514

the thigh did not exceed that of a nutmeg; the obturator arteryand nerve were situated behind the neck of the sac, and a littleto its inner side :’ The museum of St. Thomas’s Hospital pos-sesses.besides the preparation mentioned by Sir Astley,asecondone, illustrating obturator hernia, under No. 1353; but there is,Unfortunately, no history of the case. Mr. South remarks, inChelius’s Surgery, that the only two examples he knew ofthyroid hernia, were one from a male subject in St. Thomas’sHospital, and another in the collection of the Royal Collegeof Surgeons. We found the latter under Series xxv. Sect. iv.,No. 1359, with the following remarks:-"Part of a pelvis, witha strangulated hernia of a small portion of ileum through theforamen ovale, on the left side. The sac is opened anteriorly,it protrudes straight through the foramen. (From the Museumof John Howship, Esq.)"

’

The last example of thyroid hernia to which we shall alludeis one which was operated on at St. George’s Hospital; thepreparation is arranged under 0. b. 18. The patient, agedsixty-seven, was admitted with well-marked symptoms ofstrangulated hernia. She stated that she had been subject toa rupture in the groin for the last seven years, for which shehad always worn a truss, and that the hernia had come downbehind the truss three days before admission. She had suc- ’,ceeded in reducing a part of it herself, and a surgeon had re-turned the other on the following morning, the whole tumour ’,having been the size of a pigeon’s egg. At the time of her I,admission the various regions through which hernise occur,were carefully examined. No tumour was, however, found in Iany one of them; but on the following day a slight enlarge- ’,ment was obscurely felt in the left groin. As the symptomshad not been in the least relieved, Mr. Tatum cut down uponthis enlargement, which appeared to be of the size of amarble, and perfectly flaccid. The ring was of large size, and ’i

easily admitted the index-finger. The symptoms of strangu- Ilation were not diminished, and the patient died exhaustedtwo days after admission. jOn a post-mortem examination it was found that the slight ’,

tumour in the groin was an old hernial sac, which was per-fectly empty and flaccid, the opening of communicationbetween the sac and the peritonseum being about the sizeof a common director. On further search an obturator herniawas found on the left side, the nerve being situated on theouter side of the sac, and the neck of the latter partly en-circled by a large branch of the artery passing at its upperpart. The whole of the sac was completely covered by theobturator externus muscle, being situated between the latterand the obturator ligament. In the sac was contained a por-tion of the diameter of the small intestine, which was of adark livid colour, and strangulated at the time of the post-mortem examination. The portion of intestine above thestrangulated part was very much dilated, and filled with fluidfaeces; whilst all the portion below it was empty and flaccid.There was no lymph in the peritonaeum, but all the intestineswere much congested.The above account is extracted from the Museum Catalogue

of St. George’s Hospital. The preparation will be found avery valuable and perfect specimen of obturator hernia.

WESTMINSTER HOSPITAL.

Elephantiasis of the Leg.(Under the care of Mr. HOLT.)

THE forms of disease met with in this country are sufficientlyvarious to make it the work of a man’s life to become fullyacquainted with them; but we have likewise to study themorbid phenomena peculiar to other climes, as isolated ex-amples of them are now and then brought before us. Elephan-tiasis Arabum is well known to be endemic in Barbadoes,Ceylon, Cochin, the Malabar coast, the West Indies, Guiana,&c. &c.; yet modified examples of the disease are sometimesobserved in more temperate countries. The cases whichoccur in the London hospitals, and of which we saw a few, donot in general reach the enormous magnitude which is socommon in the West Indies; but they nevertheless prove veryslightly amenable to treatment. Patients thus affected aregenerally in a debilitated state of health, and the accumula-tion in any particular limb or organ seems to depend in agreat measure on a want of power of the absorbent system.Dr. Musgrave thought that the disease should be called.’ migratory inflammation of the lymphatic system;" and wemay remark that in the case which we have this day to bringbefore our readers, (a case of obstinate enlargement of theleg, much resembling genuine elephantiasis,) the morbid stateof the venous system of the part seems to have had a great

