1644 MR. R. C. LUCAS: ERADICATION OF CANCER OF BOTH BREASTS. treatment is adopted earlier in the disease, the tale of typical oscillations appeared. By this procedure hopelessly fatalities due to tuberculosis in organs other than the lung ill patients have regained their health ; but the risk entailed will be appreciably diminished. is considerable, even when the needle is aspirated to ascer- Coniplications and their Avoidance. tain the presence of blood in its lumen before any gas is injected. No novice should attempt this method. Much has been written about pleural reflex and gaseous embolism, the two causes of sudden death during the Results. operation. With care, both risks are negligible. The risk In such a chronic and capricious disease as phthisis an of pleural reflex is reduced by injecting eucaine or stovaine estimation of the value of any form of treatment is worthless into the pleura. Two points in this connexion are im- unless the number of patients treated is considerable, and portant. The solution of anaesthetic must be concentrated the improvement effected has stood the test of time. My so that only a little fluid escapes into the tissues ; otherwise experience, therefore, with 18 patients treated for periods fluid in the track of the pneumothorax needle will fill its ranging from 6 months to 3 years, is insufficient per se to lumen, and thus prevent the registration by the mano- build pretentious claims on, and I will but briefly touch on meter of changes in the intrathoracic pressure. If the the following points. The disease was in the third stage and operator holds the hypodermic needle lightly he can also active, and the prognosis was very bad in every case. Yet the probe with it to ascertain the pleura’s exact depth disease is either arrested or is undergoing arrest in 13. Five from the surface and its state, whether it be thickened or patients are either dead or dying ; but I sincerely believe not. I usually inject eucaine at three or four different points that the treatment has prolonged their lives. I have seen in the chest, and select for my first puncture with the no fatal accident from the treatment. pneumothorax needle that point at which the hypodermic More valuable are Dr. L. Spengler’s results, for they have needle has encountered least resistance. Unfortunately, stood the test of a longer probation period.4 He has however, firm pleural adhesions sometimes exist even where excluded all recent cases, confining himself to those in which the exploring hypodermic needle has encountered but slight a pneumothorax had been induced nine months to four years resistance. earlier. As evidence of arrest of disease he adopted the Sudden death from gaseous embolism continues to occur, following conditions : absence of pyrexia, cough, and ex- as recent publications show. But, as indicated by the pectoration ; if the latter be present, it must not contain following case recently published by Balvay and Arcelin,3 tubercle bacilli. Fifteen patients fulfilled these conditions, these deaths may be the operator’s-and not the opera- and were also capable of a full day’s work. In 12 of these tion’s-fault. The patient had acquired a fairly large the prognosis before the operation was almost hopeless, and artificial pneumothorax, but her lung was still adherent to in the remaining 3 it was very bad. Dr. Spengler con- the chest wall in places. On introducing the pneumothorax siders that these results are a satisfactory answer to the needle at a different point from that at which the first injec- objection that though a pneumothorax may cause temporary tions had been given, the operator failed to obtain charac- improvement, it does not often enough produce permanent teristic manometric oscillations. In spite of this ominous results to warrant the risk of operation. A useful review of warning the gas was introduced under considerable pressure. recent literature on the treatment is given by Dr. W. T. The patient immediately became unconscious. She coughed Ritchie,5 who has collected the results of several workers in up blood, and in 48 hours she was dead. The needle had this field. Interesting original articles on this subject have been introduced over the site of an adhesion which held a also lately been published by Dr. S. Vere Pearson 6 and Mr. portion of the lung to the chest wall, and thus gas was NnhPrt. r!hitt-t7 7 forced into a pulmonary vein. Gorleston-on-Sea. - A similar accident may occur even if the pneumothorax is and no adhesions if the complete pleural exist, A CASE OF is careless to a motionless mano- operator enough ignore COMPLETE ERADICATION OF EXTENSIVE meter. For the needle may catch in a blood-vessel super- ficial to the parietal pleura, and with this vessel impaled on RECURRENT CANCER AFFECTING ts point, it may invaginate the parietal pleura without BOTH BREASTS AND puncturing it, and may reach to the depth at which the AXILLÆ; operator on previous occasions has penetrated to the pleural DEATH 15 YEARS LATER FROM HEART DISEASE AND DROPSY cavity, and has obtained characteristic oscillations. He may AT THE AGE OF 82 YEARS. now that he is at the and that argue working right depth, BY R. CLEMENT LUCAS, B.S. LOND., F.R.C.S. ENG., no manometric oscillations appear because the needle has CONSULTING SURGEON TO GUY’S HOSPITAL AND TO THE EVELINA HOS- become obstructed a small of tissue in its transit by particle PITAL FOR CHILDREN; MEMBER OF THE COUNCIL OF THE ROYAL through the chest wall. He therefore proceeds to blow out COLLEGE OF SURGEONS AND OF THE EXECUTIVE COMMITTEE this hypothetical particle by forcing gas through the OF THE IMPERIAL CANCER RESEARCH FUND. needle. The result is more instructive to himself than advantageous to the patient. IT is not only by the consent, but also by the desire, of Gaseous embolism may happen in yet another