that time, there was no trace of enlargement. We now come to the question of treatment. In all the cases of the affection which have been published, compres sion has failed, on account of the pain which it induced; and, when we consider the anatomy of the parts, we might be led to expect as much. Ligature of the temporal artery has been tried, but, although it gave a temporary relief, it does not seem ever to have effected a cure. This, too, might have been expected; for, although the disease consists, in the main, of the convolutions of one trunk, the temporal, still the anastomoses between it and its fellow of the opposite side, as well as with the occipital and even the supra-orbital artery, must always be enough, and more than enough, to allow of the free ingress of the blood into the tumour. If this reasoning applies, and we believe that it does so, to the tying of the vessel which immediately feeds the tumour, must it not, à fortiori apply to the ligature of that great trunk which does not immediately feed it, we mean the common carotid? You tie the carotid, you expect to obliterate its dilated temporal branch, and why? Is it because a similar operation on the femoral artery will cure a popliteal aneurism? The analogy is not a fair one. Between the point of the ligature and the sac, there come off in the femoral no branches of any consequence. One or two of the articular arteries may arise just above the sac, but they are small, and, at any rate, anastomose with the tibials below, so as not to interrupt the remora in the sac itself. The new circulation is carried on principally by the branches of the profunda and common femoral, (we mean its long external descending ramus,) and not by the vessels of the artery tied. This With the carotid it is exactly the reverse. First, there is the division into internal and external, and, prior to this last terminating in the internal maxillary and temporal, there are eight branches given off, all of them having communications, more or less free, with each other. being the case, we put it boldly to any man of common sense, whether he can reasonably expect to obliterate an enlargement of the terminal branch of a vessel, whilst a full and free circulation must necessarily be kept up between that enlargement and the ligature. The conse quence of tying the common carotid is simply this, that the vessel is obliterated nearly as high as its division into the external and internal, but not one jot higher, because, above this, the circulation is brought into these vessels by their anas tomosis with the inferior thyroid of the same side, and the thyroid and other branches of the opposite, as well as by the free inosculations of the internal carotid. In fact, the man who imagines he can plug up the temporal artery by an opera. tion on the common carotid, might just as fondly attempt to obliterate the vessel of the great toe, by tying the artery at the groin! So much for what the operation has not accomplished, but let us look a little at what it has. In the case detailed by Dr. Maclachlan, there cannot be a doubt that it was the immediate cause of the patient's death-in the case which we are now to detail, there can be as little doubt that it led ultimately to the same end. J. Nowlan, æt. 22, was admited into Panton-square, with a pulsating swelling on the left parietal bone, in the situation of the posterior temporal artery. It could be emptied by pressure, but a large communicating branch passed across the vertex from the opposite temple, and contributed to supply it with blood. The cranium beneath appeared to be very considerably absorbed, and the integument above was stated in the Lancet, to be blue and ready to ulcerate, but the latter statement we have heard denied. The temporal artery had been secured, at least it was so supposed, by Mr. Babington, but with no efthe common carotid artery was tied by fect. The day after the man's admission, Mr. Wardrop, in order, as the reporter tells us "to completely arrest from almost every channel, the supply of blood to this rapidly increasing vascular tumour." Much difficulty was experienced in getting the needle round the artery, and a free bleeding took place (so goes the report) from two large thyroideal veins. The pulsation ceased, but the tumour did not collapse, and next day a thrill was again perceptible. On the fifth day, there was much fever, and he was bled to syncopeon the 7th, hæmorrhage, partly venous and partly arterial, occurred to a considerable extent, and he was again bled to fainting. On the 9th day, he was once more largely bled, venous hemorrhage had occurred daily since the operation, the wound was not disposed to unite, and the tumour distinctly pulsated. 