The following case shows this disease in its most advanced stage. It is
extracted from the fifth volume of the London Medical Journal, and is
intituled, “An Account of the Fatal Effects produced by attempting to
remove a Ganglion by Seton.” It was drawn up by Mr. W. Dease, surgeon
in Dublin.
“In July 1781, a clergyman, aged thirty-seven, consulted me about a
moveable ganglion, of the size of a small nutmeg, situated between
the fore-finger and thumb of his right hand, near the wrist. He was
eager to have it removed, and had been advised, for this purpose, to
have a seton passed through it, as the best and most certain method;
but, as he was apparently a robust healthy man, and the ganglion was
attended with no pain, I advised him to consider it as a matter of no
consequence, and not to meddle with it. Four months after this I was
desired to visit him, and found him in a melancholy situation. A seton
had been passed through the ganglion, and the consequences were, that
the back of his hand had inflamed violently, that the ganglion had
rapidly and amazingly increased, and that the openings made by the
seton were filled with an ill-conditioned fungus, which sprung up as
fast as it was removed, and was attended with frequent hemorrhage, and
much pain. In consultation, it was agreed to remove this fungus by a
free incision, which was done, and the metacarpal bones appeared bare
and rough. Another opening was made through the thenar, and a seton
passed through it, in order more effectually to prevent the growth
of fungus. The bark was administered in large quantities, an opiate
was given at night, and due attention was paid to the regimen of the
patient. This method seemed to promise the most happy event. The fungus
appeared to be entirely destroyed, a laudable suppuration took place,
the swelling of the hand subsided, and the sores in a short time
were so contracted as to indicate their speedy cicatrization. These
favourable appearances, however, were not of long continuance; for,
after some time, the fungus began gradually to rise again, and any mode
of keeping it down, either by caustic, cutting, or pressure, seemed
to produce no permanent good effect, as it increased rapidly, and at
length degenerated into the most frightful cancerous fungus I have ever
seen. Every local application that has been recommended in similar
cases was tried in this, but without success; and internal remedies
proved equally inefficacious. He took, for a considerable length of
time, two ounces of bark in substance, in the course of twenty-four
hours, so that he took, in the whole, twenty-eight pounds of that
medicine. The extract of hemlock had also a fair trial, but produced no
apparent effect.
“When he had laboured under this complaint fifteen months, he was
advised to undergo the amputation of his hand; but before he would
consent to submit to this operation, he chose to have an account of
his case transmitted to the Royal Academy of Surgery at Paris, that
he might have their opinion of it: The result of which was, that
the members of the academy pronounced the fungus not cancerous, but
merely scorbutic. This decision, by the bye, should make us extremely
cautious in delivering our sentiments on similar occasions, without
seeing the patient, as much depends on the general appearance of the
sores in cases of this sort. The academy were of opinion, that the
disease was entirely local, and required only local treatment. For this
purpose, they advised that the fungus should be taken down by means
of euphorbium, savine, &c. and afterwards washed with salt water. If
this method proved ineffectual, recourse was to be had to the actual
cautery, from the application of which they seemed to expect the most
decisive advantages. To this mode of treatment the unhappy sufferer
submitted; and, during the space of six weeks, the fungus was almost
every day burnt down with the actual cautery; but his complaint all the
while continued to gain ground apace; so that being now disappointed
in all his expectations of relief from regular practitioners, he had
recourse to quacks of every denomination. The arsenic plaster of
Plunket was applied, and he was salivated for seven weeks. At length,
after undergoing the operation of a variety of nostrums, he again
placed himself under my care. In consultation, it was much doubted
whether amputation should now be thought of, as the patient seemed
to be in the last stage of a cancerous consumption. His limbs were
swelled, and his whole habit was wasted by the repeated hemorrhage from
the fungus, which was now so increased in bulk as to weigh down his
arm, and entirely cover the back of his hand. In short, after every
return of hemorrhage, it was apprehended that the next would put a
period to his sufferings.
“The hazard of the operation, and the little chance he had of its
proving successful, being explained to him, the unfortunate man
earnestly begged to be relieved from so hideous a load, even though he
should die under the operation. I therefore yielded to his entreaties,
and took off the hand a little above the wrist, in November 1782,
although there was a small indurated gland above the elbow. On
dissecting the hand immediately after I had taken it off, the fungus,
on being cut, appeared to be extremely similar to the substance of
the brain, and to arise from the metacarpal bones of the middle and
fore-finger. These bones were in part dissolved, and the other bones of
the hand were also in a morbid state.
