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The American practitioner online

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humor has been absorbed in about ten days.

I report the last two cases as instances of injury to the eye of rather
more than ordinary interest, especially because of the rapid and com-
plete absorption of blood from the vitreus. Hemorrhage into this



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The American Practitioner and News. 381

body is often far more serious than into the anterior chamber, and often
leaves behind permanent damage.

Sloughing of the Finger from the Application of Carbolic Actd. Dr.
A. M. Vance : I saw the following case to-day, which shows,how care-
ful people ought to be in handling medicines they do not know any
thing about. A servant girl came to my office with her hand
wrapped up in a bandage. She said she had burned her finger slightly.
I found that the ring finger was gangrenous down to the second joint.
I questioned her concerning the matter, and she said her sister put
some medicine upon it, being the same medicine which she had used
for applying to an enlarged gland in a child's neck. I asked her what
it was ; she said it was carbolic acid. Her finger had been totally de-
stroyed by wrapping up a slight burn in a solution of carbolic acid.

This is a common accident. I have known of several such instances
in my experience. Carbolic acid is an anesthetic and stopped the pain
of the bum, but it destroyed the finger down to the point where it was
wrapped.

Discussion. Dr. A. M. Cartledge : It has been my experience that
some people are remarkably susceptible to carbolic acid. It should
never be applied except under the direction of the physician. I am
very much afraid of carbolic acid locally, and have used it very little
recently. A two or three per cent solution is about as much as I ever
use of this drug. I have seen two or three cases of gangrene of fingers
from its injudicious use.

Dr. T. S. Bullock : I have not been so unfortunate as to get hold of
any patients who possessed such an idiosyncrasy as has been de-
scribed. My experience with carbolic acid has been that its action is
extremely superficial even in ninety-five per cent solutions. I have
seen injured fingers, etc., dipped in pure carbolic acid (ninety-five per
cent) without any untoward results following. I am very much inter-
ested in Dr. Vance's case, and it will be a warning to me in the use of
carbolic acid in the future. I have been in the habit of using strong
solutions of this drug in the treatment of phlegmons, about infected
wounds, etc., and have never seen any bad results, although its appli-
cation has been kept up continuously for a considerable period of time.

Dr. A. M. Vance: This is the third finger — and I have also seen
one toe — that has sloughed oflF from the use of carbolic acid. It has



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382 The American Practitioner and News.

usually been in cases where the carbolic acid is bought pure and
dropped into water and used without any definite knowledge as to the
percentage of strength at which the solution was applied ; but I am
sure that a finger wrapped up in cloth and carbolic acid and confined
there, even if the solution be weak, will produce gangrene. It is a
common thing for people to use carbolic acid in the treatment of soft
corns, saturating a pledget of cotton with the solution and applying it
between the toes. When this is done, it almost invariably eats down
to the bone. I think carbolic acid topically applied is a dangerous
remedy, particularly if used without any discretion. I have seen sev-
eral cases of carbolic acid poisoning by the topical application of the
drug.

Dr. Wm. Bailey : It would be interesting to determine the method
by which carbolic acid produces the results stated. How is it that
carbolic acid can do such a thing as this? Is it by controlling the
blood supply primarily, or by its effect upon the nerves ? The nutrition
is evidently destroyed in some way, but whether it is through the
action of the poison upon the nerves of the finger or through its local
action upon the blood-vessels seems not to be understood. We know
that gangrene may be produced when the nerve influence is destroyed.

Dr. J. A. Ouchterlony: Speaking of the use of powerful local appli-
cations, I am reminded of a visit I had from a young lady who had
been troubled with warts on her hands and fingers, and who had
undertaken to treat herself. She went to a drug store and bought
some pure hydrochloric acid and applied it with such regularity and
assiduity that when she came to see me she had at the former sight of
each wart a deep excavation penetrating down to the bone. Even then
she had not desisted, but continued the daily application of the acid.
Of course I made her stop the use of it, and in the course of a few
weeks these deep ulcers had healed.

