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246 A Mirror OF THE PRACTICE OF MEDICINE AND SURGERY IN THE HOSPITALS OF LONDON. LONDON HOSPITAL. WOUND OF THE POPLITEAL ARTERY BY THE PLUNGING OF A KNIFE INTO THE THIGH; LIGATURE OF THE VESSEL ABOVE AND BELOW IT; ACUTE RHEUMATISM ON THE FOURTH DAY; SECONDARY H&AElig;MORRHAGE, AND DEATH ON THE SIXTEENTH DAY. (Under the care of Mr. WORDSWORTH.) 2Talla est jalia -pro certo noseendi via,,-nisi quam plurimas etjmorbornm et dissectionun-i tristorias, tam aliorttm propnas, collectas habere et inter se com- parare.&mdash;MORGAGNI. De Sed. et Cuus. iilorb. lib. 14. Prowmium. THE following case evidently failed from a want of power t< occlude the artery, probably induced by the concurrent rheu matism, which at one time threatened the pericardium, anc consequently required to be treated by a somewhat restricted diet. It is evident, too, that the blow was the exciting cause of the secondary haemorrhage, probably by disturbing the liga- tures, and so interfering with the formation of an organized clot, or adhesion of the divided coats. The difficulties were again increased bya very early separation -of both ligatures. In attempting a second operation, the following circumstances required to be taken into considerations ’First, the source of -the secondary bleeding. Several circumstances .pointed to the lower end of the .artery as the -origin of it; but had it been possible to decide positively on that point, secondly, in attempt- ing to re-secure it, the artery must have been sought for by opening the popliteal space from behind, -as the .artery was originally tied near the joint, and by ret-raction it would be still more inaccessible. Thirdly. But failing in that effort to restrain the bleeding-for it might have come from above- there would then be the necessity of a third operation on the common or superficial femoral, or of amputation : the former proceeding would in all probability have produced mortification of the leg; the latter, could the poor fellow have borne it, would have met all the difficulties of the case. But on a careful consideration of all the circumstances, (not forgetting the probability of a repetition of the bleeding,) it was deemed expedient not to attempt further operative proceedings, but rather to rely on pressure on the artery above, combined with such local means as could be devised to prevent any sudden and copious irruption of blood; but the separation of the npper ligature, allowing an additional loss of blood, decided the poor fellow’s fate, as fatal sinking soon followed. It may therefore be inferred that he could scarcely have survived amputation or deligation of the femoral, had either been considered justifiable. We avail ourselves of the abstract of the case, the notes of which were taken by Mr. Lloyd, the dresser of the patient. Richard B-, aged twenty-nine, in cutting open a bale of hides, plunged a knife deeply into his left thigh, wounding the popliteal artery. Great bleeding at once occurred, and he was carried off to the London Hospital as soon as possible, being at .the time of the accident in the Leadenhall market. He was admitted July 16th, 1857, under the care of Mr. Luke, in whose absence Mr. Wordsworth attended. The man was quite faint, having lost probably a pint of blood. Consequently it was considered inexpedient to administer chloroform. The wound was about an inch and a half in length and three inches in depth, on the front and inner side of the thigh, a few inches. above the knee-joint, passing obliquely downwards and inwards. The house-surgeon, (Mr. Owen,) thinking it might perhaps come from the great anastomotic, had dilated the woun I with a view of securing the vessel; but, on assuring himself of its deep source, applied pressure to the femoral, and despatched a messenger for the sureeon. The temperature of the leg was not much depressed, and pulsation could be felt in the posterior tibial at the ankle. The depth of the wound and its direction, added to the mode of bleeding, at once indicated its source. The wound was there. fore enlarged, upwards and downwards, to the extent of about five indies, the muscles freely divided in its track, and, after some tedious dissection, an aperture placed obliquely in the artery, and occupying about one-third of the calibre, was found. Ligatures were carried under the artery, by means of an aneurism needle, and tied above and below the wound. Arterial haemorrhage at once ceased, but some vein bled from the bottom of the wound; consequently graduated compresses were intro. duced, the edges brought together by strips of wet lint, ’and the whole limb tightly -bandaged from the foot, and placed ,on. an inclined plane of pillows. The patient greatly recover after the operation, which was necessarily long and tedious, and of course attended by some loss of blood. Though a delicate and spare man, he said he had always enjoyed good health July 17th.&mdash;The temperature of the limb somewhat above that of the opposite leg; no hcemorrhage since operation. 18th.&mdash;The dressings removed and re-applied; no bleeding, The dresser (Mr. Lloyd) perceived pulsation in the postetict tibial at the ankle. 20th.&mdash;A smart attack of acute rheumatism. 21st.&mdash;During the night he accidentally kicked the wounded part, and caused some haemorrhage. 23rd.&mdash;At half past five a rather copious loss of blood, of a .bright colour, which was restrained by pressure on the femoral. As the h&aelig;morrhage had ceased since the morning, and inter. ferenoe must have involved a serious operation, it was decided, after consultation, to leave the case under’strict surveillance. 25th.&mdash;Some h&aelig;morrhage ’occurred, but was soon restrained ’by -pressure. The faroe of the circulation was diminished by a weight (41bs. held on ’the artery at the groin. Pulsation - evident in posterior tibial. 27th.&mdash;Lower ligatare found loose in the wound; knot tsecure. 28th.&mdash;Profuse bleeding at eleven A.M. As the patient was too depressed for any ol;eration, graduated compresses were introduced into the wound, and pressure assiduously main- tained by the hand; etimulants were administered, without reaction. He sank a.nd died at four A.M. on the 29th. On examining the wound after death, the upper ligature was feand detached and loose in the wound (the lower had been removed on the eleventh day). Bsth ends of the artery were quite patent. The ligatures had clearly divided the coats of the artery: the upper, close to the origin of the great anas- tomotic, which was quite free, and admitted a crow-quill; the lower, near to some large muscular branches, which were un- plugged. There was no inversion of the coats of the artery at either end; no contraction, but considerable retraction; no clot in either. The epithelium was glassy and transparent, and there was no appearance of effused lymph. A general examination was prohibited. METROPOLITAN FREE HOSPITAL. SUBUNGUAL EXOSTOSIS OF THE GREAT TOE ; EXCISION WITH SUCCESS. (Under the care of Mr. HUTCHINSON.) AN interesting example of this not very rare form of exostosis presented itself a few weeks ago amongst the patients,at this hospital. The patient was a tall, florid girl, aged eighteen. The growth had been slowly increasing for about nine months, It was about the size of a hazel-nut, had a broad base, and -was situated on the outer side of the ungual surface of the right great toe. The nail had been lifted up, and partially destroyed by ulceration. Mr. Hutchinson remarked upon the campam- tive frequency of these exostoses in women, stating that his experience quite coincided with that of others respecting Jt. He thought ke had seen more than a dozen in women, and only one or two in men. He also directed attention to the age St which it usually occurred-that, namely, of adolescence, a period at which all forms of exostosis more frequently present themselves than any other. The localization of the disease was evidently due to irritation, whilst the predisposition was sup- plied by the tendency to vigorous growth peculiar to the.age. In some cases it might possibly be that the sudden cessation of natural growth in advanced adolescence caused a teinporary liabifity to these abnormal developments. Another -fact re- specting exostoses generally was that they were usually prn- duced on a surface naturally somewhat roughened and spinous.

