of nourishing or maintaining the vital properties of the tissues, of the nervous and contractile organs, and the special action of the brain, depend on the oxygen which the blood contains, in accordance with the old observations of Bichat. We have already seen that the red corpuscles are the agents by which this oxygen is taken up and distributed throughout the frame in vertebrate animals, and may well be lost in admiration of the immense import of these beautiful little organisms even in this point of view; while we can now understand the great value and interest of all well-directed research as to everything connected with their nature, and that these inquiries are, indeed, the reverse of mere curiosities. Why, to revert to the results of the experiments just cited, it would appear that the contractile tissues, the nervous tissues, and the brain, after having completely lost their vital properties or functions, recover them under the influence of the red corpuscles charged with oxygen. And, finally, that carbonic acid, so far from being all a mere useless or excrementitious substance, has a favourable influence on the formation of certain secretions; with the further conclusion, that certain contractile tissues of Vertebrata may be stimulated or excited by blood charged with this acid.

ORIGINAL COMMUNICATIONS.

A CASE OF CANCER OF THE THROAT,

INVOLVING BOTH WIND-PIPE AND ESOPHAGUS-TRACHEOTOMY

-DEATH AFTER FIVE MONTHS.

By CHRISTOPHER HEATH, F.R.C.S., Assistant-Surgeon to, and Lecturer on Anatomy at, the Westminster Hospital.

THE following case is, I think, worthy of record as an example of complicated disease, in which the patient was rescued from immediately impending death by the operation of tracheotomy accomplished under great difficulties, and survived the operation in comparative comfort for five months :

In December, 1861, Mrs. S., aged 60, the widow of a

On December 10, 1861, I was summoned, as the dyspnoea had become urgent, and met Mr. Musgrave, of the Finchleyroad, who had been called in. I found her breathing ten per minute with great difficulty, with feeble pulse, and cold skin. We agreed that an operation would be necessary in all probability, but determined to try the effect of administering stimulants for an hour. No improvement taking place, and Dr. Johnson concurring, I proceeded, at nine p.m., to perform laryngotomy, so as to avoid interference with the enlarged thyroid. Having made an incision over the crico. thyroid space, I found a portion of the enlarged thyroid overlying the larynx, and just at the spot was a portion with several large veins distinctly visible, and I was, therefore, obliged to resort to tracheotomy. I prolonged the incision to the sternum, and found an immense dense mass of tissue, apparently altered gland (qy. scirrhus), overlying the trachea. Having dissected through this, I thought I felt the rings of the trachea (in which Dr. Johnson agreed), and cut into it, but found it still to be the same dense tissue. I then cut deeper with the same deceptive sensation, but without discovering the wind-pipe. Having cut to the depth of nearly two inches without any sign of trachea, and, under the peculiar circumstances of the patient being particularly anxious as to the result, I suggested that Mr. Fergusson should be consulted before proceeding further. The hæmorrhage was only slight, and was arrested by pressure. Mr. Fergusson arrived in an hour; and, upon putting his finger into the wound, thought, as I had done, that he felt the trachea, and attempted to introduce a tube, but failed. He then cut very freely for some time without result, but, at last, some air escaped, showing that the trachea was reached. Mr. Fergusson had great difficulty in again finding this orifice, but, at last, got the handle of the scalpel into it, and enlarged the orifice downwards with a bistoury, and was then able to introduce a very long tracheotomy tube, which he had fortunately brought with him. The incision was about three inches deep. The patient could not bear the introduction of the inner tube, but breathed pretty comfortably through the divided external one. She coughed up a quantity of viscid, bloody sputum, but got some sleep after the operation. The patient was pretty comfortable next morning. She was only able to take small quantities of food at a time, owing, apparently, to the presence of the tracheotomy tube.

12th.-Much better altogether. I changed the tube, introducing one of a different angle, which permitted the introduction of the inner tube, and did not prevent her swallowing. The wound is beginning to suppurate.