Sarcoma of the Pelvis. Dr. A. M. Vance : I have had under obser-
vation for three months a gentleman sixty-two years of age. I think
he was seen about the first of the year, with what I take to be a
sarcoma, more than likely of subperiosteal origin, springing from the
inside of the right ileum. The man is very thin and anemic, and is
blind in both eyes. What the nature of his eye trouble is I do not
know. This growth has increased with wonderful rapidity ; it extends
now up to the ribs and more than half way across the abdominal cavity.



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The American Practitioner and News. 383

and has evidently involved the whole ileum, the hip-joint, and half
way down the thigh.

The point I want to raise is a discussion of the use of Coley's
erysipelas-prodigiosus toxin. Dr. Gilbert saw the man a few days ago
and suggested that Coley's fluid be tried, stating that he was treating
a patient with sarcoma of the liver that was being markedly benefited.
I had already explained this method of treatment to the patient, and had
given the opinion that it would be of very little use, and that there
was some danger in its application. He has been excited very much
since Dr. Gilbert saw him in regard to the use of the toxin. He has
also been seen by Dr. Bodine, who advised against the use of the
toxin. I would like to know what the experience in Louisville has
been with the use of this agent in treating inoperable sarcoma. Has
there been a single case in which benefit has followed the injection of
Coley's fluid? I have heard of its having been tried several times, but
have never known of a case that did not go along and die in the reg-
ular way. Coley is more than enthusiastic on the subject, and there
have appeared some very favorable reports in medical journals coming
from Eastern cities, but very few in this part of the country. Keen and
Senn reported fifteen cases each in Baltimore where Coley's fluid had
been used without any result whatsoever. I understand Coley makes
the statement that he gets a cure, or at least marked improvement, in
over fifty per cent of cases treated by his method. I know of one
physician in Shelbyville, Ky., upon whom Coley practiced this method
of treatment, who went along and died in due course of time. I
had a patient from Western Kentucky who had an inoperable sarcoma
of the upper jaw, and suggested that as it was an inoperable case he
go to New York and consult Dr. Coley. Coley injected him three times,
and some weeks afterward I had a letter from the patient's son saying
his father had been much improved by the injections. This is the
only expression of the kind that I have seen or heard of from the
injection plan of treatment in this part of the country. If any of the
Fellows have had experience with this treatment, I would like to hear
from them. Owing to this patient's debilitated condition, I am afraid
of injecting Coley's fluid.

Discussion. Dr. A. M. Cartledge : My experience with Coley's fluid
has been confined to three breast cases, one of recurrence after opera-
tion and two inoperable cases. I will say that so far I have been very



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384 The American Practitioner and News.

much disappointed in the use of the toxin. In the patient who had a
recurrence of breast cancer I am satisfied that she was made very much
worse, because she had a violent chill to follow the first injection;
after a great deal of persuasion she accepted the second one, but I
could never get her beyond that. In the other case no result was
observed.

Post'Mortem Specimen of Aortic Aneurism. Dr. Ellis Duncan :
This is a specimen taken from a man, sixty-five years of age, who died
at the city hospital yesterday. He had been in the hospital about two
months. There had been various theories advanced as to the cause
of his trouble. Dr. Stucky's diagnosis was that of aneurism of the arch
of the aorta, which the post-mortem proves to have been entirely correct.
The specimen reveals an aneurism of the arch, of the aorta with an
organized clot, the fibrin being in layers, making the lumen of the vessel
about the same as if the aneurism were not present.

The man died from asthenia. He had a severe chronic bronchitis,
also some obstruction of the circulation in the portal system which
resulted in chronic diarrhea. I suppose the bronchitis was also due to
some trouble (probably obstruction) of the circulation of blood through
the lungs.

I do not know the full history of the case, but the specimen shows
the condition very well. The man gave a history of having had
syphilis over twenty years ago.

Discussion. Dr. J. M. Ray : With reference to the laryngeal paraly-
sis in this case, it has been my observation that every case of aneurism
of the arch of the arota that I have seen has had left recurrent paralysis.
But this must not be understood to mean that in every case of left
recurrent paralysis there is also an aneurism of the arch of the aorta.
Bosworth makes a point of this, and claims that of sixteen cases which
came under his personal observation, the majority of them were due to
other causes than aneurism of the arch. But in the last ten years every
case of aneurism of the arch that I have seen in the city hospital or in
private practice has been associated with left recurrent paralysis.