METROPOLITAN FREE HOSPITAL

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246

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

LONDON HOSPITAL.

WOUND OF THE POPLITEAL ARTERY BY THE PLUNGING OF A

KNIFE INTO THE THIGH; LIGATURE OF THE VESSEL ABOVEAND BELOW IT; ACUTE RHEUMATISM ON THE FOURTH DAY;SECONDARY H&AElig;MORRHAGE, AND DEATH ON THE SIXTEENTHDAY.

(Under the care of Mr. WORDSWORTH.)

2Talla est jalia -pro certo noseendi via,,-nisi quam plurimas etjmorbornm etdissectionun-i tristorias, tam aliorttm propnas, collectas habere et inter se com-parare.&mdash;MORGAGNI. De Sed. et Cuus. iilorb. lib. 14. Prowmium.

THE following case evidently failed from a want of power t<

occlude the artery, probably induced by the concurrent rheumatism, which at one time threatened the pericardium, ancconsequently required to be treated by a somewhat restricteddiet. It is evident, too, that the blow was the exciting causeof the secondary haemorrhage, probably by disturbing the liga-tures, and so interfering with the formation of an organizedclot, or adhesion of the divided coats. The difficulties were

again increased bya very early separation -of both ligatures.In attempting a second operation, the following circumstances required to be taken into considerations ’First, the source of -thesecondary bleeding. Several circumstances .pointed to thelower end of the .artery as the -origin of it; but had it been