way. Duringthe relatives of this patient that I publish the details of her a first the thrusts the needle injection operator through thecase, and its publication may perhaps assist other surgeons chest wall till characteristic manometric oscillations showto persuade their patients to avail themselves of the only that its is in the He now holds the point pleural cavity. known means of cure for cancer, rather than gamble needle at this lest it should and securely depth pass deeper away their only available chance of safety by resorting to the visceral But neither the penetrate pleura. though useless methods of treatment so temptingly put forward by nor the needle has been the patient apparently moved, designing persons, who play upon the fears and encourage oscillations as a to the may suddenly cease, owing, rule, the natural dread that everyone feels at the idea of having over the the parietal pleura having slipped point of needle, an which is to both of the operation performed. consequently again superficial layers E. J. was a patient of Mr. J. A. Hosker, of Boscombe, The because he has once obtained pleura. operator who, Bournemouth, and she had been some and because he thinks the needle has not operated upon years typical oscillations, before I saw her by a Bournemouth surgeon, who had moved in the face of a motionless since, injects nitrogen amputated her left breast for cancer, but had not carried manometer, will sooner or later have a sudden death to his incision into the axilla to clear away the lymphatics in explain. that situation. In the interval between the and It follows that however secure the feel. operation operator may the recurrence of the disease the operating surgeon had died, his only safe course is to watch every movement df and this fact may have made the patient hesitate some time the manometer, and to cut off the as soon as gas before consulting her own medical man as to her tumours oscillations cease. When, hour after hour, satisfactory when recurrence took She, had a he has tried in vain to obtain oscillations place. however, nephew satisfactory by in our Mr. W. Watkin of who’ in several the to 11 shove in profession, Leigh, Treharris, puncturing places, temptation at one time had been my dresser at Guy’s Hospital, and gas and see what happens " is great. Cases have, in fact, been recorded in which no oscillations were obtained till a 4 Münchener Medizinische Wochenschrift, Feb. 28th, 1911. little gas had been forced into the pleural cavity, after which 5 Edinburgh Medical Journal, July, 1912. 6 Brit. Med. Jour., Oct. 12th, 1912. 3 Archives Générales de Médecine de Lyon, May 29th, 1911. 7 Medical Press and Circular, Nov. 13th, 1912. MR. E. C. ALLES: MUCOCELE OF THE ANTERIOR ETHMOIDAL CELLS. 1645

through him, with the consent of her own medical man, she wound was completely closed. Again, whilst the first came up to London to consult me in the year 1897. operation wound was being sutured, the other side was I saw the patient first on August 23rd, 1897, when she was resting on sterilised pads, and, these being removed, the a widow, 67 years of age. She was a somewhat slight but a wound of the second operation was sewn up with a con- very active, energetic, and healthy looking woman. She had tinuous suture, no drainage being provided for on either suffered from bronchial asthma, and on this account had side. I learnt from Mr. Hosker that complete primary resided during the previous 15 years at Bournemouth. For union took place on both sides without any fever, and that some months she had noticed a hard lump, about the size of he removed the sutures about a week later. a nut, in the outer axillary side of her rigat breast, but had Microscopic examination of the growths removed showed paid little heed to it, as it had caused her no pain ; still, she them to be composed of scirrhus cancer. became anxious from recollection of the operation on her left Convalescence was very rapid; about a fortnight after the breast. When examining her my attention was first directed operation her medical attendant sent the patient out for a to the left side, to discover if any recurrence had taken drive in her carriage. place in the direction indicated by the previous operation. On Feb. 6th, 1900, about two years and a half after the The scar was healthy, but I soon discovered under the edge operation, the patient came up to consult me about a slight of the pectoral muscle a thickened lymphatic chain which swelling on the outer side of the left leg, which I thought due led to a hard lump of the size of a walnut in the left axilla, to the plugging of a varicose vein dependent on a gouty ’clearly indicating recurrence of the original disease in the phlebitis. There was slight eczema below, but she attributed axillary glands on that side. Proceeding to examine the this to a liniment she had applied. She gave me an right side, a hard tumour of the shape of a large almond opportunity of thoroughly examining her chest, neck, and was felt at the upper and outer part of the right breast, axillæ, but I could find no trace of any recurrence of the in that situation where the breast tissue (as I have else- growth. She had the appearance of perfect health. where pointed out) is weakened in its resistance by the On June 21st, 1906, the patient consulted me again, being friction of the upper edge of the corset. On raising the then 76 years of age, and extremely active and well. She breast slight dimpling was noticed opposite the tumour, had come up chiefly to arrange the electrifying of her house indicating that it was attached to the skin, and on carrying at Bournemouth, but was suffering from slight gouty eczema the hand into the axilla it was easy to feel enlarged and of the forehead and legs, and looked in to see me. She hardened glands in that situation. As the result