119

generally held, when the amount of fluid threatened suffo-cation, but also, as in the case under consideration, when thepowers of life are manifestly giving way. He also urged theinsertion of the drainage-tube in similar cases ; for althoughin this instance recovery did not take place, the good effectsof this plan of treatment were sufficiently manifest. Dr.Fincham pointed out that these good effects were twofold. Inthe first place, it prevents the reaccumulation of pus, and so doesaway with the necessity of repeated tappings ; and, secondly,a most important point, by its favouring the escape of pus assoon as it is secreted no decomposition can take place withinthe cavity of the chest, and thus absorption of poisonous gasesis rendered impossible. In the present case the change in thecharacter of the discharge after the insertion of the drainage-tube was most marked: the pus became healthy and dis-charged freely, and the fetor ceased; whereas previously, al-though the silver canula was constantly worn, and the chestfrequently syringed out with a weak solution of Condy’s fluid,only temporary good was effected. It was hoped that thehyposulphite of soda, as advocated by Dr. Polli, of Milan, asan antidote to septic poisoning, might have proved of service;no advantage, however, appeared to have resulted from its use.

WEST LONDON HOSPITAL.

VERY LARGE ANEURISM OF THE ABDOMINAL AORTA.

(Under the care of Dr. MAUDSLEY.)FoR the notes of the following extremely interesting case

we are indebted to Mr. G. Jackson, house-surgeon to the hos-pital. The tumour was distinctly made out during life, butits nature was doubtful until death revealed it.

J. B-, aged forty-three, admitted February 12th, 1865.Had been a soldier, and had enjoyed good health up to abouttwelve months ago, since which time he has suffered from painin the left side, extending down the left leg, which has alsohad a sense of numbness in it, and he has walked lame on thatleg. He has drunk hard, been in hot climates, smoked much,and had syphilis.About a fortnight before admission, when first seen, he had

pleurisy on the left side; in about a week the symptoms ceased,and then a rapid swelling of the abdomen suddenly tookplace, its surface being tensely cedematous, especially over theleft half, which was more prominent. The left leg also becamegenerally and largely oedematous. His face was blanched andexceedingly anxious. He suffered from constipation. He wasnot emaciated, but his general state was low.

Feb. 21st.-The cedema of the abdomen having greatly sub-sided, a more or less defined tumour was noticed in the leftlumbar region, extending from the last rib to the crest of theilium. No pulsation was felt, or bruit heard. ’

As a rule he did not complain of much pain; once or twicehe said that he felt a darting pain in the region of the tumour.Urine acid, sp. gr. 1028; lithates abundant; no albumen ornasts.March 3rd.-Died this evening, having gradually sunk from

the time of admission.Autopsy, fifty hours after death.-Old and firm pleural ad-

hesions on both sides, extending over almost the entire surfaceof both lungs, which were much congested, the lower lobe ofleft lung being hepatized. The valves of the heart werehealthy; but the left ventricle was greatly hypertrophied. Alarge mass filled up the whole of the left side of the abdominalcavity, and to it the descending colon was adherent in itswhole course; it extended from the lower surface of the dia-phragm down to the left iliac fossa, the upper part of thehollow of which formed part of its bed. It was impossible toseparate it from the posterior wall of the abdomen, to which itwas matted. There was extensive caries of the left side of thelumbar vertebras, and of the last rib, which was completelyulcerated through, and of the crest of the left iliac bone on itsinner and upper surface. The tumour was an immense aneu-rism of the abdominal aorta, filled up with multitudinouslayers of fibrin, more or less firm, and with a large quantity ofcoagula. The left kidney was flattened, atrophied, fatty, andglued in the wall of the sac. The walls of the sac were verythin in some places, and closely adherent in others to thebodies of the vertebrae. The upper limit of the aneurism wasabout the spot at which the thoracic becomes the abdominalaorta ; the lower limit thereof was immediately after the en-trance of the left common iliac artery. The thoracic aorta wasadherent to the walls of the aneurism for about two inches be-fore it entered the sac.

The great difficulty in the diagnosis of tumours is well illus-trated by this case. No bruit or expansion being noted all"that could be said with certainty was, that a large tumour ofsome kind filled up the left half of the abdomen, and pressedupon the left iliac vein so as to cause oedema of the parts,which passed their blood into that channel.

It is worthy of remark also that a man with so vast a mass.of mortal mischief in his abdomen should have apparentlysuffered so little as to be able to continue his work as agardener, as this patient did until obliged to give up by reasonof an attack of pleurisy.The treatment in this case at the time it came under obser-

vation was, of course, only palliative. Whether, if it had beendetected earlier, pressure might have been applied, as is saidto have been done successfully in one case, must remain verydoubtful.