14th. The patient is able to take solid food. No medicine given, but wine at short intervals. There is but little expectoration, and that quite clear. Dr. Johnson examined the chest, and found the lungs quite clear.

From this time to March 16, 1862, Mrs. S.'s condition was very satisfactory. The enlargement in the neck diminished slightly, but continued to be of stony hardness, and the glands under the sterno-mastoid became enlarged and very hard. Some difficulty was caused by the contraction of the wound, and, on one occasion, I enlarged the internal orifice slightly with a curved bistoury. To obviate the difficulty caused by the granulations finding their way into the outer tube, I had an old-fashioned double tube made with no split in the external portion, and this proved quite satisfactory. The patient's general health was pretty good, and she was up every day, and went out once for a drive. A slight difficulty of swallowing had occurred on two or three occasions; and she found, during February, that she was obliged to be careful, in swallowing, to take as much fluid as possible, and to take plenty of time. No air whatever passes through the larynx.

From March 10 to 16 there was a good deal of difficulty of respiration, due apparently to some pressure against the tube, for by tilting the lower end slightly backwards it was immediately relieved. This difficulty I attempted to remedy by altering the curve of the tube, without much effect; and the attendant found that most relief was given by passing a piece

of whalebone down the tube, so as to alter slightly its direction.

On March 16 it was noticed that some of the breakfast passed through the tracheotomy tube, giving rise to severe cough, which was also excited by swallowing the saliva. I was out of town, but saw the patient the next morning, and tried to pass a tube down the esophagus, but failed. I succeeded, however, with a No. 10 elastic catheter, through which she was fed by means of an India-rubber bottle. was ordered to spit out the saliva, as it invariably gave rise to cough when swallowed. The attendant to feed with the tube four times a-day.

She

March 23. Mrs. S. has decidedly lost ground during the week, and has lost heart too. The nurse manages the feeding with the catheter very well.

April 1.-A decided improvement in the general appearance. Was able to drive out for an hour yesterday. Feeding

continued as before.

12th. The difficulty in passing the tube down the cesophagus has increased, and a larger quantity comes through the tracheotomy tube at each feeding. Each feeding produces a violent paroxysm of coughing, which distresses her much. I ordered a tube to be made of the size of No. 10 catheter, but as long as the stomach tube in ordinary use, in hope that, by passing the fluid further on, it might not be vomited again.

17th. I had a note to say that the patient was suffering so much at each time of feeding, that on the previous day Mr. Musgrave recommended that it should be abandoned, and that food should be administered per rectum. I went to see her, taking with me a small rectum tube, as the long catheter was not ready. I passed the rectum tube for a short distance down the œsophagus without difficulty, but then found an obstruction, through which the tube passed with difficulty, giving rise immediately to violent coughing, air being drawn freely in and out of the tube. I ventured to push the tube a little further on, in hopes that, if it were in the oesophagus, it might go beyond the opening in the trachea, but was obliged to withdraw it, as it nearly suffocated the patient, having, I believe, passed into the trachea. I believe, therefore, that the oesophagus is nearly or entirely obstructed by the cancerous growth, and that a large opening exists between it and the trachea, through which the food has for the last few days either found its way directly, or perhaps a very small quantity having passed into the stomach, has afterwards been vomited, and has thus got into the trachea.

19th.-Having procured the long catheter I made another attempt with precisely the same results, and, therefore, gave them up for the future. Mrs. S. has nourishment administered per rectum every four hours, and is relieved at not having to undergo the painful operation of feeding.

26th.-IIas decidedly lost ground since the last report. Is troubled with occasional efforts at vomiting, though, of course, nothing comes up. Within the last two days the left arm has become somewhat swollen and edematous, and, I find, that there a few large glands in the left axilla.

May 3.-Condition much the same; but the patient is weaker, and has constant sickness, and brings up bile through the tracheotomy tube. Face slightly puffed.

12th.-Lying in an unconscious condition. 13th. Mrs. S. died quietly at 6 a.m.

