35

order to make a semi-fluid mass of consistence sufficient to pre-vent its running beyond the spot on which it is placed. Themixture should be kept in a stoppered bottle, and be appliedwith a small glass spatula or rod. Before using it, the sur-rounding parts should be protected by a thick layer of cerateor firm ointment, so as to form an embankment limiting thesurface to be destroyed, and a layer of the caustic may be madeupon this of about the eighth or tenth of an inch in thickness.This is allowed to remain. As in the case of other caustics, Ibelieve, the pain is less in the superficial than in the deeperdiseased tissues. In the case mentioned, but little sufferingfollowed the first application, but in subsequent dressings, asdeeper and more highly organized tissues were reached, thesuffering was severe. Incisions were made through the firstslough to admit of the access of the caustic to these parts. ’,There appears to be reason to believe that the amount of pain icaused by all caustic applications is less the result of any specificproperty of the caustic itself, than of the degree of sensibilityexisting in the part or structures attacked. Other thingsbeing equal, there is little doubt that the more powerful andrapid is the action of the caustic, the less is the pain inflicted.On this account also, as well as on other grounds named, thepaste in question has appeared to me to deserve the attentionof the profession, for use in those instances in which its employ-ment is to be regarded, as in the case cited, a better method ofprocedure than ablation by the knife.Wimpole-street, Cavendish-square, Jan. 1858.

ON A CASE OF

ANEURISM OF THE INNOMINATA ARTERYTREATED BY PRESSURE ON THE CARO-TID AND SUBCLAVIAN TRUNKS.

BY A. M. EDWARDS, F.R.C.S.E.,DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY OF EDINBURGH.

SURGERY can do so little towards relieving the disturbedsymptoms produced by aneurisms at the root of the neck, thatany contribution to our knowledge on the subject must havesome value; but I am induced to lay the following case beforethe profession, not so much on account of any merit speciallypertaining to itself, as that it may set other men thinking, andmay lead them to some more efficient means of alleviating thesufferings of those who are the victims of deep-seated aneu-risms :-

In September, 1856, Mrs. L-, aged fifty, was recom-mended to my care by Professor Simpson. She was a sallow-complexioned woman, with hanging, flabby cheeks; her lips,which were always apart, were livid and drawn down at theangles, and she breathed rapidly. Her countenance presentedthe peculiar anxious expression of one suffering from a fataldisease. On examining her neck, I found on the right sideabove the sterno-clavicular articulation a tumour, the size of anapple, situated between the sterno-mastoid muscle and themiddle line of the neck, which pulsated violently, was soft andcompressible, giving to the fingers much the same feeling as avulcanized india-rubber ball, which, though easily compressible,expands again immediately the pressure is withdrawn; andwith the expansion of this tumour, fluid seemed rapidly to fillthe interior, and to be separated but by a thin partition from thefingers. Another pulsating tumour rose in front of the trachea.They were, though apparently distinct, evidently bulgings outof the same aneurism, as pressure on the one was followed byincrease in size of the other. The patient had remarked thesetumours about two months before I saw her, and they were,according to her account, increasing rapidly. Any pressureupon them was attended with pain and an increase of cough.She suffered from constant dyspnoea, had entirely given up herordinary household occupations, and had frequent fainting fits;she rarely ventured even at night to lie down in bed, as, afterfalling asleep, the laryngeal spasm became so violent, that anattendant had to be on the watch ready to administer restora-tives. The ordinary internal remedies were tried, but withoutmuch benefit.As I considered that the aneurism was one of the innominata

artery, I thought of placing ligatures on the vessels accordingto Wardrop’s method; but Dr. Laycock, who at my requestexamined her chest with the stethoscope, considered that thearch of the aorta was also aneurismal, so I gave up the idea ofa cutting operation. But it struck me that Mr. Wardrop’s

principles could be applied to compression, and Mr. Young, ofPrinces-street, constructed for me an instrument which I shallendeavour to describe :-A broad leathern belt to go round the chest, and fasten in

front with three straps and buckles. On its left posterior andright anterior upper margins are brass buttons. In the middleof its posterior aspect is an iron plate perforated with severalholes to admit screws, which attach to it an upright steel rodabout eighteen inches long. This rod supports an arc of steel,which is attached to it by a screw allowing a certain amountof motion. In front, this arc is perforated by another screw,about an inch long, with a small cross handle; this projectsbackwards, and bears a conical piece of cork covered withwash-leather. When the instrument is applied, the upright isat the back and right side of the neck, which rests in the are,and, by shifting the lower end of the upright, pressure withthe cork can be regulated and efficiently maintained upon thecommon carotid artery, the conical shape of the cork enablingone to confine the pressure to the artery. A strap is carriedover the right shoulder from the buttons behind to those infront; on it slides another cone of cork, which can be adjustedover the subclavian. It will be seen that in principle this in-strument resembles Bourgery’s tourniquet for subclavia.npressure.

