discharging little, the cure by eschar will be preferable; especially in
those little irritable and painful ulcers often seen about the ancle and
tendo Achillis. Apply first a cold poultice, and then form the eschar,
which may be freely exposed to the air. Should the matter, nevertheless,
collect, it should be evacuated by puncture as often as necessary, until
the eschar remains adherent.
This practice is recommended by Mr. H., in various other affections; as
in inflammation of the fingers; in the fungous ulcer of the navel in
infants; in _tinea capitis_, &c. In this last case, we have ourselves
used it with marked advantage. In all cases, the lunar caustic has a
decided effect in _diminishing the irritability_ of the parts to which
it is applied; and hence should usually be preferred for the purpose of
forming a "_scab_," for such the eschar really is, in a practical view;
and we think that our author has hardly done justice to nature's
methodus medendi by "scabbing;" while he so ably and strenuously
recommends his own imitation of her process. Scabs may be formed by the
coagulation of blood; by the drying of mucus or pus; and by the
formation of an eschar, by the actual or potential cautery. The surgeon
may frequently reduce parts to the same situation, by the use of
gold-beater's skin, court-plaster, or other unirritating applications,
which prevent exposure and evaporation. In all cases, care must be taken
to prevent the surrounding inflammation from transcending the adhesive
stage.
45. _Haemorrhage from Lithotomy._--In the London Med. and Phys. Jour. for
Jan. Mr. JOHN SHAW has published an account of a patient, who
unfortunately perished from haemorrhage, in consequence of being cut for
the stone. The parts being injected after death, it was found, that the
bleeding proceeded from the _unusual distribution_ of a branch of the
pudic artery, which traversed the neck of the bladder, and lay directly
in the way of the incision. The pudic artery was uninjured.
46. _Extirpation of the Parotid Gland._--The best surgical writers have
condemned this operation, if not as absolutely impracticable,
nevertheless, as too dangerous to be ever attempted. Successful cases
have however been reported, and Mr. A. COOPER, in a letter to the
operator in the following case, avers, that he twice removed the parotid
gland in one year. Mr. KIRBY, late president of the Royal College of
Surgeons in Ireland, in a work published in 1825 at Dublin, on
haemorrhoidal excrescences, has given the details of a diseased parotid,
and of the operation for its removal. We condense from Johnson's Review
for April, 1826.
The patient was a poor female, aged 40, who had a tumour extending from
above the zygoma downwards on the neck, two inches below the angle of
the jaw, stretching as far forwards as the anterior edge of the masseter
muscle, forcing the ear backwards, and raising it outwards from its
natural position. Above the surface, it was about the size of a
goose-egg; immoveable; painful when handled; irregular on the surface,
and of a deep livid colour over the prominent points. Pains of a
lancinating character, extended over the head and neck, producing
sickness and want of sleep.
The operation was performed chiefly by the fingers and the handle of the
knife, after dividing the integuments by a crucial incision. The
branches of the portio dura were of course divided, and great
embarrassment arose from a copious haemorrhage, caused by the bursting of
the tumour, while Mr. K. was rooting it out from between the pterygoid
muscles. The bleeding was restrained by the finger of an assistant, and
the complete extirpation of the diseased gland was effected. Mr. KIRBY
says, "the space between the pterygoid muscles was void--the auditory
tube was fully exposed--the articular capsule of the jaw was brought
into view--the finger could trace the length of the styloid process, and
on sponging the wound of its blood, it could be seen by those who
surrounded the chair." The haemorrhage was restrained by a sponge firmly
lodged at the bottom of the wound, covered by compresses of lint, and
the whole secured by a double-headed roller.
The patient was much exhausted, slept tolerably well the next night,
complaining of thirst and inability to swallow. On the 2nd day,
inflammation, swelling, and fever followed--erysipelas appeared on the
neck--patient lethargic--pulse small and frequent. Fourth day,
suppuration--symptoms improving--no relapse. The patient completely
recovered, without any regeneration of the tumour.
In FERUSSAC'S Bulletin Universel for Jan. 1826, we observe the following
notice, from a German Medical Magazine, conducted by M. D. Schmidt.
A female, aged 33 years, had suffered for 9 years from a diseased
parotid gland, which had gradually attained a large size. It was
extirpated by Dr. PRIEGER, and the patient soon returned home in good
health, and little disfigured. The tumour measured 8 inches in
circumference, and weighed three and a half pounds. (Livres.)
