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A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

LONDON HOSPITAL.

LIGATURE OF RIGHT COMMON ILIAC ARTERY FOR INGUINALANEURISM.—LIGATURE OF SUBCLAVIAN AND COMMON

CAROTID ARTERIES FOR INNOMINATE ANEURISM.—

LIGATURE OF SUPERFICIAL FEMORAL ARTERY FORPUNCTURED WOUND.—OVARIOTOMY.

(Under the care of Mr. MAUNDER.)

Nulla autem est alia pro certo noseendi via, nisi quamplurimas et morborumet dissectionum historias, turn aliorum, tum proprias collectas habere, et interse comparare.- MORGAGNI De Sed. et Caus, jtfof&.. lib. iv. Procemiutn.

ON Saturday last we saw Mr. Maunder perform ovariotomy,and, in another case, ligature the right common iliac arteryfor inguinal aneurism.The patient the subject of ovarian disease had been enor-

mously distended, the apex of her heart having been noted byDr. Sutton to beat opposite the second intercostal space. Threedays before operation, to relieve her distress and to diminishthe risk of fatal syncope during operation, the patient hadbeen tapped, with great relief, to the extent of fourteen pints.

In the case of inguinal aneurism, the operator reached theartery with tolerable facility by an oblique incision on theright side, from the point of the last rib downwards and for-wards to an inch within and below the antero-superior spine ofthe ilium. The broad muscles and transversalis fascia werecarefully divided, and the peritoneum was cautiously raisedfrom the iliac fossa by the fingers and hand of the operatortill the forefinger of the left hand reached the pulsating artery.With the finger-nail the artery was cleaned, and a ligaturepassed around it on an aneurism-needle, guided by the senseof touch only. The application of the ligature was facilitatedby the employment of two tongue-depressors, which, held upby Mr. Couper, supported the intestines. The peritoneal cavitywas not opened, and there was comparatively little bleeding.The vessels in the abdominal wall were tied as soon as exposed.’We were also shown a patient under the care of Dr. Davies,

Dr. Sutton, and Mr. Maunder, upon whom the latter hadthree days previously performed Brasdor’s operation of liga-ture of the common carotid and subclavian (third part) arterieson the right side for suspected innominate aneurism. The

patient had been advised to submit to operation three weeksbefore, but refused till the tumour became very large, theneck oedematous and brawny, and the superficial veins greatlydistended. The abnormal condition of the tissues renderedthe operation tedious, twenty minutes having transpired beforethe vessel was secured. All veins bleeding were at once liga-tured during the progress of the operation; the cords of thebrachial plexus were felt in their sheath, but not seen, by theoperator; but the external jugular vein, now swollen to thesize of the forefinger, traversed the wound obliquely, and atthe depth of an inch and a half from the surface. At some

depth beneath this vessel the subclavian artery was picked up,clean, off the first rib, and could be seen by many bystanders.The common carotid artery was now tied high up (by reasonof the prominence of the aneurism), and here again the infil-trated state of parts and congested veins necessarily made theoperation longer than usual. The patient, having recoveredconsciousness, said the pain in his shoulder, which had beenthe chief source of discomfort, was gone. When we saw himon Saturday the tumour pulsated strongly, and a successfulresult did not appear probable.The third case in the list above is that of a young man

engaged as a clerk in the Provincial Bank of Ireland, who afortnight since accidentally stabbed his femoral artery in themiddle of his thigh. Profuse haemorrhage followed, and waschecked by the application of a handkerchief tied tightlyover the wound. Mr. Maunder was summoned, and was for-tunate in obtaining the assistance of Dr. W. P. Woodman, of

