15th, the aneurismal tumour was large, apparently extending the whole length of the common femoral artery; rather triangular in form, occupying the triangular space between the sartorius and pectinæus; reducible, but not removeable by pressure; bounded abruptly above by Poupart's ligament; and pulsating very forcibly. Pressure upon the external iliac arrested the pulsation, and diminished the tumour, whilst pressure on the superficial femoral below* lessened the pulsation, but had little or no effect upon the tumour. The whole limb was swollen and tense, the foot oedematous and numb. There was much pain in the direction of the external branches of the crural nerve; the countenance was sallow and anxious; the appetite indifferent; tongue red; bowels costive; pulse quick and hard. Under these circumstances, he was placed in bed, bled once or twice, and purged, until the 21st, when, being in a more favourable state for the operation, and rather anxious for its performance, the external iliac was tied by Mr. Brodie. We were present at the operation, and must say that it was performed with a great deal of coolness and facility. The plan adopted, was that of Mr. Abernethy's, with some little modifications, and the artery was readily discovered and secured, but, in consequence of the vessel having contracted some adhesions to the surrounding parts, care was required in passing the ligature around it. A thin silk thread was employed, one end cut rather short, and the other brought out at the external wound, which was brought together by sutures and adhesive straps. In the evening, the pulse had got up a little, and at 12 P. M. next day, he was labouring under the following symptoms. Countenance anxious-breathing hurried and difficult-pain in the right side, increased on making a deep inspiration, speaking loud, or coughing-pulse corded and full-surface covered with perspiration tongue white and thickly coated-thirst confined bowels. He was bled to oz. xviij. with the effect of relieving the pain and diminishing the anxiety of countenance. He was likewise directed to take a senna draught every six hours until it operated. From this time no unfavourable symptoms had occurred up to the 28th, when we saw the patient. He still laboured under some cough, but it was unattended with pain in the side, or hardness of pulse. The countenance had lost the anxiety which marked it prior to the performance of the operation-the pain in the thigh had entirely disappeared the swelling of the limb was subsiding, and the wound was going on very favourably. It may be mentioned, that on drawing the ligature, the pulsation in the tumour ceased, and never afterwards returned, but the tumour did not very materially diminish in size at the time. Since that, however, it has gone on steadily decreasing, and a pulsation is distinguishable in the superficial femoral, as well as in another branch on the inside of the knee, probably the anastomotica magna. It will be observed that Mr. Brodie rating, in preference to adopted Mr. Abernethy's mode of opeCooper's. Sir Astley In a clinical lecture on the case, Mr. B. assigned as a reason, that he had twice done the former with success, and therefore was more au fait at it, and that as he had reason to believe the lower portion of the external iliac implicated in the disease, he naturally adopted that mode of operating, which would of the artery. enable him to arrive at the upper portion There is another disadvantage attending Sir A. Cooper's method (viz. a semi-circular incision carried alring) which is this, that there is a danger most transversely beneath the internal accident happened to no less a personage of wounding the epigastric artery. This than the French "Leviathan of Surgery' M. Dupuytren, in 1821, and the patient died of peritoneal inflammation. These were some of the reasons assigned by Mr. B. for operating as he did, but there was yet one more, and that a forcible one. In the low, or Sir A. Cooper's, operation, the ligature is applied just above the giving off the epigastric and circumflexa ilii, and the consequence is, that the plug may be so " inconsiderable between the ligature and these vessels, as to afford no sufficient security against secondary hæmorrhage. This is no visionary objection, for in a case in which M. Dupuytren tied the vessel at this situation, in the Hôtel Dieu, the patient nearly sank under secondary hæmorrhage evidently proceeding from the lower portion of the artery. On examination, M. D. perceived the epigastric to have become enormously enlarged, and to have brought the blood round almost to the verge of the ligature, on the separation of which, the adhesion between the inner coats of the vessel gave way, and bleeding was the result. In another instance, Sir A. Cooper tied the femoral artery, immediately below the origin of these branches, the epigastric and circumflexa ilii, and in that case also secondary hæmorrhage followed. The same thing, we believe, happened to Mr. Cline; and in the case at St. George's Hospital, upon which so much valuable indignation has been lately thrown