Dr. PRIEGER had previously extirpated a scirrhous parotid successfully.
M. WIENHOLD affirms, that he has extirpated three parotids; the details
of these operations are published. M. SCHMIDT, however, suggests some
doubts, as to the _nature_ and _seat_ of the tumours removed.
47. _Aneurism from a Wound, cured by Valsalva's method._--This
interesting and valuable case, is condensed from Le Propagateur des Sci.
Med. for March, 1826. M. Antouard, a healthy female, aet. 18, was wounded
on the 18th of June, 1825, by a poniard, in the left carotid artery,
below the superior extremity of the sternum; the instrument passing
obliquely inwards and downwards. The anterior and lateral portions of
the neck, were enormously distended with blood, and syncope supervened.
Four days after the injury was received, an aneurismal tumour was
observed at the edge of the sternum, the surrounding effusion being
greatly diminished by absorption; and at the expiration of a month, when
she was first seen by Dr. SOUCHIER, it was of the size of the two fists
of the young female. The pulsations at this time, were nearly equal over
the whole surface of the tumour; but rather more distinct over the
orifice in the vessel. The surrounding blood was entirely absorbed. No
pain was experienced, unless from the pressure of the swelling; from
which cause also, resulted a troublesome and continued headach. Dr.
SOUCHIER, not believing an operation adviseable, during the warm season
of the year, and on a tumour, situated so much under the sternum,
determined to fulfil the following indications: 1st. To lessen the
quantity of blood; and thus, to diminish the stimulus to the heart, the
projectile force it exercises, and consequently, the rapidity with which
the blood escaped from the ruptured vessel, and the impulse hence
imparted to the sides of the tumour, preventing, in some degree, the
coagulation of the blood. 2nd. To increase the effect of general and
local bleeding by the use of _cold_, of _pressure_, and especially, of
the digitalis purpurea: that thus the force of the circulation may be
lessened, the blood allowed to coagulate, and a radical cure be
accomplished.
Mademoiselle Antouard, determined to yield herself to this plan, and was
directed: 1st. Rice-water, acidulated with lemon-juice, and an infusion
of mallows, for _food_ and _drink_. 2nd. To employ frictions on the
abdomen, and on the insides of the thighs, morning and evening, with
eight grains of the pulverized leaves of digitalis, previously macerated
for 24 hours in a sufficient quantity of saliva. 3d. To apply every day
12 leeches, near the aneurismal tumour, and after favouring the flow of
blood by emollient fomentations, to cover the part with compresses, wet
with a saturated solution of the acetate of lead, to be frequently
renewed, so as to be kept below the temperature of the skin. 4th. The
effect of these means to be augmented by pressure, made by means of the
base of a glass tumbler, fixed by the hands of assistants; and 5th. To
be kept at rest, and in perfect silence.
_Fourth day of treatment_, being 2nd of Aug. 1825. Pulsations more
central; tumour very sensibly diminished; pulse less strong and reduced
from 86 to 74 in the minute; the menses, which had been suppressed for
two months, appeared on the 31st ulto. and still flow. _Prescription_,
V. S. [Symbol: ounce]xviij. next day, twelve leeches, on the lateral
parts of the tumour; gr. xxiv. of digitalis in three applications
through the day. Continue ut supra.
Aug. 8th. Patient tranquil; pulse 60, full, not active; face not
flushed, but preserving a delicate tinge of red; headach now slight; no
nausea; menses continued until the 6th inst. _Prescription_, V. S.
[Symbol: ounce]xij.--fifteen leeches to-morrow; increase digitalis to
gr. xxviij. daily; the rest, ut supra. The tumour has diminished at
least one-fourth.
Aug. 12th. Tumour reduced to 3-5ths of its former volume; pulse at 56;
her nights are comfortable; has some headach, and lately, cardialgia;
complains of hunger and weakness, and from the fatigue of her
assistants, the pressure was made with a bandage less effectually than
before. This was allowed, as the pulsations are weakened, and more and
more central, while the elevation of the tumour is trifling. For fear
her health might be injured, she was permitted to rise a little from
bed, and to add to her rice water, some light jellies, (cremes) made
from the same grain. V. S. [Symbol: ounce]x. and every 2nd day, eight
leeches around the tumour; digitalis increased to 32 grains daily; warm
pediluvium for one hour, morning and evening; silence as complete as
possible.
