Cases in Su~'gery. By MR. ]~. HAMILTON. 315

or years, one eye becomes gradually blind, with irregular lateral contraction of the field of vision, diminution of S., and atrophy of the disc; and in which the second eye follows the first at an uncertain interval.

There are, finally, many patients who seek relief, not on account of obviously defective sight, but on account of fatigue and pain which attend upon, or even altogether forbid, any prolonged exertion of the eyes. Some of these cases depend upon unsuspected hypermetropia or astigmatism, either of which conditions would be detected by the methods of examination already laid down. Others depend upon hyperesthesia of tile retina, and are often relieved by blue spectacles. Others, again, depend upon weakness or insufficiency of the internal recti muscles, which become tired, and unable to maintain the convergence of the eyeballs required for close attention.

When the internal recti are weak, if we direct the patient to look steadily with both eyes at some object not much beyond his near point, and if we then interpose a hand, so as to shut out the object from one of his eyes, the eye thus excluded from the visual act will immediately lose its convergence, and wander outwards, usually beyond the median line. Distress from this affection is most common in myopic persons, who require to maintain habitually a greater degree of convergence than is necessary for others.

ART. XIII .--Cases in Surgery. By EDWARD HAMILTON, F.R.C.S.I., one of the Surgeons to Dr. Steevens' Hospital.

EXTIRPATION OF THE THYROID BODY.

THE operation of removal of the thyroid body, for the relief of bronchocele, has found little favour in the eyes of practical surgeons, as even the most superficial examination of its anatomical relations and connexions must impress us with the difficulties and dangers to be encountered in such a proceeding; the close proximity of the organ to the carotid artery, jugular vein, the trachea, larynx, and esophagus; the large supply of vessels, both arteries and veins, so freely distributed to it from various sources, are ahnost sufficient in themselves to proscribe any operation for its excision ; and when we consider that the diseases to which the organ is liable, although producing most unsightly deformity, do not usually threaten life or

316 Cases in Surgery. By MI~. E. HAMILTON.

interfere with vital functions for a considerable period of their duration, we cannot wonder that opinions such as the following have been expressed against operative interference : - -

"Excision of the tumour is seldom to be thought os " The disease is such as should not at once be removed with

knife, nor indeed should any attempt of the kind ever be made excepting under peculiar and urgent circumstances."--Fergusson.

" No operation is justifiable in such cases for the removal of deformity."--Liston.

" Attempted removal by knife would scarcely fail to prove fatal by hemorrhage."--Miller.

"Very dangerous and almost entirely to be forbidden."--Chelius.

Forcible interdictions such as these, emanating from the highest authorities in our profession, must command the deepest respect from every prudent and conscientious surgeon, and make him pause and anxiously deliberate before he determines on an undertaking so fraught with dangers and difficulties, and even cause him to shrink from it altogether; and yet cases occasionally present themselves to our notice which appeal so plaintively and forcibly to our sym- pathies as to make us reluctant to acknowledge the limited resources of our art, when we pronounce them beyond the pale of surgical interference, and tempt us from the beaten path os routine by a bold and decisive operation to get rid of an intractable disease, entailing on its unhappy victim consequences from which the sensitive female mind recoils almost as from death itself---con- spicuous deformity, ever increasing and hopelessly incurable--such thoughts were suggested by the subject of this memoir. The history of the operation, while it records some sad and appalling failures, affords many examples of brilliant success; to none has so much honour in this department of surgery fallen as to ttedenus, who gives the details of six operations, the results of which were satisfactory. Sedillot records three successful cases; Graefe had two; Voisin, Voget, and Cabaret detail successful results, and many others are recorded 111 our own periodical literature, which leave us not without hope that in cases selected with care and judgment the operation may be attended with favourable results; and, as stated by Velpeau, we should be wrong in censuring in absolute terms the essays made to render us more familiar with this operation.

~OL. XI,. NQ, IXXX. N.,'t.

Cases in Surgery. By MR. E. HAMILTON. 317

M. M., an interesting glrl, aged sixteen, resident in the County of Meath, was admitted into Steevens' Hospital on the 10th of May last, presenting manifest enlargement of the thyroid body. The accompanying plate, by Forster, copied from a very graphic drawing by Connolly, will convey a more satisfactory idea of the appearance caused by the deformity than any verbal description. That portion of the enlargement marked A struck me as being more movable than bronehoeeles usually are, gliding freely under the skin, as if attached by a pedicle; some large veins coursed over its surface. The tumour marked B seemed to be more fixed, to have much deeper connexions; the movement of this also produced some pain. Both portions of the tumour followed readily the motions of the larynx in deglutition; they were soft and elastic at points, giving an obscure sense of fluctuation. No pulsation or bruit could be observed. She suffered much from headaches and dizziness. The uterine functions were regularly performed. There was no evidence of cardiac disease, nor any proptosis. She stated that the disease was of six years standing; that she had been treated for it in many different ways; the swelling some times diminishing, but quickly regaining its size.