away, the ligature is said to have been applied a little below the giving off of the profunda, and it is not unreasonable to conclude that this circumstance favoured, if it did not actually occasion, the occurrence of the secondary hæmorrhage. In the report it will be observed, that the subsidence of the tumour did not immediately follow the application of the ligature, and this, we believe, is always the case in what Scarpa calls "false aneurism." In the "true aneurism," which is merely a dilatation of the vessel, and which if left alone, will very often remain stationary for a considerable length of time, or even during the patient's life, if it be an old person, the contrary is the case, the tumour generally collapsing remarkably after tying the vessel. This, we apprehend, will afford a key to several circumstances connected with some of those operations on the arteries, which have lately astonished the surgical world. The bleeding practised in this case on the day after the operation, was bold and decisive, and was, in all probability, the means of saving the patient's life. The pleuritic affection with which he was attacked was insidious, but not the less dangerous, and had it not been "put out" at once, as it was by the decisive bloodletting, it might soon have proved more than a match for the lancet, or any other remedy. These inflammations of the pleura, all know, are not uncommon after severe injuries or operations, and in the case of ligature of the carotid, recorded in our third fasciculus, it carried off the patient in a very few days. We see nothing in the details of the case which would lead to an unfavourable prognosis. The ligature is yet to come away, but there is no good reason, which we are aware of, to apprehend secondary hæmorrage on its separation. However, as the French say-nous verrons. The patient, æt. 52, of "lax fibre" and intemperate habits, received a lacerated wound over the patella, denuding the bone, but not opening into the kneejoint This was on the 23rd, and on the 26th Dec. the wound was granulating, and all was well, save that at the lower part of the patella, there was dark coloured slough, the size of a shil He was orling, partially adherent." dered quinine, porter, and diluted nitric acid lotion to the part, and the next date of report is Jan. 30th, upwards of a month. At this time the slough had partially separated, so that it must have been almost in statu quo; the bone was exposed; there was severe pain in the joint, and on pressing the side of the wound, fetid pus escaped. Pulse small and quick--bowels costive. Wine and opium were administered, but an opening formed on the outer side of the joint, leading into its cavity, and discharging a quantity of dark-coloured, offensive pus, and on the 5th Feb. the leg and foot were dematous-the integuments inflamed and painful-discharge from the joint profuse-and the pulse small, weak, and innumerably rapid. These symptoms are noted down with the most careful ambiguity, but still they seem to * Lancet, No. 234. furnish an idea, faint and glimmering we own, of the characters of an affection, termed by nosologists erysipelas; at any rate, if the cedema, and inflammation of the integuments did not depend on erysipelas, we confess that we are totally unable to divine what they did depend upon. Under these circumstances, amputation of the thigh was proposed, and performed by Mr. Travers, at its middle, in consequence of the "cutaneous inflammation" having extended to its lower part. On examining the amputated limb, the leg and foot were found enormously enlarged, a large gangrenous patch, surrounded by a livid redness, occupied the calf, and there were several vesicles at the upper part of the leg. On making an incision into the limb, a mixture of pus and serum, escaped from the subcutaneous cellular tissue, as well as from that connecting the various muscles. The joint contained much offensive pus-its synovial membrane was highly inflamed-its cartilages softened, and in one part ulcerated, and the patella was softened, and "partially detached." The patient, on the second day after the operation, became delirious -there was pain in, and profuse discharge from the stump, which was of a dirty ash-colour, and on the morning of the 11th, he sank. jury in Mr. Stanley's case, by which the said non-professional public are taught to place no reliance whatever on the professional skill or veracity of a Cooper, a Brodie, a Bell, a Travers, an Abernethy, &c. By proving that such men are ignorant, the Lancet sagaciously concludes that the public will at once, decide that surgeons in general are infallible-that, in fact, the detection of an error in the former class will forever absolve the latter from all suspicion of such weakness! "As to the effect (says the Lancet) produced by this trial on the minds of the public, it is decidedly favourable to the great body of the Profession. It is calculated to raise the great mass of English surgeons, absurdly denominated GENERAL PRACTITIONERS, in public estimation.' This specimen of reasoning has no parallel in the annals of