On

Post-mortem Examination.-I removed the tongue, larynx, œsophagus, and enlarged glands in the neck, en masse. laying open the esophagus from behind I found that it was completely obstructed by the thick edges of an ulcer, of malignant appearance, in the centre of which was a large aperture, opening directly into the trachea, opposite the wound made in the operation. Several rings of the trachea were gone at this point; and, in fact, there was one large cloaca at this spot. In the larynx on the left side was a growth of soft cancer, completely blocking the passage, and, no doubt, this was the original cause of the dyspnoea. The cricoid and thyroid cartilages were necrosed, a large portion of the former being wanting, and the latter being broken in half. The thickened tissue in front of the trachea seemed to have almost entirely disappeared; but there was a mass of cancer on the left side of the neck, through which the vessels and nerves ran, and with which the muscles were inseparably involved, but this did not seem to have exercised pressure in the trachea. The thyroid gland was a little enlarged on the right side, but could not be defined on the left.

There can be no question, I think, that the primary disease

and cause of the dyspnoea was the growth in the larynx; and had the laryngoscope been as much in vogue then as it is now, it is probable that this might have been discovered. Even then, however, I do not see that any other treatment than that adopted could have been pursued, since it would have been impossible to have interfered with the growth from the mouth. The difficulties encountered in the operation of tracheotomy were such as will be seldom met with, for even Mr. Fergusson, with his immense experience, had never met with a parallel case. It may be questioned whether the opening into the œsophagus was not the result of the irritation and pressure of the tracheotomy tube, since several cases have been recorded of this nature; but I am inclined to believe that in this case the disease commenced in the esophagus and eat through into the trachea, on account of the difficulty of swallowing, noticed prior to the formation of the opening, and also on account of the disease found in that viscus. What the tissue was which caused the extreme difficulty in the operation of tracheotomy must remain undecided, as the growth had almost entirely disappeared (no doubt partly by suppuration) at the time of death, five months after the operation, at the date of which it presented every appearance of scirrhus. Mr. Bryant, of Guy's Hospital, has recorded a case (Clinical Surgery, Part II.) in which a tumour in a similar position, and necessitating tracheotomy, entirely disappeared after the operation.

31, Sackville-street, W.

CLINICAL MIDWIFERY.

By FRANCIS H. RAMSBOTHAM, M.D. Physician-Accoucheur to the London Hospital, etc.

(Continued from page 508.)

THE following seven cases of transverse presentation occurred in my practice during the years 1843 and 1844:—

Left Shoulder Presentation.

Case 166.-On February 24, 1843, at 2:30 p.m. I was sent for by one of the midwives of the Royal Maternity Charity, to Mrs. J, Spitalfields, in labour of her fourth child. With her first child the head presented; the second and third had been transverse cases. I found that the membranes broke at 12 noon, and that just before I was sent for the hand appeared externally. The left shoulder was occupying the pelvic brim, the arm down, the palm of the hand was looking forwards, and the head was resting on the left ilium. There had been scarcely any uterine action since the liquor amnii was discharged. I introduced my left hand without difficulty into the uterus, hooked my finger in the left ham, turned, and extracted the child easily. It was living. The placenta was expelled speedily, and she recovered well.

Transverse Presentation.

Case 167.-On September 2, 1843, at 9:30 a.m., I was sent for by a Medical friend to Mrs. T., Limehouse, in labour of her second child; the first was born nine years ago. The membranes broke at 7 o'clock the evening before, previously to which my friend "could not feel any presentation." After that the uterus remained passive for three or four hours, and then began to act vigorously, when the right hand came down into the pelvis. Being foiled in his attempts to turn, he sent for a neighbouring Practitioner, who also failed; and then a third was summoned, who was as unsuccessful as the other two. Throughout the night I understood that many abortive efforts at delivery were made. When I arrived, the patient, her husband, and two sisters all declared that nothing more should be done, but that she should be allowed to die in peace; however, after reasoning a little with them, I was permitted to make an examination. I found the right hand external, much swollen, and livid, the palm looking forwards, the head resting above the right ilium, and the edge of the right scapula presenting very high at the pelvic brim. The left hand and forearm were also in the pelvis at the posterior part; and the left foot, with the noose of a tape around it, and the ankle joint severed, was at the brim towards the left ilium. The uterus was very strongly contracted round the child's body, and the vagina and external parts were acutely tender. The conjugate diameter of the pelvis at the brim measured but little over three inches. I was told the first labour had been easy; but it is quite