She was much fretted at the prospect of the continued deformity, and expressed her most urgent desire to submit to any operation rather than remain in her present condition. The extreme mobility of the tumour suggested to my mind the idea that it might be eradicated without any dissection after the free division of the integuments, and that the subsequent steps of its removal might be accomplished by the use of the 6craseur without any serious risk of hemorrhage, which constitutes so formidable an obstacle to the proceeding.

While engaged writing this memoir I have found that I have been anticipated by Dr. Voss, who records a case thus treated with perfect success in American Medical Times, 1862. Having ex- plained my views to my colleagues, in consultation, it was decided that the operation might be undertaken. The presence of the catamenia obliged us to defer it for some days.

On the 10th of June, chloroform having been administered, the patient lying on her back, a pillow placed under her neck, with the head well depressed, so as to make the turnout as prominent as possible, an incision three or four inches long was made in the middle line directly down on the turnout; the fascia connecting the sterno-hyoid and thyroid muscle was carefully divided on a

318 Cases in Surger3t. By MR. ~E. HAMILTON.

director to the same extent as the cutaneous incision; the finger was passed around the tumour on the left side, which was easily turned out; that on the right side with somewhat more difficulty, yet, still with wonderful facility; as they both protruded through the wound they pulsated very strongly, large vessels entering from all directions. Considerable bleeding issued from the lower part of the incislon--brlght, but yet not projected per saltum; there was also smart hemorrhage from the upper part; this must have pro- ceeded from a number of small veins torn in turning out the tumour, as all use of the knife was avoided after the fascia was freed; the loss of blood was so great that we did not consider it advisable to wait for the slow action of the dcraseur, but having raised up the tumour we passed a strong ligature around its neck, and proceeded to tie it firmly. This seemed to interfere in an alarming way with respiration, producing cough and much distress; we at once removed it, and having transfixed the narrow part with a ligature of very thick silk, tied each segment separately, and then cut away the tumour in front of the ligature. The surface bled very freely after its removal, but pressure commanded it without much difficulty ; the patient was exceedingly faint from loss of blood; the wound was left exposed to the air, ice applied to the surface, and an intelligent dresser directed to remain constantly at the bed-side, and control any bleeding which might arise by pressure; bloody serum oozed for some time, but no further hemorrhage occurred. The great faintness required the constant administration of brandy, with small doses of opium.

]Evening visit.--Patient has had some sleep; pulse 130; very thready. There had been some slight hemorrhage from the wound, induced by an attack of vomiting, which was easily arrested by digital pressure. The sides of the wound were supported by a single strap of adhesive plaster, but not brought together; a piece of ice on muslin was lald over it.

Ordered to continue brandy and opium, with strong beef-tea as a drink.

June l l . - -Passed a quiet night; no return of bleeding; reddish serum in large quantity flows from the wound; pulse 120. The brandy to be given at longer intervals; to have beef-tea and arrow- root; complains of some soreness in swallowing.

F~verdng visit.--General appearance much improved; pulse 110; complains of some soreness in the wound, the edges of which present a slight blush of inflammation. Omit brandy and opium.

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Cases in Surgery. By MR. E. HAMILTON. 319

June 12.--Continued improvement; pulse 100, full; complalus of cough, which causes much distress, disturbing the wound. Ordered to have inhalation of steam, with a little gum in the m o u t h .

Evening visit.--Cough much relieved; less difficulty in swallow- ing; pulse 100. To have a full opiate; wound to be poulticed.

June 13.--Passed ~ ~'ery good night; pulse 98; wound sup- puratlng; discharge somewhat fetid; cough very slight. Ordered warm dressing to the wound, wlth a linseed poultice ; to h~ve wine, with arrow-root, beef-tea.

June 14. "Wound suppurating freely, with a grey slough in the centre; pulse 95, firm; was somewhat restless in the night. Ordered an aperient draught, with sulphate of magnesia and infusion of roses.

June 15.~Passed a much better night; quite cheerful; pulse 90; ordered to have chicken.

June 16.--From this date the reports presented little variation of ~ny interest, each day exhibiting marked improvement.

June 21.--Ligatures came away, being the l l t h day after the operation. Allowed to leave her bed.

The lithograph shows her appearance on the 6th of July, before she left the hospital. A cross, suspended from a neck ribbon, served completely to conceal the small line of cicatrix which remained. She was much pleased and happy in her mind at the removal of the deformity.

On examining the turnout, the movable portion (A) presented the cystic variety of bronchoeele, the other exhibited simply hypertrophied thyroid structure.