possible to decide positively on that point, secondly, in attempt-ing to re-secure it, the artery must have been sought for byopening the popliteal space from behind, -as the .artery wasoriginally tied near the joint, and by ret-raction it would bestill more inaccessible. Thirdly. But failing in that effort torestrain the bleeding-for it might have come from above-there would then be the necessity of a third operation on thecommon or superficial femoral, or of amputation : the formerproceeding would in all probability have produced mortificationof the leg; the latter, could the poor fellow have borne it,would have met all the difficulties of the case. But on acareful consideration of all the circumstances, (not forgettingthe probability of a repetition of the bleeding,) it was deemedexpedient not to attempt further operative proceedings, butrather to rely on pressure on the artery above, combined withsuch local means as could be devised to prevent any suddenand copious irruption of blood; but the separation of the npperligature, allowing an additional loss of blood, decided the poorfellow’s fate, as fatal sinking soon followed. It may thereforebe inferred that he could scarcely have survived amputation ordeligation of the femoral, had either been considered justifiable.We avail ourselves of the abstract of the case, the notes ofwhich were taken by Mr. Lloyd, the dresser of the patient.Richard B-, aged twenty-nine, in cutting open a bale of

hides, plunged a knife deeply into his left thigh, wounding thepopliteal artery. Great bleeding at once occurred, and he wascarried off to the London Hospital as soon as possible, being at.the time of the accident in the Leadenhall market. He wasadmitted July 16th, 1857, under the care of Mr. Luke, inwhose absence Mr. Wordsworth attended. The man was quitefaint, having lost probably a pint of blood. Consequently itwas considered inexpedient to administer chloroform. Thewound was about an inch and a half in length and three inchesin depth, on the front and inner side of the thigh, a few inches.above the knee-joint, passing obliquely downwards and inwards.The house-surgeon, (Mr. Owen,) thinking it might perhapscome from the great anastomotic, had dilated the woun I witha view of securing the vessel; but, on assuring himself of itsdeep source, applied pressure to the femoral, and despatched amessenger for the sureeon.

The temperature of the leg was not much depressed, andpulsation could be felt in the posterior tibial at the ankle. Thedepth of the wound and its direction, added to the mode ofbleeding, at once indicated its source. The wound was there.fore enlarged, upwards and downwards, to the extent of aboutfive indies, the muscles freely divided in its track, and, aftersome tedious dissection, an aperture placed obliquely in theartery, and occupying about one-third of the calibre, was found.Ligatures were carried under the artery, by means of ananeurism needle, and tied above and below the wound. Arterialhaemorrhage at once ceased, but some vein bled from the bottomof the wound; consequently graduated compresses were intro.duced, the edges brought together by strips of wet lint, ’andthe whole limb tightly -bandaged from the foot, and placed ,on.an inclined plane of pillows. The patient greatly recoverafter the operation, which was necessarily long and tedious,and of course attended by some loss of blood. Though adelicate and spare man, he said he had always enjoyed goodhealth

July 17th.&mdash;The temperature of the limb somewhat abovethat of the opposite leg; no hcemorrhage since operation.

18th.&mdash;The dressings removed and re-applied; no bleeding,The dresser (Mr. Lloyd) perceived pulsation in the posteticttibial at the ankle.

20th.&mdash;A smart attack of acute rheumatism.21st.&mdash;During the night he accidentally kicked the wounded

part, and caused some haemorrhage.23rd.&mdash;At half past five a rather copious loss of blood, of a

.bright colour, which was restrained by pressure on the femoral.As the h&aelig;morrhage had ceased since the morning, and inter.ferenoe must have involved a serious operation, it was decided,after consultation, to leave the case under’strict surveillance.

25th.&mdash;Some h&aelig;morrhage ’occurred, but was soon restrained’by -pressure. The faroe of the circulation was diminished by aweight (41bs. held on ’the artery at the groin. Pulsation- evident in posterior tibial.

27th.&mdash;Lower ligatare found loose in the wound; knottsecure.

28th.&mdash;Profuse bleeding at eleven A.M. As the patient wastoo depressed for any ol;eration, graduated compresses wereintroduced into the wound, and pressure assiduously main-tained by the hand; etimulants were administered, without

reaction. He sank a.nd died at four A.M. on the 29th.On examining the wound after death, the upper ligature was

feand detached and loose in the wound (the lower had beenremoved on the eleventh day). Bsth ends of the artery werequite patent. The ligatures had clearly divided the coats ofthe artery: the upper, close to the origin of the great anas-tomotic, which was quite free, and admitted a crow-quill; thelower, near to some large muscular branches, which were un-plugged. There was no inversion of the coats of the artery ateither end; no contraction, but considerable retraction; no

clot in either. The epithelium was glassy and transparent,and there was no appearance of effused lymph. A generalexamination was prohibited.

