593

tate of ammonia, half an ounce; tincture of the sesquichlorideof iron, twenty minims : three times a day.* The whole sur-face of the body and limbs to be sponged with glycerine andwater in equal parts night and morning. The effect of theglycerine was soon developed in a free and gentle perspiration.The dropsy began rapidly to subside, the amount of albumenin the urine to diminish. The skin now feels natural, and per-forms its functions actively. It is probable that glycerine hasa twofold action on the skin, both tending to the same end-1st, it softens the cuticle, and removes obstructions from theorifices of the sweat-ducts; 2ndly, it possibly acts by inducingthe escape of fluid by exosmosis. I have used it in severalcases of acute dropsy with albuminuria after scarlatina, withgood results. I have not found it to produce any injuriouseffects in any case.

Woburn-place, December, 1861.

DISLOCATION OF THE ASTRAGALUSOUTWARDS.

BY EDWARD CROOKE, M.D. EDIN.

J. A-, a thin, spare man, aged forty-five, whilst cleaninga window about fourteen feet from the ground, on the 10th ofOctober, fell from the ladder on which he was standing. I sawhim about one hour afterwards, and found him in a very pros-trate condition, complaining of intense pain in his left foot andankle. Upon examination, the foot was seen in a very exag-gerated position of talipes varus. Externally was a hard swel-ling, over which the integuments were very tightly stretched.The swelling was easily distinguished to be the displaced astra-galus, with the superior surface looking outwards, the inferiorinwards, the internal upwards, the external downwards, theanterior and posterior maintaining their usual aspects in a semi-inverted position. The manner in which the foot came incontact with the ground could not be described. Contrary tomy expectation, (on account of the nature of the injury,) reduc.tion was easily effected by flexing the leg, and the use of mode-rate extension, pressure being at the same time applied to thebone in an upward and inward direction. At the end of sevenweeks the man returned to his work.

Chorley, Lancashire, Dec. 1861. I

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

UNIVERSITY COLLEGE HOSPITAL.

DIFFUSED FEMORAL ANEURISM, THE RESULT OF SPONTA-NEOUS RUPTURE FROM DISEASE ; DELIGATION OF THEEXTERNAL ILIAC ; DEATH FROM PELVIC ABSCESS.

(Under the care of Mr. ERICHSEN.)

Nulla est alia pro certo noseendi via, nisi quam plurimas et morborum etdtssectionum historias, tam aJiornm proprias, collectas habere et inter se com-parare.-MORGaGNI. De Sed. et Caus. afo)-5., lib. 14. Procemium.

IT will be remarked that the patient in the following casewas in comparatively good health some eight days before hisadmission into the hospital, when, after a fatiguing walk offive miles, he noticed a swelling in his thigh. This was the

result of spontaneous rupture of the femoral artery at a partaffected with calcareous disease, with the formation of a dif-fused aneurism.On examination, the true nature of the malady was at once

apparent, for, besides the other symptoms present, when the* I have used the tincture of the sesquichloride of iron in the most acute

forms of dropsy with albuminuria from the earliest period of its accession, andthe almost invariable effect has been a diminution in the amount of albumen,and an increase in the quantity of the urine.

’

swelling was grasped with both hands the distensile pulsationwas so strong as to separate them. Mr. Erichsen therefore hadrecourse to immediate operative measures, and placed a liga-ture upon the external iliac artery. The great effusion ofblood over the common femoral, and the probability of itsbeing much diseased, wholly precluded any interference withthat vessel. The patient progressed very favourably for somedays, but afterwards became low and feeble, although sufferingno pain, and died on the thirty-sixth day, the fatal result beingmainly brought about by intra-pelvic abscess, situated especiallybetween the rectum and bladder, and unsuspected during life.The following notes were kindly furnished by Mr. R. T.

Warn, the dresser of the patient.Samuel H-, sawyer, aged sixty-four years, married; has

always had good health; lived regularly and well; has been asober man; was admitted August 7th, 1861. On the 30th ofJuly, he walked about five miles, and came home very tired,but does not recollect to have had any blow or sudden strainon his leg. He then first noticed a lump on his thigh, aboutas large as a hen’s egg. This appeared to him to pulsate, andhe poulticed it. It gradually increased in size, and then, onthe 3rd of August, some discoloration of ecchymosis came onthe thigh above the swelling. He saw a medical man, whosent him to this hospital. On admission, a large tumour wasobserved on the front of the right thigh, about the junction ofthe middle with the upper third. This was tense and shining,and of the natural colour of the skin; it had a distinct eccentricimpulse; on listening with a stethoscope, the aneurismal bruitcould be heard. Above the tumour considerable ecchymosisand fulness were observed, not reaching above Poupart’s liga-ment, and chiefly on the inner side of the thigh. The limbwas cold, but not cadematous. The patient was faint, his pulseweak, and he had an arcus senilis on both corneas. Mr. Erichsensaw the patient at two P.M., and decided on tying the externaliliac, which he did by a semilunar incision just above Poupart’sligament. One small bleeding point required ligature. Theartery at the point deligated—viz., just above the epigastric-appeared to be quite healthy. The wound was broughttogether by a couple of points of suture, and the right limbordered to be wrapped in a dry flannel, and kept in an elevatedposition.Aug. 8th.-Fleveu A.m., twenty hours after the operation:

Feels very comfortable; no pulsation in tumour; temperatureof right foot 84°, of left, 83°; rather faint. Ordered beef-teaand brandy.-Five P.M.: Going on well; temperature of limbgood; no pain.9th.-Ten A.Ikf.: Temperature half-way up right leg, 96";

between the toes of the same, 83°; sound leg, 94°. Sleptpretty well last night; ecchymosis less; tumour less pro-minent.