Dr. William Cheatham: I examined the patient from whom this
specimen was removed during my service at the city hospital, and he
had left recurrent paralysis.

Dr. J. A. Ouchterlony: That this man had syphilis reminds me
that a good many years ago the statement was made upon high authority



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The American Practitioner and News. 385

that the vast majority of cases of aneurism of the aorta occurred in per-
sons who had had syphilis, and that the lesions in the aortic walls which
preceded the formation of the aneurismal sac were probably a syphilitic
arteritis. In this case it is difficult to say exactly what the relations of the
aneurismal sac are to the heart, but it seems to be unusually far forward
and to the left, and is confined entirely to the left of the heart. In most
instances it is the ascending or transverse portion of the arch that is
the seat of the aneurismal dilatation. The descending portion of the
arch and the descending aorta within the thorax are very seldom the
seat of aneurismal dilatation. It is also peculiar that death occurred
not from rupture, but from some of the secondary lesions incidental to
the presence of the aneurism, such as congestion or hyperemia of the
lungs and interference with the return of the venous blood.

Dr. T. H. Stucky : The clinical history of this patient presented
some very interesting aspects ; the absence of tumor, absence of any
bulging over the manubrium, the absence of any localized pain, and the
absence of bruit made it very difficult to make a diagnosis. The diag-
nosis was based upon the absence of any apparent superficial nervous
lesion, with recurrent laryngeal paralysis and an exaggerated impulse
at this point. I watched the case with much interest. I am especially
pleased to see a confirmation of the diagnosis that was made, based
upon comparatively simple symptoms.

The essay of the evening, " Malignant Diseases of the Sigmoid
Flexure," was read by Dr. John A. Ouchterlony. [See page 369.]

Discussion. Dr. A. M. Cartledge : The paper covers the ground so
completely from the standpoints of symptomatology, diagnosis, and
pathology that there is little left to be said. The treatment of this
disease, whether recognized early or late, may be considered surgical.
In regard to the diagnosis, I think the most trouble will arise in con-
nection with tuberculosis. Fortunately tuberculosis of the * sigmoid
proper is not so common as it seems to be about the cecum. As the
doctor has shown in his paper, cancer is more frequent in the sigmoid
than it is in the cecum, which is an important diagnostic point. The
temperature history is of great value. I made the statement that this
was a surgical disease as far as its treatment is concerned, whether
recognized early or late ; I base that upon the fact that if seen even
very late after obstruction, after a considerable tumor has formed, with

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pain after the lumen of the bowel is obstructed, it is astonishing how
much good can be derived in the way of prolongation of life and relief
of the obstructive symptoms by anastomotic procedures in this locality.
There is one striking feature about cancer of the alimentary canal, and
that is its exceeding chronicity. From my experience I would be
inclined to say that the duration of life in cancer of the sigmoid and colon
is even more than four years. I am sure that I have known a patient
to live eight years with a cancer of the sigmoid flexure. Of course it is
always a doubtful question whether primarily the neoplasm was not of
a simple nature, which later has undergone secondary malignant
degeneration. The only case of cancer of the sigmoid that I have
submitted to operation was an advanced case that I have reported
before this Society as being the first instance of the use of the Murphy
button in Louisville. The result in this case was so striking in what
appeared to be an almost hopeless condition that it leads me to say
that we ought to operate upon all these cases, provided obstructive
symptoms occur, even although there be an enormous tumor with
advanced and pronounced cachexia. This lady was over fifty years of
age, and had marked symptoms of intermittent obstruction, which
finally terminated in complete obstruction. The bowels were in the
habit of going from ten to twelve days without moving, long periods of
constipation alternating with diarrhea, and during the latter period
there was complete obstruction, it having been eighteen days since the
bowels had moved when the operation was performed. There was
enormous distension of the remaining portion of the large bowel; it was
three or four times its normal size, filled with liquid feces, and there
was a tumor which could be felt behind the uterus as large as my fist.
The diagnosis was not made positively in this case whether there was
pressure upon the bowel from without or whether the tumor was con-
nected with the bowel itself. An exploratory incision was advised for
diagnostic purposes. Nor was the diagnosis of malignancy made
positively. We did not know but we had a floating pedunculated
fibroid tumor that had formed adhesions, exerting pressure upon the
sigmoid and producing obstruction in this way. When an exploratory
incision was made the bowel was found enormously distended above
the tumor, which proved to be a cancerous growth of the sigmoid. I
opened the bowel above the distension and anastomosed the descending
colon to the rectum below with the largest sized Murphy button, which
was a diflScult matter on account of the enlarged and infiltrated condi-