A LARGE TUMOUR OF THE PAROTID REGION SUCCESSFULLY

REMOVED.

J. N., aged fifty, a strong heMthy-looklng man, residing in the country, presented a large tumour, occupying the lower part of the parotid region on the left side; it was globular in shape, and somewhat nodulated--the projections con~'eying a feeling of hardness. The integument covering it was vascular, but did not adhere to the tumour at any point. I t was not tender to the touch, nor did it occasion any pain or inconvenience by its pressure, the deformity alone urging the patient to seek relles

He states that it commenced, without any assignable cause, twenty or twenty-five years ago, as a small pea-llke body, movable

320 Cases in Surgery. By MR. E. HAMILTON.

under ~he skin; that its increase for the last two or three years has been very much more rapid than previously; his general health has ahvays been good; had fever before the disease appeared. On careful examination the tumour was found to be perfectly movable and unconnected with any important structures, the external jugular vein was the only vessel of any size in danger; its removal was accordingly at once determined on. On Saturday, August 5, chloroform having been administered, a curved incision was made obliquely over the tumour, from the lobe of the ear to an ifich in fi'ont of and below the angle of the lower jaw; a second curved incision between the same points included an oval portion of the skin, which was removed along with the tumour; the skin was carefully dissected back i~om each side, while the growth was steadied with a vulsellum, and well raised from its bed by my colleague, Dr. Symes ; by means of the finger passed around it, and a few touches of the knife, it was turned out without difficulty. The bleeding vessels were now carefully secured, requiring five ligatures. Cold water was poured over the bleeding surface to wash away clots and cause immediate contraction of the smaller vessels, as I was most anxious to avoid any collection of blood in the cavity which might tend to unhealthy inflammation. The external jugular vein appeared of large size at the bottom of the wound, but was carefully avoided ; the edges were united by sutures of silk, a large compress being placed over each flap, and finally secured in its place by a bandage, so as to prevent pouching. The patient was placed in bed, and a full opiate administered.

,Evening visit.--Itas been very easy, having had some sleep; pulse 90; no appearance of bleeding.

August 7.--Passed a quiet night, is now somewhat feverish; skin hot; tongue coated; pulse 100. Stitches were all removed--a process much facilitated by having left one end of the silk suffi- ciently long for traction. Cold was still applied to the surface.

8th.--Skin cooler; tongue cleaning; no pain in the wound, which was ordered to be poulticed every six hours; to have beef-tea.

9th.--Wound suppurating freely, matter discharged along the ligatures; treatment continued.

10th.--One ligature away. 14th.--Two ligatures away. 16th.--Remaining ligatures detached. The tumour weighed 1lb. 4oz. ; its external surface was vascular ;

on section it presented a whitish granular appearance, resembling

Diphtheria and Diphtherial Paralysis. By DR. CuM)IINS. 321

boiled rice ; a soft pulpy material oozed From it ; the granular matter was composed of small cyst-like bodies; the denser nodulated por- tions cut like true cartilage, and exhibited, under the microscope, cells almost identical with that structure.

ART. XIV.--Diphtl~eria and Diphtl~erial Paralysis. By W. J . CVMMIZ~S, M.D., Member of the King and Queen's College of Physicians; :Physician to the Cork Dispensary, &c., &e.

THw question is often asked, " is not diphtheria a new disease ?" and in Ireland it may be answered that it is still so far new that many physicians of experience have never seen a case, while to the majority the instances that do present themselves appear rather as curiosities than as harbingers of a pestilence which seems gradually establlshing itself amongst us. But although unknown until lately by the present generation, diphtheria is by no means a new disease, for besides having been described by Fothergill in 1728, and in France, by t~retonneau, under the name of " Diphtherlte," in 1821, accounts of various epidemics are to be met scattered through the medical literature of Europe for the last 350 years--(Gibb~). Bretonneau, in his second memoir, tells us that "ever since the end of the sixteenth century diphtherlte has almost constantly shown itself in every region of the old and new continents. A t first it continued for a long time in Spain, and during nearly forty years was noticed in different parts of the Peninsula. I~ather later all Italy was successively afflicted by it. In two years it killed more than 5,000 persons in Naples. Towards the middle of the last century epidemics prevailed in England, France, Sweden, and America."

Since the re-appearance of this disease it seems to have spread in England and Scotland much more rapidly than in Ireland--where, judging from the ~Reglstrar-General's report for 1864, it has prevailed more extensively, and been more fatal in the north than the south.

W e find, however, occasional mention of it in the Transactions of the Cork Medical Society, which, as a permanent record of the

Diseases of the Throat and Windpipe.

VOL., XL., NO. 80 , N .S. ,ff