ST. THOMAS’S HOSPITAL.TRAUMATIC ANEURISM OF THE FACIAL ARTERY, CURED

BY LIGATURE OF THE VESSEL.

(Under the care of Mr. LE GROS CLARK.)

’ AN engine-fitter, aged twenty-six, was admitted into thishospital on April 10th, 1865. He is a temperate man, of goodconstitution. About five weeks since he received a kick froma man on the left side of the lower jaw. There was no externalwound. In a few minutes the injured part became very tumid,and he could feel the swelling throb. The injury was nottreated in any way; and the patient stated that in the courseof a fortnight the swelling had nearly subsided, but the pulsa-tion continued. Subsequently suppuration occurred, and pusand clotted blood escaped through a spontaneous opening inthe mouth, near the molar teeth. Pulsation continued, andthe wound closed. It was then reopened, and a considerablequantity of arterial blood was lost on several occasions. Whenadmitted, there was a pulsating tumour in front of the mas-seter muscle, and the man was beginning to show the effectsof the loss of blood. As pressure on the facial artery arrestedthe pulsation, a ligature was placed on this vessel as it crossesthe ramus of the jaw. There was no return of pulsation, andthe patient left the hospital in a fortnight, well.Remarks.-The blow ruptured the facial artery. A diffused

aneurism was the consequence. This became, subsequently,by the absorption of the clot, a circumscribed false aneurism.In this suppuration took place, and the lancet only madematters worse by establishing an exit for the blood. Theligature was the remedy indicated, and its application wassuccessful-an epitome of what is seen in the femoral andother large arteries.

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

TUESDAY, JUNE 27TH, 1865.DR. ALDERSON, F.R.S., PRESIDENT.

A SECOND SERIES OF FIFTY CASES OF OVARIOTOMY; WITHREMARKS ON THE SELECTION OF CASES FOR

THE OPERATION.

BY T. S. WELLS, F.R.C.S.,BURGEON TO HER MAJESTY’S HOUSEHOLD, AND TO THE

SAMARITAN HOSPITAL.

THE author has constructed a table showing at a glance theresult of the fifty operations ; the recoveries being to the deathsin the proportion of two to one. The most favourable age forthe operation appears to be before twenty-five or above forty.The conjugal conditions of the patients seem to have littleeffect on the result. Hospital cases have been more successfulthan private cases. The result of the operation depends butlittle on the season of the year in which it is performed. Ad-hesions of the tumour to the abdominal wall and intestinesare of little importance; adhesions to the bladder, iliac vessels,ureters, or rectum are very unfavourable. A short pedicle isalso very unfavourable. There is no doubt that the cases

where the stump of the pedicle can be kept external to theperitoneum are much more uniformly successful than those inwhich the stump is allowed to sink into the abdominal cavity.

120

Of this latter class of cases the least unfavourable are those in i is not mercurial cachexia : it is syphilis in a constitution modi.which the ends of the ligatures are cut off short. The size of fied by mercury." an ovarian tumour does not of itself affect the result; but size ; Dr. Drysdale observed that his own experience completelyand solidity together, by affecting the length of the incision ; corroborated the remarks of Bidenkap and Barensprung. Henecessary for the removal, appear to be of some importance. gave the details of several cases recently treated by him with-A short incision is much more favourable than a long one. The out mercury, with immunity from any but trifling lesions.probable result of ovariotomy can be estimated with far greater In conclusion, Dr. Drysdale said he believed that syphilisaccuracy by a knowledge of the general condition of the patient in adults was not always, but almost always, a very mild dis-than by the size and condition of the tumour, ease, when treated without mercury ; that rupia was extremelyREMARKS ON SOME RECENT EVIDENCE AGAINST THE INTERNAL

rare when no mercury was used ; that bone-disease did notADMINISTRATION OF MERCURY IN SYPHIILIS, WITH occur unless in mercurially treated cases ; and that, in short,

CASES TREATED BY THE AUTHOR. the internal administration of mercury in syphilis, or in in-..

fiammatory diseases, had neither any rational theory to appealBY CHARLES R. DRYSDALE, M.D., M.R.C.P. LQND., to, nor was it supported by the experience invoked in its de-- PHYSICIAN TO FARRINGDON DISPENSARY, HOLBORN. , f ’ ence. H e t rus t ec 1 th a t t1 .Ie verdict of the profession would’The author observed that, as a Commission was endeavouring soon be against the internal use of mercury in syphilis.