medical literature! Those men who have arrived at universal eminence in their professionby whom a great portion of the Profession has been taught-whose opinions are sought after and respected, both by medical men and by the public at largethese men, we say, are to be held up to ridicule, as totally ignorant-and, as a natural corollary, all those who have derived their opinions and practical precepts from these men, must rise in public estimation! One would really suppose that the Lancet considers its readers as totally incapable of a single exertion of This report is so confused, and the language so unlike what is commonly known as the King's English, that we cannot be at all sure of the exact nature of the case ;-as far, however, as we can judge, it appears to have been an attack of " gangrenous erysipelas" occurring, as that terrible disease generally does *We would ask the Lancet where is occur, in a person of weakened frame, the absurdity, or the degradation of the term Whether the and intemperate habits. suppuration within the joint, preceded, accompanied, or succeeded the erysipelatous inflammation, is not particularly clear, but, whichever was the case, it is obvious that amputation was, indeed, a dernier resort, and moreover, a very hopeless one. 8. CURIOUS SPECIMEN OF RATIOCINATION. The Profession is well aware that the Lancet has plumed itself for the illumination which it has been able to throw on the non-professional public, and on the "GENERAL PRACTITIONER?" It is that under which Hippocrates, and some of the most eminent in our profession have practised. It supposes a general acquaintance with all branches of the Profession-and without which acquaintance, no surgeon, no physician can be a good practitioner. This sentence of the Lancet is the greatest libel ever penned against the "GENERAL PRACTITIONER." The Lancet is for ever running out against " pure surgeons," and now it turns round and ridicules the term "GENERAL PRACTITIONER," by which it must advise the change to " pure surgery;" such as it is practised by Thomas Wakley, William Lawrence, and James Wardrop. thought as completely devoid of every particle of intellect! The conclusion which the PUBLIC must draw from all this (as far as the public can be influenced by such a tool as the Lancet) is this-that we are, one and all, from the highest to the lowest in the Profession, a set of blockheads-ignorant of our art-and leagued to screen each other when detected! Among practitioners, we have not heard a single dissentient voice as to this effect which the writings of the Lancet are calculated to produce. But we shall come a little closer to the point, and prove to a demonstration, the inconsistencies of the Lancet's reasoning. This instrument, this "scarificator," in its rage to excoriate an hospital surgeon, has trod under foot and traduced three GENERAL PRACTITIONERS-and then, with unparallelled effrontery, tells these last, that the whole procedure is decidedly favourable to that class of the profession to which they belong! First, here was Mr. Jarman, who saw Mr. Rolfe immediately after the accident-who washed away the gravelwho found a "hard moveable substancc in the interior, lying about an inch from the knee-pan"-who attended the pa tient home, helped Mr. Stanley to examine the limb, and applied himself the splints. Now we do not attach the slightest blame to Mr. Jarman for not discovering the true nature of the accident-but, in the name of justice, is he not as much responsible for the mistake as Mr. Stanley -must not all censures leveiled by the Lancet against the one, fall equally on the other, in the minds of the public? Then, again, there was Mr. Janet, whom we happen to know, and who is an experienced and able general practitioner He attended with Mr. Stanley-but he could not ascertain the precise nature of the hard substance near the patella, and he, too, is included in the sweeping accusations brought against the hospital surgeon. We now come to Mr. Lilly. This gentleman candidly acknowledged in court, that, after several examinations-"he felt the hard substance, and thought it was bone."-Lancet, No. 234, p. 746. It is true that Mr. Lilly discovered his mistake, when the flint perforated the skin, and displayed its real character; but surely there was nothing in this to ground a contrast between his judgment and that of Mr. Stanley. Thus, then, we see three GENERAL PRACTITIONERS, and one HOSPITAL SURGEON, all involved in one general charge of ignorance or incapacity, (for where all were concerned in the case, and neither of them discovered the stone till it partly came through the skin, all are necessarily included in the accusation, whether ill or well founded) and yet this instrument of justice insults the understandings of its readers, by asserting that, in damning one out of the four, the other three must be benefited! An impartial examination of the evidence, then, as well as of the general practitioners who actually saw the case, as the distinguished surgeons who heard of it, leads us to infer, that the obscurity of the accident would have prevented the generality of surgeons, of whatever denomination, from ascertaining, with any degree of certainty, the true nature of the case, before the flint made its way through the skin.