Aug. 18th. No tumour visible; pulsations can yet be felt; the skin is
thickened; pulse at the wrist is at 50. V. S. [Symbol: ounce]viij.--six
leeches every 4th day until menstrual period; digitalis reduced to gr.
xx. and still to the same parts; continue the pressure; allow some rice
jelly, vermicelli soup, gentle exercise; silence to be preserved,
continue pediluvium, and relieve constipation by simple enemata.
In 15 days, Dr. SOUCHIER again visited his patient. It required an
experienced hand to distinguish, at the spot where the artery was
cicatrized, an elevation rather more evident, than over the rest of the
artery. Pulse 48 per minute; hunger great, and the remedies now
unpleasant. Most of them were suspended, and fruit and the white flesh
of poultry added to her diet list. The digitalis reduced to 12 grains a
day. Compression, silence, and moderate exercise, to be continued as
before. The menses appeared at the expiration of twenty-five days, and
were more abundant than at the last period.
At the end of a month, no trace of the tumour was discoverable. The
young lady had carefully increased her nutriment and exercise without
inconvenience, and all remedial measures were now omitted.
During the months of December and January last, she remained free from
any inconvenience from the tumour, and the union of the parietes of the
artery was therefore regarded as complete.
In the above account, we have only to regret that the state of the
artery above the tumour, before and after the treatment, had not been
noticed. Perhaps this may be supplied by Dr. SOUCHIER, in the
commentary, which he proposes publishing on the above case.
48. _Protrusion and Wound of the Stomach._--Mr. TRAVERS, in the Edin.
Journ. of the Med. Sciences, for Jan. 1826, relates, that a female, aged
53, and the mother of _nineteen_ children, inflicted on herself a wound
in the abdomen, three inches in length, and in a transverse direction.
When admitted into St. Thomas' Hospital, at the expiration of six hours,
the greater part of the large curvature of the stomach, the arch of the
colon, and the entire large omentum, were protruded and strangulated in
the wound. The omentum was partially detached from the stomach, which
organ was wounded in two places; one, half an inch long through the
peritoneal coat; the other, a perforation of all the coats, admitting
the head of a large probe, and giving issue to a considerable quantity
of mucus. Patient faint; pain slight; pulse 102, and irregular; some
hiccup. A silk ligature was placed round the small puncture in the
stomach, and the displaced viscera returned, after enlarging the
external wound. This last was closed by the quill suture. Warm
fomentations and abstinence from food and drink enjoined. 2nd day, some
re-action; had been sick in the night from some drink given; is free
from pain; pulse 120; pain on pressure; an enema ordered. _Evening_, a
dose of castor oil, and twenty leeches to the abdomen. 3d, much fever;
V.S. [Symbol: ounce]xviij. and 20 leeches to the abdomen; bowels not
opened. 4th day, two stools; pulse 98; tension of the abdomen; three
more stools during the day. 5th, sutures removed; wound united, except
at its right extremity, where a serous fluid is discharged in
considerable quantities. On the 6th day, was allowed food, and on the
23d of Dec., about two months after the accident, was discharged cured.
49. _Oesophagotomy._--This operation has been objected to, not only on
account of the dangers attending its performance, but from the alleged
difficulty of promoting the union of the wound in the oesophagus; as
it is seldom at rest, the lips of the incision being often separated,
and the mucous coat adhering with difficulty under any circumstances.
Hence we are induced to notice the following case, in which the
operation was successfully executed on an inferior animal, by M. FELIX,
a veterinary surgeon of Bergelac. The account is published in the Feb.
No. of Le Propagateur des Sci. Med.
A _Cow_ was threatened with immediate suffocation from the lodgment of a
potato in the oesophagus. It had shortness of respiration, an
incapacity of swallowing even its saliva, which flowed from the mouth,
was in great distress, and covered with a cold sweat. Being properly
secured in a horizontal posture, an external incision was made on the
inside of the sterno-mastoid muscle, and a cautious dissection practised
until the tumour was completely exposed. The oesophagus was divided by
"an incision extending the whole length of the foreign body, which was
extracted without any force, _which is almost always fatal_. I
immediately made two close sutures; and also two others in the skin, on
each side, adapting to them two pieces of packthread, more easily to fix
the dressings. I dressed the wound with brandy, filling the opening with
hemp soaked with brandy." The animal was kept on very little food or
drink. On the third day the wound was dressed for the first time, and a
digestive ointment applied.