METROPOLITAN FREE HOSPITAL.

SUBUNGUAL EXOSTOSIS OF THE GREAT TOE ; EXCISION WITHSUCCESS.

(Under the care of Mr. HUTCHINSON.)AN interesting example of this not very rare form of exostosis

presented itself a few weeks ago amongst the patients,at thishospital. The patient was a tall, florid girl, aged eighteen.The growth had been slowly increasing for about nine months,It was about the size of a hazel-nut, had a broad base, and -wassituated on the outer side of the ungual surface of the rightgreat toe. The nail had been lifted up, and partially destroyedby ulceration. Mr. Hutchinson remarked upon the campam-tive frequency of these exostoses in women, stating that hisexperience quite coincided with that of others respecting Jt.He thought ke had seen more than a dozen in women, and only one or two in men. He also directed attention to the age Stwhich it usually occurred-that, namely, of adolescence, aperiod at which all forms of exostosis more frequently presentthemselves than any other. The localization of the disease was

evidently due to irritation, whilst the predisposition was sup-plied by the tendency to vigorous growth peculiar to the.age.In some cases it might possibly be that the sudden cessation ofnatural growth in advanced adolescence caused a teinporaryliabifity to these abnormal developments. Another -fact re-

specting exostoses generally was that they were usually prn-duced on a surface naturally somewhat roughened and spinous.

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Thus their frequency on the linea aspora of the fumur, andespecially on the ridge leading from it to the inner condyle,also on the borders of the bicipital groove of the humerus,whilst they are rarely ever found growing from surfaces per-fectly smooth, whether round or flat. This condition of rough-ness is possessed remarkably by that part of the terminalphalanx which supports the nail. The wearing of much closerfitting shoes was no doubt the reason, why women have themon, the toes so much oftener than men. The great toe was innineteen cases out of twenty the one affected, and almost in-variably its outer border, just where the shoe would press. IWe have seen this form of exostosis once on the finger, thepatient being a young woman under the care of Mr. SpencerSmith in St. Mary’s Hospital. If we remember right, thethimble-finger was the affected one. With regard to treatment,although amputation of the phalanx had been advised by Mr.Liston, and subsequently by M. Lenoir, of the Necker Hospital,simple excision is- perhaps much preferable when it can bedone. It must, however, be done deeply, and requires a smallcrnved pair of cutting pliers. It is essential to cut out the

growth from its very base, as if merely its surface be removeda, troublesome sore is apt to remain. This case turned outwell.

CLINICAL RECORDS

TREATMENT OF TIC DOULOUREUX BY DIVISION OF THE NERVE.

WHEN all other means have failed to cure that agonizingaffection, tic douloureux, the next thing which comes under con-sideration is the division of the nerve, or the removal of a por-tion of it. We have seen both of these practised many times.The latter is, perhaps, a preferable proceeding, because, insimple division, the ends of the nerve are sure to reunite, withsubsequent return of the old pain and extension of the influ-ence along its course, like a connected electric wire. Thisconnexion is certainly destroyed when a piece of the nerve isremoved. On the 22nd of August, Mr. Fergusson divided thesub,maxillary branch of the fifth nerve, as it passes throughthe mental foramen, of an old man who has been for years sub-ject to this painful disease, which-the old story-has resistedeverything that usually affords relief. Under the influence ofchloroform this was easily effected. It may produce a cure, asit sometimes does: it will, no doubt, for a time afford relief.At the same time .Mr. Fergusson showed another man, an oldpatient of King’s College Hospital, in whom the nerve hadbeen twice divided, with relief for a time, the pain returning.On the third occasion he removed a piece of the nerve by meansof a gouge applied just over the bone; this was more effectualfor a longer time, but still the poor man, who is otherwisestout and ablebodied, is a great sufferer. The anxious expres-sion of countenance, with the worn-out aspect, is really dis-tressing to witness in these cases. We are not aware whetherit has ever been tried in tic douloureux, but we should like tosee the nerve destroyed by the delicate wires of the electric

cautery, which is being used with so much advantage at thepresent time in a variety of affections.

RECURRENT EPITHELIOMA OF THE LIP.