Stoke Newington, who happened to be in the house. Thewound in the thigh was enlarged upwards and downwards,while the operator kept the point of his left forefinger uponthe hole in the artery, which was readily felt at the depth oftwo inches from the surface. The hole in the artery havingbeen clearly demonstrated, a ligature was applied above andbelow it, and no further bleeding ensued. The youth wasleft in the office of the bank for some hours, that he mightrally from the shock and loss of blood, and was then conveyedto the hospital. No local discomfort whatever followed the ap-plication of the ligatures, and both have just come away. Thewound is healing soundly, and the patient will leave thehospital next week to avoid any possible risk of pyaemia.During the operation an important fact was noted. When

the finger was shifted off the hole in the artery towards theknee of the patient, arterial blood flowed; but when thewound was exposed so as to allow of regurgitation along theartery on its distal side, dark, venous-looking blood flowed.This observation (already made by Guthrie) shows howquickly collateral circulation may be established, even though,as in this instance, the tourniquet acted inefficiently.We shall watch and report the progress of these highly

interesting cases. _______ ___

KING’S COLLEGE HOSPITAL.CASE OF POISONING BY OXALIC ACID ; DEATH ; AUTOPSY.

(Under the care of Dr. BEALE.)IT is worth while noting that in the following case the

autopsy showed the tongue and mouth of the patient unalteredin appearance, whilst a large slough was found at the lowerpart of the greater curvature of the stomach. It is rare forfatal cases of poisoning by oxalic acid to be unattended by awhitened and softened state of the mouth, and it is also rare,perhaps, for the acid to produce such strong corrosive actionupon the cardiac and intestinal mucous membranes as wasnoticeable in this case. Dr. Charles Kelly, medical registrar,has obligedus with particulars.

Sarah S-, aged thirty-four, married. On May 22nd,previously in good health, she voluntarily took half an ounceof oxalic acid. Directly afterwards she felt a burning pain inthe throat and epigastrium, and was giddy ; in about fifteenminutes she was very sick; an hour after she was purgedviolently, and passed blood in the stools ; she also vomitedblood. On admission she had severe pain in the stomach,retching, great thirst, cold extremities, sunken eyes, and

pallid countenance. Chalk and water, and afterwards half adrachm of carbonate of magnesia, were given her, with the effectof lessening the pain; and vomiting was kept up by a mustardemetic and warm water. At first her pulse could not be felt;but the circulation was soon restored, hot bottles being placedat her feet and stimulants given internally. Vomiting con-tinued through the night, and she passed much blood andmucus by the bowels. Milk was given her, but rejected.Her pulse was 104. Next morning she had great pain over abdo-men and was very sick; her voice was very hoarse ; pulse 72.Enemata of milk and brandy were given.May 25th.-For the last two days she has had less pain and

sickness. Her mind has always been clear. She sleeps better;purged a little.27th. -No purging; no blood in stools; tongue clean; slight

headache; less pain; no sickness.29th.-Is much worse. Has severe pain across the abdomen

and back, and has been purged a great deal. Constant sicknesscame on, and she died in a few hours, apparently from ex.haustion.Her diet consisted of iced milk and beef-tea, with a little

brandy occasionally.A2ctopsy, twenty - - th,ree hours after death. - Body fairly

nourished; no lividity; slight rigidity of the extremities;tongue and mouth normal; epiglottis red and eroded on theunder surface. Most of the mucous membrane of the œso-

phagus was stripped off, especially at the lower part. Thestomach was congested and distended. At the lower part ofthe greater curvature was a slough, irregular in shape, aboutthe size of a crown-piece. The wall was thicker than usualhere, and the peritoneal coat was opaque, and covered. Theslough had not begun to separate. All through the intestinesthe walls were congested, and thicker than usual. In thelower part of the ileum, for about three feet, and leaving offsuddenly about six inches from the caecum, were numerous

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sloughs, of an ochre-yellow colour, and involving the whole ofthe bowel, and not Peyer’s patches or solitary glands only.The serous covering was congested. No ulceration in the largeintestine; but the solitary glands were enlarged. There wasno peritonitis. The trachea and bronchi were normal; lungsrather congested at their bases. The heart and liver werehealthy. The cortical portion in each kidney was ratherswollen and cedematous, and in some of the tubes there wasan increased quantity of cells. The mesenteric glands werenormal.

