5urdi(al £m% ■i Service of R R BIGGAR, Jr., M. D. > it fevii A -■ %- AC'ft j. /i ' ,J-: '.■■-.'y\ ::^--^. " .a.'N..>."" '■ '-!.-■■ ': ■ /'-^■.i y SURGICAL CASES SERVICE OF H.RBIGGAR,Jr.,M.D. The Surgical Institute, ) Ci^EVELAND, May, 1896. ) Case I. — Mrs. S. — aet. 50. Two years ago was operated on by a skilled surgeon for carcinoma of the mamma ; it returned, and she consulted me for a second operation. The disease was located in the old cicatrix and had encroached upon the axilla. The incision fol- lowed the scar of the former operation and the cicatri- tial tissue was dissected away. 1 he axillary glands were found to be enlarged and hard ; they were carefully re- moved one by one far up in the arm pit and a short dis- tance down the arm. The indurations followed closely the course of the large vessels, and in particular the axillary vein. Some of the glands were attached to the sheath of the vein itself and required most careful dis- section to remove them without injury to the vessel. They extended up into the space of Mohrenheim and even so far as the internal surface of the clavicle. The dissections in the proximity of the large blood vessels were entirely done with the fingers. After all the enlarged glands had been removed and the oozing of the small vessels stopped by means of pressure with iodoform gauze, the incision was closed with a contin- uous catgut suture. Three silkworm gut sutures were put in as stays. A strip of iodoform gauze was left in the axillary extremity of the wound for drainage ; also at the lowest point of the subcutaneous wound a punc- ture was made with a knife through the skin and a' glass drainage tube introduced. The wound was dusted with iodoform and dressed antiseptically with iodoform and sublimated gauzes, cotton and a many- tailed bandage over all. In twenty-four hours the dressings were saturated with watery exudate. They were changed, and in forty-eight hours, the dress- ings being clean, both drainages were removed and the loose stitch drawn taut Against all persuasion, the patient refused to remain in the hospital longer than six days, as she felt so well, and returned home. Her family physician re- ports a rapid recovery to health v/ith no return so far, though only eighteen months have elapsed. Of all tumors of the breast, carcinoma occurs in about 87 per cent. Operative procedure must be done early in the course of the disease, in fact, an early diagnosis is most important to cure. Hal- stead finds that by his operation lie lowers the mortal- ity considerably. By the old method of the simple elliptical incision, the short axis of the ellipse hardly brought the incision free from the skin involvement. Then the circular incision was used and is still today. But as the sheath of the pectoralis muscle is frequently involved, and even the muscle itself, Halstead began his incision high up, almost over the outer end of the clavicle, and by sweeping inwards and downwards, toward the sternum, encircled the breast, ending in the first line of incision. He removes the breast, pector- alis major and all the glands in this region, in Mohren-, heim's space and in the axillary space. He finds that a higher percentage of those operated on pass the 3^ year limit, and surely in this dread disease a woman should be <^iven every opportunity. It is a question as to whether all glands should be removed. Some take out healthy glands on suspicion, but, as every healthy gland has a functon to perform, a great deal of usefulness is lost by so doing. Case H. — Carl G. — aet. 15. Eighteen months ago he fell from a bicycle and injured his right hip. It re- fused to get well, and he was obHged to be in bed for eight weeks. Since the injury he has been greatly troubled with his leg. At times he could not even sit up and has been confined to his bed ever since. He was sent to a sanitarium and treated for rheumatism for six weeks with no result. On his coming to me I found a distinct tubercular history on the maternal side. J put him under chloroform and gave him a thorough examination, and found impairment of mo- tion of the right hip joint and considerable difference in the dimensions of the two legs. In length, from ilium to malleolus, the right was one inch shorter. The calf of the right leg was one-half inch smaller, and the thigh less by three-fourths of an inch. I painted the right hip daily for a week v>rith tincture iodine, and gave him internally rhus toxi- codendron. For six weeks I gave electricity daily along the course of the sciatic nerves and along the hip and thigh, anteriorly and posteriorly, from" the spine to the knee. He was massaged daily by a professional masseur, and during the entire 8 course oi treatment he wore a brace of .my de- sign — a modification of Thomas' extension brace. At the end of six weeks he went home cured ; the meas- urements of the two legs are identical, and he walks, runs, rides a bicycle and has full faculties of his leg as before. Case III. — Mrs. W , aet. 32. She came to me suffering from a growth of some kind in the abdomen. The symptoms she presented were frontal and occipi- tal headache, severe pain in her back, prostration, urine frequent and scanty, and bowels very irregular and constipated. The tumor was of such size that it encroached upon the free motion of the lungs, and she had great diffi- culty in breathing. At times she would become almost asphyxiated. On examination I found she had a large ovarian cyst of the left organ. She had been to a sur- geon of repute who had declined to operate, believing that her condition was so low as to contra-indicate it. She was in the hospital two days before the operation in order to tone up the heart and general condition. She was given two-drop doses of digitalis every four hours, and a whiskey sling immediately before the operation. She also had hot water given her three times a day in pint draughts, and a pint three hours before the operation, in order to thoroughly soak the tissues of the body and overcome the distressing after- thirst. Chloroform was given and the abdomen opened. The diagnosis was correct. . The cyst was found to be adherent to the peritoneum and to the tube and broad ligament of the left side as well as to the intestines and omentum. It was emptied of four gallons of thick, heavy, pea-soup fluid. 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