“No accident occurred during the amputation; but soon after it, a
colliquative diarrhœa came on, which seemed to be increased by opiates
and astringents, but was at length checked with draughts of fixed
alkaline salt and lemon juice, swallowed in the act of effervescence.
He afterwards took the bark, drank seltzer water, and was allowed a
liberal use of wine. The suppuration for some time was ichorous and
bad, but he gained strength daily. At the end of seven weeks, the
stump was completely cicatrized, and the indurated gland above the
elbow had disappeared. He went into the country, drank goat’s whey,
bathed in the sea, became very corpulent, and seemed to be in perfect
health, but had somewhat of a sallow bloated appearance. He continued
well till July 1783, when he began to complain of pains in his back,
attended with rigidity. These pains, as they increased, extended down
his thighs and legs, and occasioned him to sleep ill at night. He grew
feverish, his pulse beat extremely quick, and his countenance acquired
a shining yellowish red colour, an appearance which I have remarked
to be characteristic of a cancerous habit. He now began to walk with
difficulty. I took a small quantity of blood from him, and found the
texture of the crassamentum extremely loose, and the serum in too
great quantity. He was very difficult to purge, and unfortunately was
under a constant necessity of taking medicines to procure the necessary
discharges. Antimonials in a variety of forms were given, and the bark
was again tried, as were all the medicines that are usually prescribed
in rheumatic cases. Blisters were applied, and issues cut in his
thighs, but all to no purpose. He was obliged to take to his bed in
August, and never after quitted it.
“It is difficult to form an idea of the constant and excruciating pain
this poor man suffered. Opium, though given in large doses, afforded
him but little relief, and at last none at all. He generally lay on
his back, fixed as it were to the bed, the least motion occasioning
the most intense pain. As the disease advanced, he complained of a
difficulty of passing his urine, which was loaded with a viscid mucus,
and he once discharged an oblong calculus; but at last he voided his
urine involuntarily, and sometimes even his fœces, but the latter
only rarely, when he had taken a purgative, which, as I have already
mentioned, was required to be of the most active kind, otherwise it
produced no effect.
“During the whole course of the disease, his pulse was rapid, but
his tongue was remarkably soft and florid. He was never delirious.
Latterly, he spit blood once or twice; his lower extremities became
very œdematous, and his back was covered with eschars; but these
dropped off, and the sores suppurated and healed kindly. Two months
before his death, his pains abated considerably. He died without pain,
March 4 1784, which was about two years and nine months from the time
the seton was passed, and a year and four months from the time he
underwent the amputation.
“His body was opened a few hours after his death. The abdominal viscera
appeared to be perfectly sound, and of their natural colour, except the
liver, which had a small steatoma on its convex surface, but was in
other respects healthy. The gall bladder was rather fuller of yellow
bile than it is generally found to be. The left kidney was enlarged,
and on dividing it longitudinally, much red gravel was found in its
pelvis, and the ureter seemed much lessened. The urinary bladder
was contracted, and its coats uncommonly thickened, but no sabulous
concretions were observed in it.
“On each side of the vertebræ lumborum, the lumbar regions were
rendered convex by a large cancerous deposition, which elevated the
psoæ muscles; and when the cellular investitures, which were condensed
into a cyst, were opened, the cancerous matter appeared in a large
quantity, in colour and consistence exactly resembling the fungus of
the hand, and not unlike the substance of the brain. The whole weighed
about five pounds; and when this was removed, the last vertebra of the
back, and the three first of the loins, were found to be in a softened,
eroded, and in some parts a totally dissolved state. There appeared
not the least mark of ichor, sanies, inflammation, or hardness of the
soft parts; nor were the mesenteric glands at all affected. The matter
seemed to have been really a cancerous exudation, and to be formed
chiefly of coagulable lymph. This cancerous mass seemed to possess a
remarkable dissolving power, which was exerted wholly on the bones, and
did not, as usual in cases of this sort, cause any schirrous hardness
of the surrounding soft parts.”