10th.--Temperature between right toes, 86°; half-way upthe leg, 95°. o. No pulsation in posterior tibial artery; verylittle venous congestion; tumour diminishing; passed a com-fortable night: wound looking well. and suDDuratins kindlv.

12th.-Patient feels pretty comfortable; appetite good;tongue clean ; surface of limb covered with enlarged veins, andlooks congested, not swollen or cedematous ; good motion andsensation. Temperature of right foot, 88°; half-way up leg,93°; left leg, 96°. Wound healthy; sutures removed; dis-charges freely.13th.-Bowels open twice to-day (first time since operation);

expresses himself as much better ; wound looking healthy, andsuppurating kindly; no pain. Temperature between righttoes, 88°; right leg, 95°; left toes, 80°.14th.-Tongue pretty clean ; bowels open yesterday ; swel-

ling much diminished, and ecchymosis also less; woundhealthy, and suppurating kindly. Temperature of right leg,95°; toes, 850; left leg, 88°; toes, 80°. Some venous congestionon surface, but not more than on other leg; posterior tibialartery not to be felt; appetite good; slept well last night ; zaltogether better since the operation.20th.-Patient improving; wound healing fast; ligature not

come away; tumour slightly increased in size since last note ;temperature of both limbs the same.24th.-Tumour a little larger, fluctuating under the finger ;

otherwise the patient is going on well. Ligature not come

away; no rigors. Ordered the whole limb, including thetumour, to be enveloped in an elastic web bandage.30th.-Tumour very little larger; appetite not good. Or-

dered one ounce of quinine mixture three times a day. Somesoreness of the back ; to have applied to it collodion and castoroil in equal parts.

Sept. 2nd.-Tumour seems to be diminishing in size; appe-tite improved; ligature not yet come away. The patient is

594

getting very emaciated, but says he feels well in himself. The 1’wound is healing up in the centre, but the lower part seems tobe sloughing; less ecchymosis above the tumour.

4th.-Appetite not good. Ordered mutton broth. Says hefeels very weak. The wound ordered to be well poulticed.

7th.-Pulse 112, and very weak. Patient says he does notfeel so well to-day, and has no appetite; tongue dry, andcoated with a thick brown fur; emaciation still more marked;wound looks angry; ligature not come away.

10th.- Patient better ; appetite improved ; wound is veryoffensive to-day. Ordered to have a large poultice of charcoaland linseed-meal applied. Tumour about the same; makes nocomolaint of nain.

12th.—Patient seems very low to day; pulse 70, very weak,intermittent; wound has sloughed more lately; appetite notgood; ligature not yet come away.-Half-past six: Patientdied.

Autopsy forty-six hours after death.-Track of the woundsloughy; ligature separated, and came out without traction. iTrack of common iliac was carefully traced as far as the pointof ligature on the external iliac. External iliac is firm and

plugged up to junction of internal iliac; orifice of upper open-ing patent, and admitted a probe for half an inch. Lower

opening sealed and plugged for half an inch, but lookingsloughy. No inflammation of vein. On carefully dissectingthe femoral artery as far as Hunter’s canal, a firm clot, oval inform, and about the size and shape of a healthy kidney, wasfound, being on the inner side opposite the middle third of thethigh. This was sufficiently firm to turn out easily, but hadno special sac surrounding it. Having detached it, a circularopening was seen on the inner side of the artery opposite thecentre of the clot, which was attached to it by a firm plugpassing through the opening into the artery. The hole wasabout the size of a threepenny piece, and had firm, well-definededges. The vessel at this spot, and for an inch and a half aboveand below, was slightly dilated. Some calcification of thecoats; same condition more marked in some of the branches.No signs of peritonitis. Small intestines glued at two or threepoints to parietal peritoneum around point of ligature. Subse-quently a large abscess was found situated between the bladderand rectum, extending in all directions in the pelvis, andreaching as high as the promontory of the sacrum, and contain-ing about half a pint of yellow pus. The bladder was empty,and offered no signs of previous retention. Abdominal visceranatural.

____________

LONDON HOSPITAL.

HÆMORRHAGE FROM THE AXILLA, THE RESULT OF

ULCERATION FROM MALIGNANT DISEASE ; LIGATURE

OF THE AXILLARY ARTERY ; DEATH ; AUTOPSY.