share in the development of the disease. It is very probablethat in many of those chronic enlargements of the neck,breast, abdomen, thigh, and leg, usually called elephantiasis,the venous circulation is more or less at fault.The patient is a servant girl, twenty-five years of age, of a,

strong and sanguineous constitution, who was admitted on the22nd of January, 1851, under the care of Mr. Holt, withelephantiasis of the left leg. She has generally lived verycomfortably; the catamenia have always been regular; shewas not overworked, and states that no affection of this kindhas been noticed in her family. It appears that six yearssince the patient was treated in St. George’s Hospital forascites, and three years afterwards she was attacked withmaculated fever, for which she was treated in the ChelseaInfirmary. During this illness the leg and thigh swelled andinflamed considerably, the pain in the whole limb being verygreat; these symptoms gradually receded as her convalescenceapproached, and the oedema had almost entirely subsidedwhen she returned home. The patient had the misfortunesoon afterwards to bring the shin-bone of the affected leg inviolent contact with a hard substance; this accident occa-sioned much suffering, and she was soon obliged to apply te-the hospital. She was admitted about a twelvemonth ago,under the care of Dr. Kingston, and subsequently transferredto Mr. Holt, the case having become a surgical one.A variety of means were used to allay the constant pain

and reduce the cedematous condition of the leg; but thesemet with little success, the limb was getting denser and larger,and the pain incessant. An incision in front of the tibia,made some months before, never showed any decided ten-dency to cicatrize, and had yielded but a trifling discharge.The girl left the hospital to trv the effect of country air; buthaving returned with no amendment, Mr. Holt proposed theremoval of the limb, to which measure the patient readilyconsented.On the day previous to the operation, the diseased leg was-

about twice the size of the sound one; the bones were so com-pletely covered and surrounded by a dense lardaceous deposit,that they could not be felt; the anterior portion of the limb andthe dorsum of the foot were the most distended, and to sucha degree that the parts could not be made to pit on pressure.Mr. Holt performed amputation a little below the knee

whilst the patient was under the influence of chloroform; andsome difficulty was experienced in tying the vessels from therigid flexion of the knee and the toughness of parts. Thegirl progressed very favourably, the stump healed in a fewweeks, and she is now on the eve of being discharged, a fallon the stump having delayed the complete cicatrization.The limb was carefully examined a few days after the

amputation; the tough and hard portion was found composedof that lardaceous substance which in similar cases has beenlooked upon as the result of effusion of serum, gradual absorp--tion of the fluid, and deposit of fibrinous matter. The veinsof the part, both deep and superficial, were more or lessobliterated, the vena-saphena-major being more completelyso. It is likely that this patient had had several attacks ofphlebitis of the adhesive kind, which at last terminated in theobliteration of most of the venous trunks of the leg; andhence the continual effusion into the cellular tissue, and thethickening of the limb by the absorption of the wateryparticles and fibrinous deposits.

It is, however, maintained by some authors that the pecu-liarity of the disease is that the effused fluid is always coagu-lated, and that this therefore differs much from ordinaryserous effusion. The disease in the present case seems to havebeen quite localized, and not depending on any constitutionalpeculiarity or diathesis. In the latter case, writers on thedisease discountenance the amputation of the enlarged limb,and they assert that the constitutional symptoms after removalof the limb are apt to recur accompanied with inflammation ofsome of the viscera, or of an extremity on the other side of thebody. We should not omit to mention that M. Bouillaud,Physician to the Charite at Paris, attributes elephantiasisArabum to the obliteration of veins; but some of his opponentshave stated that M. Bouillaud has confounded cause witheffect, and that the obliteration of the veins is produced bythe same influence which gives rise to the hypertrophy of thewhole limb.

Malignant Disease of Upper Jaw; Post-mortem Examination.(This case was reported in a former Mirror.)

(Under the care of Mr. HOLT.)

I IT will be remembered that a short time since we putI upon record a case of malignant disease of the upper jaw, in

515

which Mr. Holt refrained from interfering, (THE LANCET,March 1,1851, p. 237.) The patient died a few weeks ago,and we beg to subjoin the appearance of the parts involved.The particulars -were noted by Dr. Shearman, house-surgeonto the hospital.