Mrs. L- had worn this instrument for several hours oftwo days, when I was alarmed by observing that the tumourhad visibly increased in size. Its walls felt thinner, and thecontents were distinctly fluid. The bruit de soufflet was veryloud, and the pulsation violent. The treatment, however, wascontinued, and the pads adjusted so as to stop all pulsation inthe branches of the external carotid and in the right wrist.On the fourth day, the tumour, though larger than when theinstrument was first applied, was much harder and less com-pressible. The tracheal portion still, however, pulsatedviolently. Every morning, for the first two weeks, I ad-

justed the apparatus, at the same time manipulating the tumourrather roughly, with the view of breaking up the fibrine in thesac. But she soon learnt how to apply it for herself, and find-ing decided benefit from it, bore the treatment cheerfully. Shesaid it was irksome, but never complained of pain.

After the first week, the laryngeal symptoms entirely dis-appeared and did not return, and she had no more fainting fits;but she complained of some impediment in swallowing, as ifsome hard body stopped the food in its passage down thegullet. I now feared that the apparent improvement was de.ceptive, and that the tumour was increasing towards themsophagus; but as this symptom disappeared with the gradualdecrease in the bulk of that part of the aneurism which wecould judge of by external examination, I now conclude thatit arose from the solidification of the contents of the sac inclose apposition to the gullet.By the end of three months, she was well enough to lay asido

the instrument and resume her former household duties. Sherepeatedly walked a distance of three miles and back to myhouse, and passed tranquil nights. The external part of thetumour was then and is now the size of a nut, and hard; thetracheal portion has entirely disappeared; the aortic aneurismseems to have made but little progress, and, with the excep-tion of attacks of neuralgia in the face and head and a chroniccough which troubles her every winter, she has been in goodhealth since. She gave up the instrument more than tenmonths ago. Before she began to use it, a surgeon of greatexperience told me he expected the external tumour wouldburst in a day or two, and Dr. Laycock was of the same opinion.Of course, I cannot hope to avert the fatal termination wemust always expect in thoracic aneurisms; but I am convinced,and so is the patient, that the compression of the vessels be-yond the aneurism was attended with marked benefit, and wasthe direct cause of its hardening and subsequent rapid decreasein its size.As far as I am aware, this mode of treatment has not been

tried on any previous occasion.I India-street, Dec. 1857.

ON A CASE OF FRACTURE OF THE CRANIUM,WITH PROTRUSION OF BRAIN.

REPORTED

BY JOHN ROSE, A.M., M.D., Surgeon R.N.I

A. B-, a boy aged fifteen, fell from the main deck to the

lower deck of H.M.S. -, a distance of seven feet, his headcoming in contact with a, small stanle in the deck. He was

36

soon afterwards admitted into Haslar Hospital, and placedunder the care of the late Dr. Lindsay, and afterwards of Dr.McKechnie, at whose request the following notes were pre-pared, and permission obtained from the Director-General topublish them.The upper and back part of the squamous portion of the

temporal bone was found to be fractured to the extent of aninch and a half, with a corresponding wound of the scalp, fromwhich a portion of brain protruded; pulse 112, rather full;pupils contracted; is perfectly sensible, and does not complainmuch of pain. Fomentations of wet lint were applied to thescalp.

Oct. 4th.-Has slept during the greater part of the night;continues perfectly rational, and complains little of pain;pulse 108, and of some volume. Ordered, calomel, ten grains,every four hours.5th.-Is quite sensible; bowels have been opened by an

enema; little change since yesterday, except that headache iscomplained of. Continue calomel, and take an ounce and ahalf of saline mixture every three hours.6th.-Had a restless night, but complains less of headache;

pulse still accelerated, with considerable heat of skin. Had asenna draught this morning. The gums are very slightlyaffected with mercury. Continue calomel and saline mixture.7th.-Had a very restless night, and has much headache;

gums tender; pulse 84; tongue clean; bowels open. Continuesaline mixture as before.-Evening : Increased headache andgeneral uneasiness. Six leeches to be applied to the occipitalregion.8th.-Was restless during the night; tongue slightly coated;

pulse still frequent, but not so full. To have an enema withan ounce of castor oil.-Evening : To take a drachm of tinctureof hyoscyamus at bed-time.

9th.-Slept better during the night, and is easier thismorning; pulse and tongue as yesterday. Repeat tincture ofhyoscyamus at bedtime, and calomel, two grains.

10th,-.No change to be noted.llth.-Had a very restless night, and complains of great

pain in the head and neck. Fomentations of decoction ofpoppies to be applied to the head and cervical region.

12th.-The wound continues to discharge considerablequantities of pus, as well as brain. I examined the dischargeunder the microscope, and found the characteristic cerebralfibres and globular network, &c. Other symptoms as formerlynoted. Continue treatment as before.

13th.-Is easier this morning. In the course of the day,much pain was again complained of, and there was considerablefebrile excitement. Continue poppy fomentations, and a drachmand a half of tincture of hyoscyamus at bedtime.14th.-Much pain is still complained of, with considerable

nervous irritability and exhaustion.17th.-General improvement; had a good night; pulse 72,

natural; bowels open; there is less discharge from the wound,the granulations are healthy, and it appears to be closingrapidly; is perfectly sensible, and more cheerful; has a goodappetite. Allowed half-fowl diet, with rice.18th.-To take a little of the saline mixture during the day.