In the course of the 2nd week, the cicatrization of the oesophagus
occurred; the part was dressed with lint; and by the 20th day after the
operation, the animal was quite restored.
This case would have been more useful, if more precision had been
employed in describing the dressing and subsequent treatment of the
wound. It would seem that the sutures were passed through the parietes
of the oesophagus only, and that the external wound was kept open by
being filled with tow. Certainly, union by the adhesive inflammation
ought to have been attempted in all parts of the wound; but whether
sutures in the oesophagus are advantageous, or whether the uniting
bandage be preferable, is not so easily determined. In the two cases
described in 3d vol. of the Mem. de l'Acad. de Chirur. the uniting
bandage was alone employed, and with success.
50. _Retention of Urine, caused by a Stricture of the Urethra, relieved
by a forcible but gradual Injection._--The editor of Le Propagateur des
Sci. Med. in the No. for Feb. 1826, introduces the following case, by
observing, that it reflects great honour on M. AMUSSAT, and that his
discovery merits the greatest praise. M. D... aged 70 years, of a
plethoric constitution, had suffered about 30 years before from three
attacks of gonorrhoea; since which period he has had a difficulty in
urinating, and can never discharge more than one or two ounces of urine
at a time.
At eight o'clock, P. M. of the 1st of Feb. he tried to urinate, but
could not succeed. He suffered great pain. Pulse agitated; face flushed;
belly swelled, and globular at its inferior part; the subcutaneous
abdominal veins distended, and the penis in a state of semi-erection.
All attempts to urinate were painful and ineffectual. At ten o'clock, A.
M., on the 2nd, M. AMUSSAT visited him, and passed a bougie. This was
arrested by a contraction near the bulb of the urethra, and caused the
discharge of some blood. No urine had been passed for 14 hours, while
ordinarily he urinated 12 or 16 times through the night. The obstruction
was so great, that none of the usual means of relief remained, except
_the forcible introduction of the catheter_, or the _puncture of the
bladder_. M. AMUSSAT resorted to the following plan which he had
devised, and which completely succeeded. He injected warm water
forcibly, but gradually, into the urethra, which, dilating the orifice
of the stricture, forced backwards the thickened mucus which had
obstructed it. As soon as the liquid injection met the urine, the
patient cried out that he was saved, and immediately was able to urinate
as formerly. At two trials, he discharged nearly two pints of thick
urine. There was no return of the retention, the patient continuing
well.
Should subsequent experience confirm this experiment of M. AMUSSAT, this
simple measure will be a most valuable substitute for those dangerous
measures hitherto resorted to for retention of urine, in cases where the
obstruction arises from thickened mucus, from small calculi closing the
orifice of a stricture, from inflammation, or from what are termed,
(justly or not,) spasmodic strictures.
51. _Tracheotomy._--In the Amer. Med. Review for April, Dr. JOHN ATLEE,
of Lancaster, mentions that on Wednesday, Aug. 11th, he was consulted by
a child ten years old, who had that morning, while running, put a
button-mould into his mouth, which during respiration was drawn into the
trachea. He complained of uneasiness in respiration, with a slight
rattling, and pointed towards the upper part of the sternum, as the
situation of the button. On coughing, a rattling was heard, and
immediately after, a sudden check to expiration, from the lodgment of
the button near the rima glottidis, requiring a sudden and violent
effort of inspiration to remove the sense of suffocation. An emetic was
given with no advantage. During the night, he had two or three spells of
coughing, threatening suffocation.
An operation was urged, to avoid immediate and subsequent dangers from
the lodgment of this extraneous body, and was agreed to by the parents,
and by Dr. HUMES, who was called in consultation. It was performed on
the 14th of Aug.; a cathartic, and afterwards an opiate, having been
given.
An incision, one inch and a half long, was made through the integuments,
extending downwards from above the cricoid cartilage, and exposing the
sterno-hyoid and thyroid muscles, which were then separated. After
exposing the trachea, a longitudinal incision, about three-quarters of
an inch in length, was made through its parietes at the third ring. This
was held open, and the patient requested to cough. This was ineffectual.