11th day, Pain in the left eye-ball and orbit, with deafness, drowsiness, and mental disturbance, which increased on the 12th almost to coma, with contracted pupil. On the 13th day, he was better, but the eye-ball was found to be greatly protruding, which was attributed, by Messrs, Lawrence and Wardrop. to a powerful compression on the brain, exercised by an aneurismatic state of the vessels of the dura mater, communicating through the skull with the tumour on the head! This was certainly an odd notion enough, and turned out to be any thing but the true one. The protrusion in the eye-ball, however, continued to increase the sclerotica sloughed, and the humours were discharged. The ligature came away on the 25th, and the wound quickly healed. On the 26th October, the case was brought forward by Mr. Duncan, the very intelligent house-surgeon at Panton-square, in the Westminster Medical Society. After detailing the case, he requested the opinions of the members on the treatment to be adopted, for, at this time, the tumour was very little better than before the performance of the operation. It would not be difficult to raise a laugh, were we to record many of the opinions as to the nature of the disease expressed by gentlemen on that occasion. Mr. Mayo proposed excision of the tumour. Dr. J. Johnson recommended circumvallating it by a circular incision, and tying the vessels which fed it directly, as well as those which supplied it by anastomosis. Nothing further was heard about the case until the 4th January, when the poor fellow was admitted into the Middlesex Hospital, with lumbar abscess, and altogether in a most miserable state. On the 21st he died. The tumour, at this time, was large and pulsated very strongly. On dissection,* the posterior temporal artery was found to divide into two branches, one running, as usual, beneath *The principal facts stated here were given by us upon the cover of the last Fasciculous. We thought it better, however, to repeat them, that the case might not be incomplete. the skin, the other perforating the tendon of the occipito frontalis, and then, considerably enlarged, twisting and turning and coiling upon itself, looking, when injected, as like a varicose vein, as it is possible for a vessel which has no valves, to resemble one which has them. On examing the neck, the common carotid was obliterated, and converted into a cellular chord just up to its bifurcation, whilst the jugular vein was in nearly the same state of degeneration from the site of the ligature up to the division of the carotids, from which to the base of the brain it was plugged with coagulum There was much pus at the basis cranii, and around the commissura tractuum opticorum; it lay between the pia mater and arachnoid, and was continued within these membranes down the whole length of the spinal chord. The cranium was somewhat grooved beneath the tumour, just as it would be beneath a powerful muscle, but the pericranium was entire, and the inner surface of the bone was perfectly smooth and equal. We have thus given an abstract* of this very interesting case, and it seems to us entirely to confirm what we observed upon Dr. Maclachian's It establishes most completely the inutility of the ligature upon the carotid, for that vessel was plugged up no higher than (indeed not so high) its bifurcation. This is a fact of some importance, for, although we cannot well be accused of belonging to that IGNAVUM PECUs, who are eternally prating about "the wisdom of our ancestors," and entertain a most conscientious horror of every thing which was not known to pathologists in the good old days of Noah, still we do think that if any thing is car ried to excess at the present time it is the rage for tying carotid arteries. The operations on this vessel which have been performed of late by Mr. Wardrop, have been most unfortunate, and sorry as we should be, to attach blame to any man who endeavours to establish a principle in surgery, we would yet intreat Mr. Wardrop for his *The account of the case is culled from the LANCET; the dissection is recorded in the 9th Number of the MEDICAL GAZETTE, but we had also an opportunity of inspecting the parts ourselves. own sake, and for the sake of science, to pause awhile ere he repeats them. The only two proposals which appear to us in any way applicable to this pulsating tumour of the temporal artery, are those which were made by Mr. Mayo and Dr. Johnson, to wit, excision, and circumvallating the tumour by an incision. The second is certainly less formidable than the first, and would prove quite as effectual. If, as in Dr. Maclachlan's case, the disease be too extensive to admit of complete circumvallation, those branches which go to, and those which go from the tumour might still be tied, and that, from their increased size, without any great difficulty. This, after all, is in principle, only the operation daily performed upon a punctured artery, namely, the cutting off all influx of blood into the wounded part, by a ligature above and below. Some questions present themselves upon Mr. Wardrop's case, viz. the loss of the eye, and the obliteration of the jugular vein, but our limits will not allow us to consider them fully. We think, however, from the difficulty experienced during the operation-from the venous bleeding at the time, and from that which occurred afterwards, that the needle was unfortunately pushed through the coats of the vein, and part of it, at any rate, tied with the artery. Whether the ligature of both had any effect upon the eye, is more than we can pretend to say. very severe, and his health was a good deal broken in consequence. He could lie only in the