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The American Practitioner and News. 387

tion of the bowel. The patient passed the button on the eighth day,
and there almost immediately passed an enormous quantity of liquid
feces, resulting in great relief. She made a rapid and complete recovery
from the operation. The operation was performed in March, and the
tumor at that time I am sure was as large as my two hands closely
grasped, and obstruction was complete. She lived until the following
February, and then died as the result of an accident, having fallen from
a chair, striking the back of her head. The bowels had performed their
functions and had moved satisfactorily during the period of almost a
year after the operation. Dr. Mathews was present at the operation
and will probably remember the case. The result obtained in such an
extreme case as this leads me to say that although the case is inoper-
able from a curative standpoint, the results following the palliative
treatment of anastomosis are such that I do not believe we ought to
deny this to any of these patients.

One word in regard to the operation of excision, where the patient
is seen suflBciently early. I firmly believe that from the nature of this
disease, its slow progress in this locality, we have the best assurance
of success if any thing like complete removal of the disease can be
practiced, by excision. I certainly would not hesitate, even in rather
advanced cases of cancer of the sigmoid, to excise the growth and prac-
tice either anastomosis by the button or suture, whichever seemed
most advantageous. I think the prognosis of radical removal of cancer
of the alimentary canal is the best of any part of the body. The rec-
tum, in my experience, if the case is seen early enough, is certainly the
best part of the body from which to remove a cancer, so far as perma-
nent results are concerned. The same thing will apply to cancer of
the sigmoid flexure.

Dr. Turner Anderson : Cancer of the bowel of the scirrhus, enceph-
aloid, colloid, and epithelial varieties are not so exceedingly infre-
quent. The special feature of interest in a general way may be said to
center, to those of us who are doing any work in pelvic surgery, in the
great diflSculty of making a diagnosis. The symptoms are so insidious
and the diagnosis is so diflScult that we may really mistake almost any
intra-pelvic affection with pressure symptoms upon the bowel for
malignant trouble.

I saw to-day a woman who presented many symptoms of malignant
disease of the bowel, and yet I believe she is suffering from pelvic
inflammation instead of carcinoma. DiflBculties of this kind are only



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388 The American Practitioner and News.

cleared up by an exploratory incision. The symptomatology does not
help us very much. The fact that cancerous affections of the bowel
are more frequent in connection with the bend in the bowel constituting
the sigmoid flexure, that they are not often found within three inches
of the anus, helps a little ; but it does not assist us in a positive way.
I really do not know that we have any special lines to guide us in
doubtful cases except an exploratory incision.

Dr. W. O. Roberts : I was surprised at the statement of one of the
authorities quoted of cancer in this locality occurring in so young a
subject. It is generally conceded now that cancer is exceedingly rare
under thirty years of age. Sarcoma occurs before this time; but
sarcoma is more frequent in other portions of the bowel than in the
sigmoid. My experience with cancer of the sigmoid proper is very
limited. I can recall but two cases where only the sigmoid was
involved, and in both of these the symptoms developed suddenly, that
is, alarming symptoms drawing attention to the disease. The symp-
toms were those of obstruction, and they came on suddenly. One of
them I saw with Drs. Mathews and Grant, and this case is reported
in Dr. Mathews' book. In this case the man had been the subject of
constipation for a long time, and when the condition of obstruction
came on he was apparently in perfect health. He had lost nothing in
flesh. He was a large man, and weighed over two hundred pounds.
His rectum was entirely free from the disease, it being confined entirely,
as far as the examination showed, to the sigmoid. This man lived in
the city, and was afterward operated upon. The other was an out-of-
town case, and I was called to see him because of obstruction of the
bowels. In this case there had been no hemorrhage, and nothing but
pain indicating the seat of the trouble. Obstruction was complete, his
abdomen was enormously distended, and I did a colotomy. He lived
several months after the operation, but finally succumbed to the
disease.

