UNIVERSITY COLLEGE HOSPITAL. Cases of Nœvus, with a new mode of applying the Ligature to particular forms of these growths

Mr. Erichsen
1851 The Lancet  
31 yielding contraction; in fact, the urethra appeared to be obliterated. It was now resolved to make a passage to the bladder, of sufficient size to admit a full-sized catheter, if possible. With the assistance of my friends, Messrs. Pearce and Gibb, I performed the operation on the 13th of March, eleven days after the first operation. He was placed in the position for lithotomy, and, after having been rendered insensible by chloroform, a catheter was introduced as far as the bulb of the
more » ... e bulb of the urethra, and an incision made down to the point of the instrument ; with the aid of a director and the catheter, gradually advanced, the incision was carried to the prostate gland, where the instrument came in contact with another calculus, which occupied almost the whole of the prostate. An incision was then carried through the lower part of the prostate, and'a stone about the size of a large filbert-nut extracted, and the catheter now glided into the bladder. From this time the man has gone on well; the catheter was at first allowed to remain in about a week, but it is now only introduced occasionally for a few hours in the day. The external wound is almost healed, and very little urine flows from it. April 8th.-The urine flows in a full stream from the urethra, and the man's general health is better than it has been for several months. This operation may be considered as a modification of that advocated by Professor Syme, for the cure of stricture. With the learned Professor, it is a sine quc2 non that a grooved staff be passed into the bladder. In this case, all efforts of myself and friends to pass an instrument proved fruitless. Probably Professor Syme might have succeeded, as he scarcely admits having failed to pass an instrument in every case that has <come under his care. Cases of Nœvus, with a new mode of applying the Ligature to particular forms of these growths. (Under the care of Mr. ERICHSEN.) Nulla est aHa pro certo noscendi via, nisi quam plurimas et morborum, et I dissectionum historias, turn aliorum proprias, collectas habere et interse compa.rare.—MoncAGKi. De Sed. et Caus. Morb., lib. 14. Prooemium. I IT will be allowed by all those who have paid attention to the improvements introduced within the last ten years in the ' , treatment of nsevus, that a considerable amount of ingenuity ' , has been evinced by several of our hospital surgeons. We ' , see a great many operations for the removal of these vascular ' tumours, and have witnessed different modes of applying the ligature to them. These methods we have duly recorded in ' , former "Mirrors," (THE LANCET, Feb. 9, 7850, p. 186; Feb. 23, 1850, p. 246; Oct. 12, 1850, p. 421;) and by perusing these descriptions, our readers have certainly become convinced that considerable strides have been made in the treatment of tlaevi. The variety affecting merely the capillaries of the integuments is not generally interfered with; that principally situated in the areolar tissue, and presenting an unelevated appearance, is often treated by potassa fusa, (see below.) But the ligature, the arrest of vascular supply, or attempts at a change of structure, is brought to bear upon that variety which is composed of dilated bloodvessels, raised above the surface, either pulsating or not. As to the deligation of the tumour itself, we beg to record the following cases, which illustrate the latest views of Mr. Erichsen upon the subject. ' CASE 1. N aeVU8 of the anterior fontanelle. -A child, six months old, strong and healthy, was admitted, under the care of Mr. Erichsen, Nov. 1850, with a naevus on the anterior fontanelle. The tumour is almost as large as a pigeon's egg; it occupies the whole of the fontanelle, extending over the osseous boundaries of this space on the left side. The heaving of the brain can be distinctly felt underneath it; there is no pulsation in the tumour, but several large veins are seen running from it on each side. The mother states that she noticed the discoloration of the skin shortly after birth; it increased rapidly since that period, and almost visibly during the last fortnight. Mr. Erichsen resolved to use the ligature, seeing the size and prominence of the growth; but the difficulty in the application of this means consisted in passing the threads across the base of the tumour without wounding the membranes of the brain, which lay in immediate contact with it. This difficulty Mr. Erichsen overcame by using a blunt-eyed probe to convey the threads, instead of the common naevus needle. A puncture was therefore made about an eighth of an inch above the tumour, and an eyed probe, conveying the whipcord, was pushed across the base of the mass. Mr. Erichsen then cut down upon its point when it projected below the tumour, and then drew it across; the transverse threads having been carried through in a similar manner; the knots were tied in the usual way, and the mass firmly and effectually strangulated: the child, having been under the influence of chloroform, suffered no pain. The threads and sloughing mass. separated in three days, leaving a healthy granulating surface, which speedily cicatrized. CASE 2.-A heavy child ten weeks old, was sent to Mr. Erichsen on May 28th, with a naevus situated, like the lastmentioned, in the anterior fontanelle. It was about as large as a walnut and was growing rapidly. Mr. Erichsen operated in this, as in the former case, by carrying the threads across the tumour with a blunt-eyed probe through punctures in the healthy neighbouring integument. The case did perfectly well. CASE 3.-On the same day in which Mr. Erichsen operated in Case 1, we saw him remove, by the double whipcord ligature, an ulcerated and bleeding nmvus, as large as half an orange, from the back of an infant eleven weeks old. The child having been rendered insensible by chloroform, bore the operation (an extremely severe one for so tender an age remarkably well, making a perfect recovery without any bad. symptom. The treatment of long, flat nsevi, when above a certain size, is always a troublesome matter. If small, they may be readily removed, either with nitric acid, or passing threads across their substance, or by the introduction of needles, &c. We have seen Mr. Lloyd operate with great success at St. Bartholomew's Hospital upon flat nsevi. The method consists in destroying the abnormal growths by potassa fusa freely applied for a few minutes. We recollect one child in particular, less than a twelvemonth old, who presented a naevus of this kind on the inner surface of the labium; the same caustic was used by Mr. Lloyd, and with the best results. But if so large and elevated as to require more energetic means, the surgeon often finds himself much embarrassed in the proper application of the ligature. Mr. Luke some years ago published a description of a mode of effecting this, by carrying a single thread, having several needles strung upon it, across the tumour, then cutting off the needles and tying the knots. We had the pleasure of describing this peculiar mode of applying threads, and adducing a case in illustration of the practice, (THE LANCET, Jan. 26, 1850, p. 129.) In the following case Mr. Erichsen adopted a very simple and successful plan of accomplishing the same object, using only one needle and a double thread. CASE 4.-A child, two years old, was admitted, on the 23rd October, 1850, under the care of Mr. Erichsen, having a nsevus on the right side of the forehead, about two inches long, three-fourths of an inch broad, and slightly elevated above the skin. Various but unsuccessful attempts having previously been made to destroy it with caustic, Mr. Erichsen proceeded to use the ligature, which he did in the following manner with complete success :-A long triangular needle is threaded on the middle of a whipcord about three yards in length; one-half of this is stained black with ink, the other half is left uncoloured. The needle is now entered through a fold of the sound skin, about a quarter of an inch from one end of the tumour, and transversely to the axis of the same. It is then carried through, until a double tail, nine inches in length, is left hanging from the point at which it entered; it is next carried across the base of the tumour, entering and passing out beyond its lateral limits, so as to leave a series of double loops at least nine inches in length on each side. Every one of these loops should be made about three-quarters of an inch apart, including that space of the tumour, and the last loop should be brought out through a fold of healthy integuments beyond the tumour. In this way we have a series of double loops, one white and the other black, on each side. All the white loops should now b
doi:10.1016/s0140-6736(02)34430-1 fatcat:ask7p5jx7re5xnhrpqipsdhbua