to arrive at some conclusion on this vexed question, he thought Mr. WFLLS said that he had never denied the possibility ofthe present a fit time to invite discussion on the subject. He disease of bone being caused by syphilis alone in cases wherebelieved, in common with Mr. Syme and M. Ricord, that this no mercury had been given; but he had never seen such adisease had always existed; and that before the time of Para- case; and it was well known that workers in quicksilver minescelsus it was mild, probably on account of the absence of mer- Iand in looking-glass factories were subject to diseases of bone.cury from the materia medica of the ancients. Dr. Ferguson, He believed that in most cases, therefore, disease of bone inin his letter from Evora in 1812, had shown what terrible syphilitic patients who had taken mercury was due rather tomutilations were caused by mercury amongst the British ; mercury than to syphilis; but he was far from doubting thewhilst the Portuguese, treated without it, had no phagedæna. great value of mercury when properly administered in secondaryM. Ricord had for some twenty years been chief of an eclectic and tertiary forms of disease, or locally used in the primaryschool, which, discarding the drug in soft sores, advised " six forms; and he certainly did not deny the possibility of syphilismonths of treatment with a daily dose of mercury (which in- alone causing bone-disease because he had not happened to seefluezzees the accidents we have to combat), followed by three a case in which it had done so.months of iodide of potassium." " Of this treatment Mr. Syme Mr. DURHAM said the time was too short to permit a full,had written that it "injures the health not less effectually discussion of the subject, but he could not allow it to dropthan the process of poisoning it professes to have so advan- without entering a protest against the doctrines of the author,tageously replaced.’’ Dr. Hughes Bennett said, " The idea and expressing his opinion that the judicious use of mercurythat mercury is a specific for syphilis, and the incalculable by inunction or by bath affords the safest, speediest, and mostmischief it has occasioned, will constitute a curious episode in successful mode of treating syphilis yet known. He wouldthe history of medicine at some future period." Mr. Weeden remind the Society of Dr. Boeck’s patient who presented him-Cooke and Mr. Spencer Wells said that syphilitic bone-disease self for examination by the Fellows at the last meeting. Thisdid not occur without the use of mercury. patient was stated to have suffered most severely for several

The author had recently received from Dr. Boeck of years from syphilitic disease. He never took mercury in anyChristiania two works: the one entitled " Recherches sur la form, although constantly under treatment of one kind orSyphilis," by Dr. Boeck; the other" Aperçu des differentes other. He finally felt constrained to take a voyage to NorwayMethodes de Traitement employées contra la Syphilis Consti- and submit to the very tedious and disagreeable treatment oftutioueliie a I’H6pital de l’Université de Christiania," by Dr. syphilization. Not very encouraging this for the non-mer-Bidenkap. Dr. Boeck, in his " Recherches," had shown that curialists ! In hospital practice cases of pure syphilis are

primary sores took, on an average, far longer to heal under rarely met with. The symptoms are usually obscured andmercury than without it (sixty-two to thirty-eight days); and complicated by the effects of dirt, drunkenness, and continuedalso that the number of secondary appearances was far greater debauchery, and the history is unreliable. In private practicewhen it was used (twenty-four to fourteen). Dr. Bidenkap it is very different. But whether in hospital or private prac-mentioned that for the last ten years there had been experi- tice, he (Mr. Durham) had almost invariably met with thements, in Christiania, as to the treatment of constitutional best possible results from the judicious administration of mer-syphilis, resulting in entirely expelling the drug. Besides cury. He had never seen any mischief ensue, nor could hesyphilization -employed by Dr, Boeck, and which, Dr. Drysdale believe that such need ever be the case if the patient beobserved, had, in his opinion, for sole merit its freedom from watched with sufficient care. The author’s references to thethe use of mercury,-Dr. Bidenkap gave a detailed account of ravages of venereal disease in the olden times, and the whole.192 cases treated by means of two expectant methods: (1) sale administration of mercury then the fashion, seemed tosweating; (2) derivation-i. e., the raising of pustules by him altogether beside the question. His (Mr. Durham’s) ex-tartar-emetio ointment over the body. In these 192 cases perience showed that under mercurial treatment chancres veryThus expectantly treated, no worse symptoms were observed quickly healed, and secondary symptoms disappeared whichthan eruptions, alopecia, sore-throat; with only five cases of under other treatment had remained long stationary. Lastly,iritis, which got well without mercury, and two cases of peri- it was worthy of note that many of the boasted cases of theostitis; and no bone-disease. Dr. Bidenkap wrote, " The very non-mercurialists were really treated by mercury after all, asrare cases of tertiary syphilis are met with among patients witness several cases recently published, in which the oint.who have undergone a mercurial course elsewhere, especially ment of the nitric oxide of mercury is stated to have been- abroad. Formerly, on the contrary, obstinate tertiary cases applied to portions of the surface of the body.formed the majority of those treated at the hospital. It ap- Dr. WEBSTER said that English physicians were apt to draw’jears, then, that the exclusion of mercury from therapeutics erroneous conclusions as to syphilis from facts obtained abroad.has been the cause of it." Dr. Ferguson’s statistics obtained from the Portuguese army