bottle to the feet. Two or three efforts at retching afterwards took place, and he once or twice vomited food, mucus, and a small quantity of blood. Warmth gradually returned to the surface, and the pulse became somewhat better in volume and power. Brandy was given at short intervals, and after about an hour a second dose of æther and ammonia, which was retained. The patient then fell asleep, slept for about a quarter of an hour, and awoke with the expression, "I am all right now," and appeared comparatively well. There was no diarrhoea throughout. He had two or three times a slight return of the symptoms; did not sleep during the night, but was quite easy; and the next morning only felt the discomfort arising from the mustard poultice and the soreness of the muscles caused by the retching. He then gave us the following account of his feelings during the attack:

"Before taking the dose of the tincture, I had consulted Pereira, and, finding Dr. Mead's dose of the Tinct. helleb. nig. to be two teaspoonfuls twice a-day, and knowing the green hellebore to be of the same tribe, I considered, in taking one teaspoonful, I was rather under than overdoing it. The drachm of the tincture was taken about half past four or a quarter to five o'clock p.m., and my stomach soon afterwards whispered that I had admitted a troublesome guest. I went upstairs and sat down, thinking a cup of tea would set all right; but the uneasy constriction of the stomach continuing, with a tendency to sickness, made me retire to the water-closet. The sickness, once commencing, soon became alarmingly violent, with the most excruciating pain in the lower part of the stomach, the pain extending to about the size of my hand; the feeling of the seat of the pain was, that all the warm tea, water, etc., that I took to provoke the vomiting, went under the pain, making the constriction more and more violent. Finding the case getting desperate, I sent off for Medical aid; the pain continued to increase, and the ejection from the stomach was now glairy mucus with blood, with running from the nose and eyes. The most painful and profuse cold sweating now came on, and the difficulty of breathing became more and more laboured. I could not help wondering at the presence of anything like heat or constriction of the throat; my mind was perfectly calm; and, although I thought it more than probable that I should die, I did not feel alarmed. Hearing and recognising the voice of one of my Medical friends is all I recollected for some time afterwards. Immense circles of green colour appeared round the candle, which, as vertigo came on, and I closed my eyes, turned to red. The pain continued excruciatingly at the pit. of the stomach, and a slight tendency to cramp existed when my legs were touched. It was some hour or more afterwards when I awoke, and found myself comparatively well. The sting of the mustard I can well recollect, and the horror of being forced to swallow brandy is even now with me. My bowels were not at all acted on. The next morning I took a dose of citrate of magnesia, and, in the evening, a blue pill, with colocynth, which relieved my bowels this morning."

Veratrum viride does not appear to have been much used in this country; but, in America, a pamphlet has been published, on its employment, by Dr. Ephraim Cutter, of Woburn, Mass.; and several articles have appeared in the Medical journals respecting it. It is also described in the last edition of Pereira's Materia Medica," where the symptoms from an overdose are stated to be precisely those observed in our patient. No authenticated case of poisoning by it has been recorded. The full dose of the tincture is eight minims.

WHALE STEAKS.-In passing along the street we saw strips of whale-flesh, black and reddish-coloured, hanging outside the gable of almost every house to dry, just as we have seen herrings in fishing-villages on our own coasts. When a shoal of whales is driven ashore by the boatmen, there are great rejoicings among the islanders, whose faces, we were told, actually shine for weeks after this, their season of feasting. What cannot be eaten at the time is dried for future use. Boiled or roasted it is nutritious, and not very unpalatable. The dried flesh which I tasted resembled tough beef, with a flavour of venison. Being "blood-meat," I would not have known it to be from the sea; and have been told that, when fresh and properly cooked, tender steaks from a young whale can scarcely be distinguished from beef-steak. -Pen and Pencil Sketches of Faroe and Iceland. By A. J. Symington. Longmans, 1862.