(Under the care of Mr. MAUNDER.)T. M-, aged thirty, was admitted with some swelling of

the left axilla, and an ulcer of the size of a half- crown in thefloor of the space near the anterior fold. The man looked pale,and said that he had lost blood from the sore. To-day (Dec.3rd) Mr. Maunder saw the case, being summoned on account iof a recurrence of haemorrhage, and found the patient in thefollowing condition:-Countenance blanched; pulse fluttering;the whole of the upper extremity swollen and oedematous;pulse at the wrist; anterior wall of the axilla thrown forwards(concealing the outline of the outer half of the clavicle), tenseand fluctuating, and thinning at the upper part, as thoughabout to yield to progressive absorption; no perceptible im-pulse communicated to the swelling. The patient was evi-dently in a most precarious condition, and as delay might provefatal (although haemorrhage had ceased for the moment), asponge was pressed up into the axilla, the arm brought to theside, and the dresser was prepared to compress the subclavianartery above the clavicle, while a consultation was held uponthe case. The propriety of tying the subclavian artery, or oflaying open the axilla and proceeding according to circum-stances, was discussed, and the latter plan decided upon.While the patient was being brought into the theatre, Mr.

Maunder explained to the pupils that the case was fraughtwith great danger to the patient and anxiety to the surgeon.The history was obscure, the patient being almost too weak toreply to questions put to him. From what could be gathered,

the disease had existed some twelve months, a lump in thearmpit being discovered accidentally one morning (which, thepatient said, was not there on the previous evening); this lumphad increased in size, becoming harder, until about a monthsince, when the skin broke. On the 29th November, bleedingto a great extent occurred, for the first time, at his lodgings,but ceased spontaneously; it returned twice during the nightof December 2nd, but was controlled by plugging with cottonwool and a solution of perchloride of iron. As to the nature ofthe malady, the man was too weak, and no time could be al.lowed, for an examination to determine. It might be eithermalignant disease involving a large artery, or a ruptured aneu-rismal sac. Under any circumstances it was deemed right toendeavour to secure the bleeding vessel, though the man should.die on the operating table, rather than, unattempted, to allowthe patient to succumb from haemorrhage in his bed. In hispresent condition, the loss of another ounce of blood mightprove fatal.

Operation.-Mr. Gowlland controlled the subclavian arterywhile the whole of the anterior wall of the axilla was laid open,from the anterior fold of the axilla to the clavicle, by twosweeps of a blunt-pointed bistoury carried along the forefinger,previously introduced into the space. This disclosed a mass of

softening, malignant disease, and coagula, involving and con.cealing the contents of the region. The parts diseased and thecoagula were quickly removed by sponges, but no clue to theseat of hsemorrhage was found. A thick cord, taking the courseof the vessels and nerves of the space, was now interrogated;whilst a slight flow of arterial blood, coming from a hollowbehind this, led to the belief that the bleeding point could notbe reached. Under these circumstances, Mr. Maunder disen-tangled the cord of vessels and nerves by scraping away thedeposit, and placed a ligature upon the axillary artery. Noblood was lost, and although the patient could be just rousedto swallow, the pulse was scarcely perceptible. Some brandywas at once thrown into the rectum, but death occurred abouttwo hours after the operation.

Aictopsy.-Besidea involving the upper part of the pectoralismajor and minor muscles, the diseasa had destroyed the poste-rior half of the circumference of the axillary artery in themiddle third of its course to the extent of half an inch in alongitudinal direction. Opposite to this, a cavity large enoughto contain a walnut, but with a hole in its wall, stained with.blood, and partly filled with coagula, existed, and was doubt-less the source of fatal haemorrhage. The ligature constrictedthe vessel about three-quarters of an inch above the wound init. The axillary vein was compressed and obstructed.

Mr. Maunder remarked, that had he known the precisenature of the disease he would have preferred placing a liga.ture upon the subclavian artery above the clavicle, rather thanattempt to secure a bleeding and probably diseased vessel in amass of malignant disease.

Medical Societies.ROYAL MEDICAL & CHIRURGICAL SOCIETY.

TUESDAY, DEC. 10TH, 1861.

DR. BABINGTON IN THE CHAIR.

AN ACCOUNT OF A CASE IN WHICH THE ENTIRE TONGUE WASSUCCESSFULLY REMOVED FOR CANCER OF THE ORGAN.

BY THOMAS NUNNELEY, ESQ., F.R.C.S.E.,LECTURER ON SURGERY IN THE LEEDS SCHOOL OF MEDICINE, BBNIOB

SURGEON TO THE LEEDS GENERAL EYE AND EAR INFIRMARY.

THE subject of the case related in this communication is aman, aged thirty-five, who states that, with the exception ofthe disease in the tongue, he never had a day’s illness. Inearly manhood he was not very steady; but for the last twelveyears he has been so. He has been married many years, andhas had eight children, the youngest being only six monthsold; all of them have been strong and healthy. There is noreason to suspect any syphilitic taint. For some years he hasbeen employed on a railway, and latterly as a guard. From

being a large, strong man, owing to the distress and pain hehas suffered and the inability to masticate food, he has becomethin, weak, and anaemic. The disease, at first slow, had lat-terly made more rapid progress, and having not unfrequently

. been compelled to pass the whole day without food, owing tothe pain the attempt to take it occasioned, he was wishful to