The wound being closed, the button was, by coughing, thrown up against
the rima glottidis. A probe passed into the trachea, produced a violent
effort to cough, by which, as soon as the instrument was withdrawn, the
button was thrown through the wound, to some distance from the patient.
The wound was dressed with two sutures and adhesive strips. Most of it
united by the first intention: and in a few days the patient completely
recovered.
52. _Fistula Lachrymalis_--At the session of the Royal Academy, on the
15th of December, M. J. CLOQUET related the case of a female, who, three
years previously, had submitted to the operation for fistul. lachrym.
according to the method of M. FOUBUT. The canula which had been allowed
to remain in the nasal canal, had ulcerated through the floor of the
nose, and presented its inferior extremity on the inside of the mouth.
A practical commentary on this mode of operating, which is still
recommended by able surgeons!
53. _Aneurisma Herniosum._--This form of aneurism is supposed to consist
of a dilatation of the internal and muscular coats of the artery; the
external cellular having been destroyed. It is termed by ARNAUD, and by
Dr. WILLIAM HUNTER, _aneurisma herniam arteriae sistens_. Its existence
in any case has, however, been denied by a large majority of surgeons;
and perhaps the only cases reported are those of DUBOIS, in 1804, found
in the thoracic and abdominal aorta of a dead subject.
The reporter of the following case, quotes also MONRO, as having cited
examples of this kind of aneurism. But what MONRO termed a "mixt
aneurism," arose from the rupture of the coats of a "true aneurism," by
which it was reduced to the state of a "false aneurism;" very different
from that here contended for. SABATIER and BOYER, also, deny the
existence of this hernia of the artery, and a good summary of facts and
arguments is given by BOYER in his Surgery, in support of this opinion,
(vide article Aneurism, tome i.) which it would be difficult to
invalidate, especially by cases analogous to the following. The
reporter, M. BONNET, of the late French army, considers this case as
proving a hernia of the artery in a vessel of medium diameter; those of
DUBOIS having been noticed in the largest arteries.
A Prussian soldier was wounded over the femoral artery by a musket ball.
No haemorrhage ensued, and the wound cicatrized. In this state, M. BONNET
visited him for a mortification of the foot of the same limb, which had
been frozen. Amputation of the leg was performed, the stump healed
readily, and in 12 days the ligatures came away. On the 13th day, (being
six weeks since wounded in the thigh,) the patient perceived a tumour at
the original cicatrix on his thigh, which had appeared during the
preceding night. On the 14th, it had enlarged to three times its former
size: it was painful; fluctuation was evident; but there was no
pulsation, not even the thrilling noise, which is evident in the last
stage of aneurism. A consultation was called, to determine whether it
was an abscess or an aneurism. The question could not be satisfactorily
answered, and it was determined to open it, after having made the
necessary arrangements to secure the artery, should the tumour prove
aneurismal. As soon as the integuments were punctured, the jet of blood
evinced the nature of the complaint; and the artery was secured by
ligatures above and below the tumour. The coagula were numerous, and the
superficial ones, quite hard and cartilaginous. The patient did well,
and there was every prospect of his recovery on the 1st day, when M.
BONNET was forced by the movement of the armies to leave him at Meaux.
Such are the facts, from which the Reporter infers, that the aneurism
consisted of a protrusion of the internal and middle coats of the
artery. The _reasoning_, founded on them, appears to us inconclusive;
but we have not space to insert it, and must refer to the March No. of
Le Propagateur des Sci. Med.
54. _Extirpation of the Two Dental Arches, affected with
Osteo-sarcoma._--Dr. GIORGI REGNOLI, physician at Pesaro, performed this
operation on a female 35 years of age, who had from infancy, been
troubled with pain and diseases of the teeth and jaws. When Dr. R.
visited her, both dental arches were enormously swelled; red and
sanguineous tumours had formed over their whole surface, and covered the
teeth. The alveolar processes were entirely softened. The diameters of
the mouth were greatly lessened; but by the touch, it was evident, that
the disease was confined to the alveolar processes of the two ossa
maxillaria. A foetid odour exhaled from the mouth. Lancinating pains
continually tormented the patient; especially on attempting to
masticate. The slightest touch was very painful, and was always followed
by an effusion of blood. There was also an alteration of voice; a
disgusting deformity of the mouth, with emaciation, fever, &c. The
operation was performed on the 18th May, 1825.