REPORTS OF HOSPITAL PRACTICE

IN

MEDICINE AND SURGERY.

CONDUCTED BY

JONATHAN HUTCHINSON,

Assistant-Surgeon to the London Hospital, and Surgeon to the Metropolitan Free Hospital,

AND BY

J. HUGHLINGS JACKSON, M.D., Physician to the Metropolitan Free Hospital.

ST. BARTHOLOMEW'S HOSPITAL.

CLINICAL REMARKS ON A CASE IN WHICH PART OF THE SCAPULA WAS REMOVED FOR MALIGNANT DISEASE.

(Case under the care of Mr. PAGEF)

IN this journal for November 15 we gave a brief note of Mr. Paget's operation for removal of a malignant tumour of the scapula, and also a report of the remarks he then made. In his next clinical lecture, Mr. Paget spoke more at length on the case. The following is a brief report of the lecture: He began by saying that, in a case like this, the whole interest before the operation lay in the diagnosis as to the nature and position of the tumour. In this case the situation of the tumour would help also to show its nature.

First, as regards the situation. It was clear that it covered nearly the whole of the infra-spinous region of the scapula. The first point to decide was, as to whether it affected the under surface of the bone as well as the upper. As the scapula was not projected from the chest wall, it seemed that the under surface was free. In cancer of bone, both sides are generally affected, and hence the fact, that in this case one side only was affected, was evidence against malignancy. It was not very important, but still it was some evidence, and might help to lead astray in diagnosis. Having thus decided that the tumour was on the upper side, the next question was, does the tumour grow from the bone? On this point there were differences of opinion. The scapula is naturally so movable that it is difficult to tell when a tumour is fixed to it or not. Mr. Paget believed that it grew from the bone. Another question was, as to the position of the tumour as regards the muscles. There was a means (Mr. Paget said) of ascertaining generally whether tumours were above or under muscles. It was this: to fix the parts which the muscles in question act on, and then direct the patient to endeavour to perform the resisted movement. The muscular action, if the muscles were under the tumour, would elevate it; on the contrary, if above, they would depress it. A peculiar sensation also was given to the hand, which was to be learned in practice, and was difficult to explain. This was only felt when the muscle was superficial, not when under the tumour. The same method would guide us in diagnosing the position, in reference to muscles, of fluid as well as solid tumours.

In this case, then, Mr. Paget came to the conclusion that the tumour was seated under the muscles, that it was fixed to the scapula, and that it did not affect both sides of the bone.

As to the nature of the tumour, it might be either fibrous, recurrent fibroid, cartilaginous, myeloid, or medullary. It might also be a deep-seated abscess, or hydatid. First, was it fluid or solid? The feeling of indistinct fluctuation was no sign at all that it was fluid. In the case of a small abscess the fluctuation might be indistinct, but in one so large as this, if fluid were present, the fluctuation would be distinct.

Another kind of fluid swelling was often taken for a solid one, viz., hydatid. We ought always to be on the alert for this, especially in tumours of bone. Hydatids may distend bone, so that their covering becomes so thin that the feeling may be quite that of a medullary tumour. Indeed, in such cases, it is wise to proceed in the operation on the supposition that it may be hydatid. As to the list of solid tumours, Mr. Paget said that he did not know from touch any characters by which medullary tumours could be certainly distinguished from the others, as even the cartilaginous tumours were sometimes soft.

The chief points in diagnosis of its nature are-1st, the position. A considerable proportion of tumours of the scapula are medullary. 2nd, the age of the patient. majority of large tumours in persons so young are medullary.

A