General cerebral structures healthy; but beneath thearachnoid on the left hemisphere, at the vertex, there is anfusion of yellowish-white gelatinous matter, partly pus andpartly exudation matter; substance ’of brain healthy, excepta small portion of the size of an almond on the lateral aspectof the middle lobe, which was of a slate-grey colour, and firmon section. Over the lateral and upper surface of thecerebrum, a large quantity of pus was effused; it extendedfrom the vertex to the front of the anterior lobe, up to theroof of the orbit. The anterior lobe on the part correspondingto the roof of the affected orbit, contains a cavity whichdisplays on its surface no evidence of effusion to circumscribeit; the walls are irregular, and of a slate-grey and purplecolour. The fluid in it is grumous, dirty-grey, and not fillingits cavity. No connexion appears to exist between the puson surface of brain and that in cavity; the substance of thebrain around the cavity is softened and purplish in colour;rest of brain healthy.The whole of the upper jaw surrounding the antrum of left

or diseased side is broken up from necrosis, and the partcorresponding to the antrum more or less made up of purulentmatter and necrosed pieces of bone. The orbit contained theusual quantity of fat; the periosteum thickened, white, dense,and almost creaking under the knife; the thickness is chieflyin the posterior part, around the optic nerve; and this seemsto be the cause of the protrusion of the eyeball; the opticnerve and globe natural. The other portions of the body were Iin a normal state, and no trace of tubercular or malignantdisease found anywhere. Under the microscope, the periosteumof the orbit was found to consist of stroma and fluid part,-chiefly the former; the fibres are in bands, and closely crossedwith one another, and also considerably interweaved; theyare wavy, and rendered transparent by acetic acid. In thefluid parts were caudate cells, with well-marked nuclei; alsocells containing several nuclei; the envelope is very fine andtransparent; size, larger than a pus globule. There are othermuch larger cells, whose walls are exceedingly fine, andthese in their turn containing nuclei.

CHARING-CROSS HOSPITAL.Aneurism of the Femoral Artery in the Groin; Spontaneous

Occlusion; Gangrene of the Leg; Death; Autopsy.(Under the care of Mr. AVERY.)

SPONTANEOUS cure of aneurism has at all times been a veryinteresting, and hitherto not quite explained, surgical fact; wehave, therefore, no doubt that a case bearing upon this subjectwill be perused with a certain amount of benefit. Nor is it

very common that an opportunity should be afforded of exa-mining the parts soon after such a natural recovery has takenplace; this, however, was the case in the instance which wehave to put upon record.Authors have generally admitted various ways in which

aneurisms may cease to pulsate, and become solid withoutsurgical interference. 1. Pressure on the cardiac side of the.sac, either by the aneurism itself, or a tumour of a differentnature. 2. Occlusion of the aperture of communication bycoagulation. 3. Inflammation and gangrene of the cyst.4. The aneurism becoming diffuse. 5. Obliteration of theartery on the distal aspect. These are the different modesenumerated by Professor Miller, in his "Principles of Surgery;"to these we would add-7. Certain circumstances which musthave some influence in spontaneous cure-viz., an increased,plasticity of the blood, and a less active circulation from what-ever cause.

Mr. Porter states, in his work on Aneurism, that the casesof natural recovery which he has had an opportunity of seeing,’occurred by means which are surrounded with great obscurity.,Still it might be inferred that such cures must, to a certainextent, have been the result of one of the above-mentionedchanges. We find three such cases mentioned by Mr. Porter.In the first, the aneurism had caused the absorption of thesternum, and seemed ready to burst; the pulsation, however,without any appreciable cause, ceased, and the patient reco-vered. The second refers to a subclavian aneurism, whichpulsated strongly. Several consultations were held upon the

,-propriety of tying the arteria. innominata, but whilst the’ope.: ,qtiou was being -delayedy-the tum6ur’lost its pulsations, the

clots became consolidated, and the disease disappeared. Thethird case is one in which Mr. Porter attempted to paSS iV 11906-ture around the innominata for subclavian anetirism; thelnno-minata artery was in too diseased a condition, and could notbe tied; but the patient soon afterwards recovered withoutthe aid of surgery. It is very probable that in these cases thesac became solid by tho occlusion of the artery On the cardi&cside.