* Two of the medical attendants (Mr. Stanley and Mr. Janet) we know personally and professionally; and, at the risk of another action for libel, we declare our firm conviction, that they are not inferior to that celebrated, experienced, and successful surgeon, THOMAS WAKLEY him. self, by whose advice, in opposition to that of Sir Astley Cooper, Mr. Lambert performed his renowned operation, now making the tour of Europe, and which enabled the said Mr. Lambert (ultimately) to remove, without pain or hæmorrhage, several inches of a troublesome and misshapen carotid, as thousands of passengers along the Strand can verify by oath. We have now, we think, proved, to a demonstration, that the attempt to draw public odium on Mr. Stanley, must in * Had we been called on for an opinion upon oath, the above is that which we would have given. A mistake was made by all concerned in this case, as the event shewed-and the probability is, that the same mistake would have been made by others-even by those who so loudly cry out shame! We neither censure nor applaud the evidence given by the hospital surgeons on this trial-we only state what we would ourselves have offered. It is porbable that a more moderate and diffident tone in the witnesses would have been better for the defendant. evitably draw public odium on all classes of the profession, not even exempting that class which has the misfortune of being selected by the most scurrilous publica tion that ever issued from the press, as the peculiar object of its mean sycophan: cy and nauseating adulation. That class stands not in need of such an advocate as the Lancet-whose censure is applause -whose praise is poison ! present, he applied cold to the headsinapisms to the legs, and cataplasms to the stomach. After these means, or with them, he employed the hydro-chlorate of iron, and the children recovered. Some cases are detailed in the Heidelberg Annals, which appear to show the utility of the medicine. 3. LIGATURE OF ARTERIES ULTRA TUMORES. VARIETIES. 1. AMMONIACAL SULPHATE OF COPPER IN EPILEPSY. some In a late Number of Hufeland's Journal, Dr. Urban, of Bernstadt, has published cases of epilepsy, cured by the above medicine, which, indeed, is not a new remedy. It is to be remembered, however, that Dr. Urban confines this treatment to those who evince no corporeal lesion, as the cause of the disease, and that he puts his patients on a very strict regimen, employing proper evacuations, sanguineous and intestinal, from time to time. These means are, perhaps, not merely auxiliaries, but principals in the methodus medendi. 2. MURIATE OF IRON IN SOFTENING OF THE STOMACHS OF CHILDren. Dr. Pommer having lost two children affected with vomiting and purging, found, on examination, that the mucous membrane of the stomach was in a state of ramollissement, or softening. He accordingly treated some other infants similarly affected, with the hydrochlorate of iron, and saved them. He was induced to employ this remedy from the recommendation of Professor Autenrieth, who found it very efficacious in arresting the distressing diarrhoeas that accompany or supervene on typhus and other bad fevers. We observe, however, that Dr. Pommer has conjoined other means which may have borne a considerable share in the cure. Thus, when the vomiting and purging were severe, he abstracted almost every kind of food and drink, except a few spoonfuls of warm milk twice a day. There being fever In the ARCHIVES GENERALES for November last, there is given an account of the wonderful success of these operations in this country, among others Mr. Lambert's case, which is introduced to our Continental brethren in the following terms:-"L'example de WARDROP a été suivi avec beaucoup de succés, dans un autre cas d'anevrysme, par le Doc TEUR JAMES LAMBERT." Mr. Lambert's case finishes, in the continental records, most successfully. "La tumeur finit aussi par disparaitre, &c." In the Ger man Journals, all these cases have been published as attended with the most happy results, and German surgeons are called upon to imitate the wonderful exploits of their English brethren! There was a saying, in the olden time, “ ominia vincit VERITAS, et prevalebit." We begin to think that the ancients were entirely mistaken, and that the adage should have run thus: "omnia vincit MENDACIUM, et prevalebit." There was a golden age-and there was an iron age -the present appears to be the age of BBASS. 4. FATAL HÆMORRHAGE FROM LEECHBITES. M. Lisfranc has lately related a case in the Royal Academy of Medicine, which occurred at LA PITIE. A female was received into the Hospital with an ulcer, and some symptoms of gastric inflammation. Thirty leeches were applied to the epigastrium, which bled moderately, and then stopped. Three days afterwards the leech-bites opened again, in the middle of the night, and the patient was found dead the next morning, from the profuseness of the hæmorrhage. |