of this again gave me an opportunity of completely examining her, examination it was clear that recurrence of the disease had when I found the scars perfect, and there was no evidence taken place in three situations. That which was much of any recurrence of the growth. This was nine years after advanced and largest, though the patient had not noticed it, the operation. was the glandular enlargement in the left axilla, the side on On Sept. 13th, 1911, a letter from Mr. Hosker informed which the breast had been previously amputated. Here we had me that his patient had kept wonderfully well until three one large hard mass, and several smaller glands could also years previously, in spite of losing a large part of her means. be felt. The tumour in the right breast had also existed a About this date she had a very severe attack of cardiac snfficient time for the infection of the right axillary glands, failure which was relieved by frequent subcutaneous injec- enlargement and hardening of which could be readily tions of strychnine. Her pulse never fell below 86 or 90 detected by the fingers. In consequence, I wrote to her after this illness, and she became subject to frequent and local medical advisers, maintaining that it would be useless severe attacks of cardiac asthma. There was no indication to attempt any operative procedure unless it were agreed of any return of the disease.’ About this time the patient that I should attack the growth and eradicate it wherever wrote to me a note of gratitude, and expressed herself as " it could be detected, and that this involved a detailed being "fairly well." dissection of both axillæ as well as removal of the remaining The patient died on June 18th, 1912. Mr. Hosker kindly breast. I further stated that from examination of the sent me the following account of her last illness: "Mrs. J. patient I thought she would bear this tax on her strength ran down somewhat suddenly at last. You will remember if she could be persuaded to sumbit a second time to when I last wrote she was subject to attacks of cardiac ’operation. asthma. These became more frequent, although perhaps not The operation.--The patient having given her consent, I so long or severe, and on June 3rd I found her legs much operated on Sept. 9th, 1897, assisted by Mr. Hosker, Mr. more swollen than usual, with some ascites, and weaker Leigh, and Mr. A. H. Vernon, who acted as anaesthetist. The cardiac action. Then followed more dropsy, and she died patient was first placed on her right side, and the left arm on June 18th." being abducted I carried my incision from the old scar across Wimpole-street, W. the hollow of the axilla, carefully dissecting out the areolar and of the lymphatic tract, tissue, deep fascia, part MUCOCELE OF THE ANTERIOR pectoral muscles leading up to the axilla, then made a com- plete clearance of the whole of the areolar and lymphatic ETHMOIDAL CELLS. ’contents of the axilla, careful to remove the two sub- being BY EMMANUEL C. ALLES, M.R.C.S. ENG., L.R.C.P. LOND. clavian glands, which, I think, are often missed and the ’cause of the cervical glands subsequently becoming infected. (From the Clinic of Professor Fuchs, Vienna.) All bleeding points having been secured, the wound edges were temporarily brought together and covered by a large FOR several reasons the following case has been con- sterilised pad. The patient was next rolled over on to her sidered sufficiently interesting and instructive to merit left side, and, the right arm being abducted, the right publication, and I have undertaken the task at the sug. breast was excised through a wide elliptical incision,gestion of Professor Fuchs-firstly, because of the rarity and the incision being continued up and across the of the case, together with its unusually long duration; arch of the axilla the infected glands and all the areolar and, secondly, because of the difficulty it gave rise to in pad of the axilla, together with the subpectoral lymphaticarriving at a correct diagnosis-a difficulty which was not ’course, were removed with the same care as on the left side, by any means lessened even by calling to our aid those All bleeding vessels having been secured, a large sterilisedmodern methods which we have at our command-namely, pad was placed over the wound and the patient was turnedX rays, transillumination, &c. The fact that the case un- back on to the right side. There being now no oozing fromfortunately ended fatally does not in any way rob it of any the left axilla, the edges of the wound were united by a con-of its interests ; indeed, it contributes a third argument for tinuous sterilised horsehair suture and sterilised dressingspublishing it, because of certain disclosures which were re- were applied. On the right side a couple of deep salmon-vealed by the post-mortem examination and which struck gut sutures were used to bring the skin together where the those1 of us who were present as very interesting and breast had been removed, and then a continuous horsehair iinstructive. suture to completely close the skin edges. The history of the case was as follows. A healthy well-built The double operation had one advantage from an operativeman, aged 25 years, presented himself at the Eye Clinic with point of view, for while the second operation was being per-a well-marked exophthalmos of the right eye. From his past formed the wound of the first was temporarily brought historyI it was elicited that he had scarlet fever when 3 years together and covered with a sterilised pad, so that by the of age, and the exophthalmos is said to have occurred soon time the second operation was completed one could be sureaftera this, and to have persisted ever since. There was also there would be no further oozing from small vessels and theana alleged injury to the right eye : the patient whilst falling