Unfortunately r Jntaneous cure is very rare, and surgeonshave for the most part to trust to deligation of the artery orpressure. In the case before us, as will be seen by the sequel,the pulsations of the sac ceased spontaneously, but other ioir-cumstances contributed to the fatal termination. We havemuch pleasure in continuing our series of aneurism cases, andfrom notes taken by the house-surgeon Mr. Lingham, wegather the following details.John Buzz, aged seventy-four, was admitted Jan. ’7, 1851,

under the care of Mr. Avery, with aneurism of the femoralartery. He stated that his habits had been temperate, andthat thirty years of his life had been spent as sailor in themerchant-service, during which period he was exposed tomany hardships. Two years since the patient contractedgonorrhoea, when a small swelling made its appearance’inthe groin; he consulted a surgeon, who gave him medicineswhich nearly, not altogether, removed the tumour. - Thelatter, however, made its appearance again in a very shorttime, and had been increasing up to admission. Patient didnot suffer much inconvenience from the swelling until aboutthree months prior to his entering the hospital, when, aftermoving some furniture (in which effort he fancies he exertedhimself too much.) the tumour rapidly increased, and a pulsa-tion was now for the first time noticed in the swelling.On examination, a large pulsating tumour-was found on the

upper part of the right thigh; it occupied the position of thefemoral artery, and extended from about three inches belowPoupart’s ligament into, and apparently entirely filling, theright iliac fossa. A pulsation synchronous with that of theheart was perceptible in every part of the tumour, an a

distinct bruit de souffiet was yielded on auscultation. Thewhole limb was swollen, cedematous, and painful, the skin pale,and the temperature below that of the corresponding leg.The femoral artery on the sound side was found small involume, its impulse feeble, and giving to the finger the sensa-tion of a peculiar sharpness. The pulsation of the radialartery was found devoid of power; these symptoms leavingbut little doubt but that the arterial system was extensivelydiseased. The patient could not assume the recumbent

posture, as the pain in the groin was thereby considerablyincreased, and he was obliged to be constantly sitting up inbed. No rest could be obtained at night, on account of thepain and the sitting posture, tongue moist and slightlyfurred.Mr. Avery ordered wine and a nutritious diet; the limb to

be bandaged from the toes upward, and five grains of soap-pill at night. On the next day it was found that the patienthad passed a restless night; the tumour has diminished insize, and pulsation had totaUy ceased in every part of it; thelimb was less swollen, and its temperature had become lowerthan it was on the previous day. The impulse of the femoralartery on the left side was now found less abrupt, and im-proved in volume. On the third day after admission, thepatient was able to lie down; he had some sleep at night; thepain was less severe, but the temperature up to the knee verylow. The leg began to present a mottled appearance,and the tumour had resumed neither pulsation nor bruit.The patient appeared weaker, but felt comparatively free frompain. Tongue cleaner; pulse seventy, feeble, but Tegular.On the fourth day, the pain was very severe in both limbs,

the lower portion of the right leg becoming colder and of adeeper mottled appearance; the left leg was at the same timeof the ordinary temperature, though the impulse of its femoralartery had again become feeble. The aneurismal tumourremained stationary. Warmth was now applied to theaffected limb by means of cotton wool. Mortification made,however, rapid strides, for on the fifth day it had appeared onthe inner side of the leg. The pulse now fell to sixty, andthe tongue became dry.The sphacelus had on the ’eighth ’day extended in evety

direction round the limb up to the knee, in which region aneffort at the formation of a line of demarcation was perceived;the pulse became small and feeble, and the tongue brown; thepatient did not suffer any pain,’ but"was becoming drowsy.The tumour presented no reaewed pulsations, and was di-’ttiinisbilÌg1in síze. ’ .on the tenth- day therl-- was considerable