ROYAL LONDON OPHTHALMIC HOSPITAL.CASES OF INFLAMMATION OF THE ORBITAL TISSUES.

(Under the care of Mr. HULKE.)

FROM an examination of his hospital case-books Mr. Hulke ]finds that periostitis is the most frequent disease of the orbitoccurring amongst the classes which supply our hospital pa-tients. In many instances it is preceded or attended by othersigns of syphilis, and is manifestly referable to this cachexia ;in a smaller number the scrofulous diathesis exists; in very fewno particular constitutional taint is present ; and in others theperiostitis directly results from external violence.

In syphilitic cases the front of the orbit is more commonlyaffected than the back. Here there is palpable thickening andtenderness of the orbital margin or of the bone just within it,and œdema, of the brow and eyelids. Pain is usually lesssevere and less paroxysmal than where the periostitis is moredeeply situated; but some degree of pain is usually felt fromthe beginning in syphilitic cases, while in scrofulous it is oftena ilate symptom. The kind and intensity of the pain are,however, Mr. Hulke thinks, characters of small diagnosticvalue, since very severe paroxysmal pain is a common andan early symptom of tumours originating in the periosteum orbone, as well as of deeply-seated inflammation of the peri-orbita. In this latter the node is often beyond the reach of thefinger, however firmly pressed in between the edge of the orbitand the eyeball, and the lids are less swollen than in superficial periostitis; but paralyses of the nerves, particularly ofthe third, are more frequent. The mobility of the eyeball isnot mechanically restrained as soon, or in the same degree, asit is by cellulitis or tumours originating in the cellular tissue.Caries and necrosis are less frequent sequelæ of syphilitic thanof scrofulous periostitis.

Iodide of potassium, as might be expected, is the most usefulremedy. A few doses of it often wonderfully relieve the pain,but its use must be continued long after the disappearance ofthe symptoms, in order to prevent relapses. Mr. Hulke hasgenerally begun with a dose of five grains three times a day,and seldom increased it above fifteen grains. These doses arewell borne when they are taken after meals, especially if alittle ammonia and hydrocyanic acid are added. The com-

pound iodine ointment is topically useful, but it may increasethe eedema of the lids if it excoriates the skin. Under thistreatment most cases of syphilitic periostitis quickly recover;but where there have been previous attacks, some permanentthickening of the bone is not uncommon.

Suppuration, except in scrofulous cases, is more frequent,Mr. Hulke thinks, in the course of cellulitis than in that ofperiostitis. The swelling and redness of the lids, and the dis-placement of the eyeball and the limitation of its mobility, aregreater; and there is more suffering and constitutional dis-turbance. Abscesses more often point through the upper lidthan through the lower. They cannot be opened too early,and their spontaneous bursting ought never to be waited for.A slender narrow-bladed bistoury is the handiest. The risksare, injury to the thin roof of the orbit and to the optic nerve,both of which have been wounded by incautious incisions: theyare reduced to a minimum by bearing in mind the direction ofthe orbital wall, and keeping the flat of the knife parallel toits surfaces and the edge away from the globe. A smallpuncture can be made in this way, and afterwards safelyenlarged if pus is found. A small drainage-tube and a poulticeare the best immediate applications; but as soon as the activeinflammatory swelling has subsided, the poultice should bereplaced by a light compress dipped in Goulard water.We publish on the present occasion notes of some illustrative

cases which have occurred under Mr. Hulke’s care in the RoyalLondon Ophthalmic Hospital, reserving for another oppor.tunity a report of others treated by him in the Middlesex Hos.pital.