A SHORT time back we witnessed the operation of removalfrom the lower lip of a cancerous growth, by Mr. De M&eacute;ric, atthe, Royal Free Hospital, and which has evinced a disposition.to recur. The particulars of the case, as furnished us by Mr.W. Curran, house-surgeon to the hospital, are, that the patientwas a labourer, thirty-one years of age, a large, muscular,healthy idan, of temperate habits, and free from any hereditarytaint. When admitted, there was a hard, irregular swelling,of. considerable size, on the outer margin of the lower lip, offour months’ growth, first noticed as a chapping, and thenassuming the appearance of a blister, being regarded as due tothe irritation of a pipe, to which, Mr. Ourran’s notes mention,the patient " clings with a tenacity worthy of a better cause."Two weeks before admission he had severe darting pain, par-ticularly at night, with aching along the face and jaws. Thedisease was entirely removed by a V incision, the edges beingbrought together by needles. The wound healed up, but lefta rugged cicatrix, at the bottom of which a fistulous tract re-mained, which admitted of the occasional escape of saliva.When we last saw this man there was an indurated fissure,with return of pain, relieved by smoking or friction. The sur-

rounding skin was hard and nodulated, and adherent to theadjacent bone, which is itself likely to become involved in the

disease. Notwithstanding all this, the man’s general health isgood.

Shortly before the operation in this case, we saw Mr. Cock,at Guy’s, remove a large cancerous ulcerated tubercle from theunder-lip of a man by V incision; it had its origin in a, pipe.The wound healed up perfectly.

This disease is most probably at first local, and free andearly extirpation is the remedy. Sometimes the cure is per-fect, at other times a relapse occurs in from six months ta twoyears.

____

THE INFLUENCE OF HEAT ON DISEASE.

THE influence of heat in producing an aggravation in thesymptoms of many diseases is a fact well known to everybody.Lately, during the very hot weather, we observed that manypatients, the subjects of exhausting diseases, whether internalor external, medical or surgical, had their sufferings greatlyincreased. Perhaps in no class of patients was this moremarked than in cancerous affections, amongst the female sexespecially. This forcibly struck us at the Cancer Hospital, aswell as elsewhere, for nearly all of the patients complained ofan increase of pain, even when the cancer was not ulcerated;and when so, the discharge was greater, as well as the painperhaps still more severe.On the 25th of August, of several cases of cancer of the

tongue which we saw, most of them hitherto doing pretty well,the greater number had slightly relapsed. One poor woman;whose case we referred to on a former occasion, who was ad-mitted almost moribund, with sub-maxillary enlarnements,conjoined with a deep ulcer at the side of the tongue, andgreat emaciation and debility, has completely recoveredunder treatment. All the lumps had become absorbed, thecancer had improved, as well as her general health in everyway, yet a few hot days threw her back.The prolonged influence of heat, such as we have had it

lately, produces a. certain amount of depression and languorin the healthy, but in the weak and oppressed by disease,particularly cancer, it is followed by debility and exhaustion,and hence an increased activity to nervous irritability and itsconsequent pain.We have observed also that operative proceedings were to

some extent inadmissible, as many cases, and s .me of themtrivial, took on a sort of low fever, which ran into py&aelig;mia anddeath.

____

URETHRO-RECTAL FISTULA.

AN abscess formed in the pennasum, about four weeks ago;between the rectum and urethra of a young man aged twenty-two years, in University College Hospital, which produced re-tention of urine from pressure on the urethra alone. This un-dermined the mucous membrane of both canals, and burst intothe rectum, and was subsequently followed by the formation of &pound;a urethro-rectal fistula. The patient’s general health was very-bad indeed. He is an assistant-tutor by occupation, and hiswhole system below par. He had the remains of an abscess(not a bubo) in the riht groin, one or two about his body, onein his left hand, and two or three about the fingers of his righthand, and his general aspect showed an absence of vital energy.On the 12th of August, all the perineal passages were laid illto-one by Mr. Erichsen, and attention was paid to his generalhealth. This treatment, when last we saw him, was answering.well; some urine still passed by the perineal wound, which may:be expected for a little while; the irritability was certainlyless; and the absence of spasm was marked since the divisionof the sphincter ani at the time of laying all the passages intoone. A good-sized catheter could be passed into the bladder,on overcoming some spasmodic closing of the membranous;portion of the urethra. We have no doubt this case will do;well.

A PAIR OF ARTIFICIAL FEET.

OUR readers will remember the description which we brieflygave of a case of spontaneous gangrene of both feet, withseparation at the epiphysis, and a sort of natural, Syme’s,amputation, at the ankle joint, at page 425 of the precedingvolume of this journal. This occurred about ten years ago,and the stumps remained so sore and painful that the patient,a girl, could not bear artificial feet. On the 20th of lastMarch, Mr. M’Whiiinie, at St. Bartholomew’s Hospital, ampu-tated the stump of the left leg, a little higher up, and which,healetl in a satisfactory manner. Some weeks later, he re-,peated the operation on the right leg, with equally good results.