Continues to improve. Sleeps without the anodyne draught.19th.—Wound healing quickly, and the patient is progress-

ing favourably in every respect.Nov. 1st.—Has now no complaint; the wound continues

healthy, and has nearly granulated over.15th.-The wound has now completely cicatrized, and the

patient is perfectly well, being without bodily or mental defect.19th.-Discharged cured.H.M.S. Nimrod, 1857.

A FAMILY POISONED,-SUPPOSED MenDER AND SUI-CIDE.—Considerable excitement has been caused at Shorehamby the mysterious poisoning of a family named Pnttick, andwhich has terminated fatally to the mother and a son. Onthe 31st ultimo, Puttick and his wife and the eldest son

dined together, having for the meal bacon and greens and somehard pudding, which Mrs. Puttick had made from some flourshe had purchased on the previous day, and of which they hadbefore partaken without experiencing any unpleasant result.It appears that Puttick has been in the habit of keeping arsenicin the house for the purpose of killing rats, and last Michael-mas he purchased one pound of it, which was kept in a chestin an upper room. It is stated that the paper wrapper wasworn, and that some of the arsenic had fallen out into thechest; but how it could find its way into the flour or puddingkept down-stairs is a matter to be inquired into by the coroner’s jury.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum etdissectionum historias, tam aliorum proprias, collectas habere et inter se com-parare.—MORGAGNI. De Sed. et Caus. Morb. lib. 14. Proœmium.

CHARING-CROSS HOSPITAL.

EXCISION OF THE ANKLE-JOINT IN A YOUNG MAN AGED TWENTY-

FIVE, FOR CHRONIC DISEASE; SUCCESSFUL RESULT OF THEOPERATION, WITH A MOVABLE JOINT.

(Under the care of Mr. HANCOCK.)IT is seldom that we have an opportunity of recording ex-

amples of excision of the ankle-joint, although other operationsabout the ankle are frequent enough ; and of those which havealready appeared in our " Mirror," all have been done by thesame surgeon, whose third case we bring before our readers to-day.Mr. Hancock has the merit of having first performed the

operation in this country. The particulars of the case, that ofa boy eight years old, appeared in a former " Mirror," (THELANCET, vol. i., 1851, p. 355.) The results were perfectly satis-factory in this case, as we recollect seeing the boy at the Medi-cal Society of London three years afterwards, when he walkedremarkably well, with scarcely any halting, and possessingconsiderable motion in the joint. The operation was performedfor scrofulous disease of the ankle, as was also the second case,in a young woman aged twenty-two, also a patient in theCharing-cross Hospital (see THE LANCET; vol. ii. 1855, p. 578).The second instance was not successful, although it promised,very favourably at the time it was recorded. The third in-stance, which we had the opportunity of seeing several times,.was done for chronic disease of the ankle, in a young man agedtwenty-five, who had undergone a variety of treatment beforehis admission. The steps of the operation we will not retrace,as they are minutely and clearly described in the case itself;but we may remark that the rapidity with which everythinghealed in the ankle was most gratifying, and not a bad symp-tom showed itself. The main feature of the operation is notdissimilar in its principles to that of resection of other joints :the broad, articular, convex surface of the astragalus is sawnoff, as well as the articulating surface of the tibia and both mal-leoli. We should say there is probably more risk of injury tothe vessels and nerves in excision of the ankle than in anyother joint, from their proceeding both anteriorly and poste-riorly from the leg to the foot. Upon the integrity of thesedepends the success of the operation. No other instances ofexcision of the ankle have come under our notice at anyother London Hospital, although it has been done with excel.lent results by Mr. Fergusson, as mentioned in the last editionof his work on "Practical Surgery." We have now placedupon record examples of excision of the three great joints ofthe lower extremity, and of the great joints of the upper also ;the shoulder and the ankle have hitherto but seldom been suh,mitted to this proceeding. In the shoulder it is not often at-tempted, unless for gunshot injuries.W. R-, aged twenty-five, born in London; when three

years old, he slipped off the pavement, and sprained his ankle,which became much swollen, and caused him to limp. Inprocess of time matter formed, and three months after theaccident the part was lanced, and a considerable quantity ofmatter let out, giving great relief. He then went to the sea-side, and remained three months, during which time his anklegot worse. He was then taken to Sir A. Cooper, who advisedamputation of the limh, but this was objected to. He wasnext sent to Killarney, where he was attended by a gentlemanwho, as he says, ’’worked wonders ;" he was made to walkbarefooted in the meadows every morning while the dew wason the ground, and to rub oil on to his ankle before the fireevery night, and at the expiration of six months was so muchimproved that he could walk without a stick, and he continuedto improve every year, though the part remained stiff. In

June, 1855, he became an in-patient of Charing-cross Hospital,