horizontal position, and referred the pain accurately to the course of the great sciatic nerve. Mr. Earle put him upon alterative doses of the blue pill, with some relief to the pain, but not making progress under this plan, acupuncturation was tried, but only with slight effect. He was then ordered the subcarbonate of iron, 9j. every four hours, the dose being gradually raised to 3ss. The medicine disagreed with his stomach, and was discontinued. Mr. Earle now applied a dozen moderate sized moxas along the thigh, and with the happiest effect, for the pain in the thigh never returned. It was necessary subsequently to re-apply the moxa on the loins in consequence of some pain there, which was not relieved by cupping and belladonna plaster. On the 1st January, he was made an out-patient, and continues so well, that he talks of resuming his old situation as courier. We think the moxa is scarcely used enough by surgeons in this country. In some cases, it is decidedly preferable to cupping, on account of the manipulation and disturbance which the part must necessarily undergo during the latter process. In an inflamed joint, for instance, we have again and again, seen cupping ordered, the surgeon not considering that the pressure of the glasses and scarificator, and the disturbance done to the joint must inevitably do, at least as much mischief, as the local depletion can do good. As far as we have seen, however, the moxa is not so applicable to the acute stages of inflammation, as to the more chronic forms of sciaticaold sprains-stiff joints after rheumatism, and cases of that description. 7. Guy's HOSPITAL. HYDROCELE TREATED ON BARON LARREY'S PLAN.* The patient was a robust blacksmith, æt. 32, the subject of a large hydrocele, which had appeared gradually after a blow, inflicted twelve months previously. *London Med. Gazette, No. 8. The tumour was tapped by Mr. Key, on the 8th December, and 22 ounces of fluid drawn off. A common gum elastic catheter was then introduced through the canula into the tunica vaginalis, secured by adhesive plaster, and the canula withdrawn. Severe pain in the testicle and cord ensued, effusion of a gelatinous consistence took place, and, on the 11th, the instrument was removed, but a fresh secretion of serum into the tunica vaginalis being the consequence, the catheter was again introduced on the 20th. On the 23d, decided symptoms of inflammation had taken place, and it was again withdrawn. Adhesive inflammation now came on, and on the 21st January, the patient was discharged, a trifling induration in the tunica vaginalis only remaining. As an experiment, this case is satisfactory enough, but certainly the catheter will never supercede the ordinary method of injection for the cure of hydrocele. The common operation is over in a few minutes, is productive of but little pain, and is exceedingly successful. This, on the contrary, is tedious, painful, and the result any thing but certain. There are, however, some cases where injection has failed, and where the surgeon is obliged to resort either to incision, or the caustic potash, both which operations are extremely severe, and not entirely devoid of danger. It is in these cases, we think, that Barron Larrey's operation is deserving of a trial, as it is much more mild than either of the above, and not by any means, so likely to induce constitutional disturbance. Mr. Key has, also, treated a case of "house-maid's knee" in the same manner, and with the same success. The trocar and canula were pushed into the most depending part of the tumour, three ounces of fluid, having a reddish-yellow colour and partly coagulating by heat, drawn off, the gum-elastic catheter introduced into the cyst, and a roller applied around the joint, which was kept cool by evaporating lotions. Much inflammation was induced, and on the 12th day, the catheter was removed, when pressure and the emp. ammon. c. hydrarg. completed the cure. The treatment is only applicable to burse which contain fluid. In such cases, the evacuation of the fluid by a puncture, and subsequent active blistering, will not unfrequently effect a cure. A very short time ago, a woman was admitted into St. George's Hospital, with a swelling, the size of a pigeon's egg, in the right ham. It had no pulsation, had an undulatory fluctuating feel, and was not very painful upon pressure. The patient stated that it had been coming on for eight years, had been once entirely removed by mercurial ointment, but subsequently returned, and was attended with such pain as to completely lame her. Mr. Brodie imagining it to be an enlarged bursa, punctured it with a fine needle, when there dribbled out about an ounce of yellowish fluid, of an oily consistence, which entirely coagulated upon heat. A blister was applied, and kept open by the savine ointment, and when we saw the patient last, the tumour had almost entirely disappeared. If, however, the bursal sac, instead of containing fluid, has become converted, as happens in a great many cases, into a solid tumour, with hardly any cavity in its centre, it is clear that neither the introduction of a catheter, nor incision, can be of any service. In such a case the sac must be dissected out, and it is really surprising how little disturbance such an operation will cause in a tolerably healthy constitution. We lately saw an instance where this operation was performed by Mr. Rose at St. George's Hospital, and the inflammation which followed was exceedingly trifling. At the same time, it cannot be denied that bad, and even fatal, consequences will occasionally follow the excision of the bursa, and that, sometimes, without the surgeon being able to detect the why or wherefore. Not very long ago, we recorded a case of this kind, which happened to M. Velpeau, at the Hôpital de Perfectionnement. 