Dr. J. M. Mathews : I am surprised to hear my friend Dr. Roberts
say that he can only recall two or three cases of cancer of the sigmoid
flexure where the rectum was not involved. I have seen in twenty
years over one hundred cases of cancer of the sigmoid flexure where
the rectum was not involved. I am sure of my diagnoses, because the
patients died of cancer.

In regard to the symptomatology, Dr. Anderson says that it is not
of much avail in these cases. In a certain way I believe that is true,



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The American Practitioner and News. 389

yet in another I doubt whether it is. true. I believe if you will take
such patients and observe them clinically after a certain length of
time that no mistake will be made as far as cancer of the sigmoid
flexure is concerned. I do not know of any other disease with which
it is closely allied, I mean in symptomatology. If you have in a general
way loss of flesh, the peculiar characteristic color, though I am not a
great believer in the cancerous cachexia, with localized pain over the
flexure, with a discharge of mucus, blood, and pus, when upon examina-
tion no disease of the rectum is found, it is safe to presume that the
disease is in the sigmoid flexure, and that it is cancerous.

In regard to the diagnosis, it is, as the other speakers have said,
very perplexing. A few years ago I reported a case to the Louisville
Surgical Society which appears so opportune here that I shall refer to
it again. I was called to a town in Indiana to examine a business man
whose doctor supposed he had some serious trouble with the sigmoid
flexure. The patient himself met me at the station in his carriage.
I observed, as Dr. Roberts has said, a man in good physical trim,,
without the loss of a pound of flesh, and I was surprised to see my
patient meet me at the station. We drove to his house, and it struck
me then to ask why they had sent for me, and I was told that the man
had suffered from obstruction, although he had had a free action o\ the
bowels that day before I reached him. I traced his history as well as
I could, and took into consideration the symptoms I have mentioned,
and said to his doctor, this man in my opinion has cancer of the sigmoid
flexure, and I do not believe it is justifiable just now to do a colostomy,
as you have called mie to do ; but at any time you will write or telegraph
me to come, I will do so and perform the operation if it seems advisable.
I returned home, and the doctor the next day advised the patient that
inasmuch as they had consulted one surgeon, that it might be well to
consult another, and asked him to go to Chicago and see one of the most
distinguished surgeons in this country, which was Dr. Senn. Dr. Senn
gave him a most careful examination, stripping him as I had done, and
informed him that he had no trouble with the sigmoid flexure, not to
speak of cancer ; that he should return home and go to work. I con-
fess under the circumstances I felt considerably embarrassed. In a
short time, certainly in less than two months, the man was walking
along the street, had a sudden pain, fell to the street, was carried away,
and died in half an hour. I was so informed, and telegraphed my
friend. Dr. Cook, of Indianapolis, to please go to the town where the



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390 The American Practitioner and News.

patient had lived and hold a post-mortem examination. He did so, and
the result of the post-mortem was that he sent me the sigmoid flexure,
which is the seat of a cancer as large as my two fists. This will evidence
at least what Dr. Anderson has said, that it is very difficult to make a
diagnosis. I contend that in a large, fat abdomen, that no man can
make out a tumor or a cancer of the sigmoid flexure positively by
palpation. I have seen a number of mistakes made in regard to the
matter, and never try to make a diagnosis, but rely almost absolutely
upon the clinical history of the case, with the symptoms which I have
mentioned.

As to the treatment of this affection, if there is any radical treat-
ment, it will of course be what Dr. Cartledge has said, surgery ; but is it



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 44 of 109)