CASE 1. Cellulitis; 1’esolution; perfect recovery.-A pale,feverish little boy, four years old, was brought to this hospitalon the 24th of September, 1864. The lids of the right eye,particularly the upper one, were red and swollen, and the eye-ball was displaced forwards about 3 I ", and slightly outwards.The child was too restless to allow a proper ophthalmoscopicexamination, but the media were found clear. The visualacuity was much lowered, but the degree could not be esti-mated. He was said to have been in good health when thepresent illness began, twelve days previously. One morning,while being dressed, he complained of pain, and the eyelidswere seen to be puffy. The pain and swelling increased, andhe became fretful, and lost his appetite.

Compresses dipped in Goulard water were applied, and he

was purged. At his next visit, four days afterwards, the

swelling of the eyelids and the protrusion of the eyeball wereless, and in a few days more he was convalescent.CASE 2. Cellulitis; abscess; complete recovery.-A German,

aged eighteen, a cork-cutter, in good health, and free fromany syphilitic or scrofulous taint, came to the hospital inMay, 1866. The right upper eyelid was swollen, red, andshining. Firm pressure under the upper margin of the orbitwas very painful, and a deep hardness, with obscure fluctua-tion, was felt here. He said that a fortnight before, afterbeing struck, the eyelids had become stiff and painful. Thesesymptoms were at first relieved by remedies ordered by aneighbouring medical practitioner, but they soon returned,and increased, so that he had not been able to open the eye

; for three or four days previous to his visit. He had hadseveral rigors.A deep puncture through the upper eyelid into the hard

spot opened an abscess, and let out several drachms of pus.Mr. Hulke could not feel any bare bone, and put in a drainage-tube. The patient made a quick and perfect recovery. In

,January of this year he brought his mother to the hospital,and Mr. Hulke took the opportunity to examine him. Thescar was scarcely discoverable. The movements of the eyeballwere perfect, and its visual acuity={.CASE 3. Cellulitis; abgce88; nettriti,3 optica from stretching of

the nerve; recovery, with blindness. -- A chairmaker, agedthirty-eight, came to the hospital on Feb. 25th, 1865. The

upper lid of her left eye was swollen, and of a dusky-redcolour ; and at its inner end, just beneath the eyebrow, therewas a hard knot, with an obscure feeling of deep fluctuation.The eyeball was displaced forwards, outwards, and downwards; 9its mobility was very limited, especially in the downwarddirection ; the conjunctiva was red and chemosed ; the pupilwas dilated and motionless ; the optic nerve-disc was red andhazy ; and the retinal veins were swollen. There was no per-ception of light. She said that she had never had any illnessuntil the present, which began with severe headache, princi-pally in the left brow ; with this she had frequent uncontrol-lable fits of sneezing, in which the pain darted into the orbit,along the side of the nose and left side of the face. After thishad lasted about three weeks, the eyelids became so swollenthat the eyeball could not be seen; and two days beforecoming to the hospital the pain was so violent that she wasafraid to rise from her bed or to move.A narrow bistoury was pushed into the hard knot where

fluctuation was thought to be felt, and at about one inch fromthe surface pus was reached. No exposed bone was discover-able with the probe. A small drainage-tube was placed in thewound. On March 1st, at her next visit, the pain was gone,and the swelling was so much less that she could now openthe eye. On the 15th the abscess had healed, leaving only aslight hardness ; and by the 29th of April no trace of this re-mained ; the eyeball had taken its proper place, and its

mobility was perfect, but it continued quite blind; its opticnerve was pale, and the vasa centralia were small.

In the following July Mr. Hulke found the optic nerve hadbecome white, the details of the lamina cribrosa were too

plain over too large an area, the surface of the disc was de-pressed, and the vasa centralia were smaller. There wasdecided atrophy of the nerve.

It is very probable that the patient might not have lost hersight had she been seen earlier, and the abscess been openedbefore the optic nerve was so stretched, and its nutrition soseriously compromised.

M. DELLA SUDDA (Faik Bey) lias presented to tlxeFaculty of Medicine of Paris the collection of simple drugs ofTurkey which is at present to be seen at the Paris Exhibition.