8. ST. GEORGE'S HOSPITAL. PECULIAR AFFECTION OF THE THIGH, thigh, dependent on rheumatic inflamTwo cases of a peculiar affection of the mation, and terminating in ulceration of the cartilages, are related in the 8th No. of the Medical Gazette. The symptoms presented by both patients bear a very close resemblance, and the affection ap pears to be an exceedingly severe, and even dangerous one. In either case the swelling came on suddenly, and was marked by some peculiar characters. It extended from the upper part of the thigh affected over the knee, for some little distance down the leg-it was not circumscribed, but still its principal seat was evidently in the lower part of the thigh and knee, above and below which it gradually passed away it was tense-elastic-exquisitely painful on the slightest pressure, and of a glossy, marbled white, bearing a very striking resemblance to the description of phlegmatia dolens. The patient could not support the least motion of the knee, but the pain, though partly in the joint, appeared to be principally in the textures around it. These, with considerable irritability and feverishness, were the symptoms presented, upon their admission, by the patients, both of whom had been much exposed to damp and cold, the first being a common prostitute-the second, a wash erwoman. We shall not follow up the details of the individual cases; suffice it to say that, in the first, which was under the care of Mr. Brodie, leeches frequently repeated, with calomel and opium, so as to affect the mouth, were employed, and with temporary benefit. Symptoms, however, of ulceration of the cartilages of the kneejoint supervened, and were attended with the most intense suffering. Leeches, blisters, fomentations and plasters of belladonna, and, lastly, a caustic issue were employed, but with no permanent good efiect. Ulcers formed over the sacrum, which somewhat relieved the pain in the knee, but the left shoulder now became affected with excruciating pain, and a bilious diarrhoea came on, and carried off the unfortunate patient. On dissection, the cartilages of the knee-joint were found extensively ulcerated, and the periosteum of the femur, though not perceptibly thickened, was easily separable from the bone, which was preternaturally vascular. The only remedy which had even a temporary effect in this case, was the calomel and opium, and Mr. Brodie, in his clinical lecture, stated that he had met with symptoms precisely similar, in a page in a nobleman's family, which were successfully treated by the above remedies. The case which we noticed in our first fasciculous, (page 450) appears to us to have been the same, or nearly the same, affection, save that, there, the inflammation had not attacked the joint, and had taken on the chronic, instead of the acute form. The second case we do not deem it necessary to relate at length here. It is still under treatment by Mr. Keate, and the reporter states, that the woman "bids fair, from the similarity of symptoms, of constitution, and even of personal appearance, to fall into the same state as the other unfortunate patient did before her. 9. ST. THOMAS'S HOSPITAL. FURIOUS DELIRIUM TREATED BY MERCURY. A young man, lately from the country, but for the last six weeks, in Barclay's brewhouse, was received into St. Thomas's Hospital (having been three days ill) with furious delirium, constant jactitation, spitting of viscid saliva, flushed face, hot dry skin-answers questions in a loud, hurried, and anxious mannerpulse 60, full, and firm. Was bled, and fainted when sixteen ounces were abstracted-after which, he was more tranquil, but seemed much exhausted. Ten grains of calomel every four hours. Towards evening, (5th Jan.) he became more anxious, and ultimately furious. Twenty-four leeches to the temples, with another interval of quietude. At 5 o'clock in the morning of the 6th, the delirium again returned. Eighteen onces of blood were drawn, and produced syncope after which, he slept, and was then more composed. But he still spoke in a hurried manner, and the pulse was 150, easily compressible. The calomel in the abovementioned doses, was still taken regularly. Had three dark, offensive, and liquid motions. Evening of the 6th. Is more furious and restless-flushed face-constant spitting-pulse quick, not firm. Leeches to the temples-blister to the head. The calomel every three hours. The mouth became sore at 8 o'clock in the morning of the 7th, aud" directly the gums were decidedly affected-he became tranquil." The pulse fell to 80, and the patient rapidly recovered.-MEDICAL GA ZETTE. |