Prof. Barensprung, of Berlin, in his work on " Hereditary ought not to be confounded with those of the English army.Syphilis" (Berlin, 1864), after enumerating mucous tubercles, The Portuguese soldiers lived very badly. Syphilis was quitesore-throat, and exanthem-like eruptions, had written:- as common in Portugal, but was perhaps milder and requiredThe above rapidly described alterations are those of which, milder treatment.in the majority of cases, the picture of syphilis is entirely com- The PRESIDENT said that the Portuguese soldiers lived chieflyposed. These may remain for weeks or months, or vanish for on vegetables and fish.shorter or longer period, or finally disappear for life. At Mr. HOLMES COOTE said he rarely gave mercury-not inleast I can certify that, in the now countless cases where I one case in fifty.nave treated syphilis without mercury, and which I have seen Mr. THOMAS SMITH had read all the author’s papers on

completely recover, there have never appeared any other forms infantile syphilis, and was surprised at the results of his ex-than those papular and exanthematous ones, with, in a few perience. His own experience was very different. Seeingcases, iritis, periostitis, and orchitis ; but in no single instance many cases of infantile syphilis, he felt it to be his duty tohas destructive perforation or necrosis appeared, provided that say that the mercurial treatment was most successful. Ino extraordinary circumstances prevailed which have the pro- reference to the question whether bone was ever diseasedperty, like mercury, of altering the character of syphilis...... where no mercury had been given, he instanced a case of’ rapid and well-marked mercurial eachexia is not the sole, : necrosis of the nasal bone, in a syphilitic infant who had neverbut the most frequent, cause of phagedæna...... Tertiary syphilis had any mercury.

121

Dr. DRYSDALE, in thanking the several speakers who hadcriticised his short abstract, observed that in the originalpaper he had quoted Mr. Wells’s own words-viz., that he hadnever seen a case of syphilitic bone-disease where mercuryhad been omitted from the treatment. This statement hadalso been made by Mr. Weeden Cooke and others. Con-

sequently he (Dr. Drysdale) supposed it could but rarely havebeen seen by other surgeons. He had never seen such a case,although he had seen nodes, iritis, and periostitis. With i

regard to what had been said by Mr. Durham, he would say Ithat he believed, as far as he had examined the question, thatsyphilization, as practised by Professor Boeck, had but onemerit-viz., that of dispensing with mercury. The true doc-trines of treatment of this disease, he believed, were, that itshould be dealt with, like other surgical complaints, by ex-ternal applications, caustics (if necessary in phagedæna), andordinary sound remedial measures; and he would observefurther that he was persuaded that Mr. Durham, in commonwith the majority of the profession, was not in a position tojudge of the course of this disease without mercury, when itwas, and had been up to this date, almost invariably treatedby this powerful remedy. His (the author’s) own paper gavenumbers of cases recently treated without mercury, all of themvery mild affairs. With regard to the argument used by Dr.Webster, he would express his humble conviction that varietyof race and climate would not account for the difference of the

gravity of the disease, as that gentleman and others seemed tothink, since in one of the warmest and in one of the coldestclimates in Europe-Spain and Norway-the disease, whentreated rationally, was mild, and when treated by courses ofmercury was one of the greatest affiictions that could attack amember of the human family. The statement of Mr. Smith,with regard to the successful treatment of the disease calledinfantile syphilis by means of mercury, was opposed to theconclusions come to by himself (the author), and to those byMr. R. Dunn and Mr. Allingham. As far as he was aware, hehad himself been one of the first, if not the first, to publishcases of infantile syphilis which had recovered without anyemployment of mercury, internally or externally ; and sincethat time Mr. Dunn had treated about fifty cases, with onlytwo or three deaths, without mercury. He submitted that

any evidence adduced by speakers this evening would be quiteinsufficient to convince a jury of scientific men, who came tothe subject without prejudice, that mercury did much good inthis disease. Finally, he had to remark that the illustriousProfessor of Surgery of the Royal College of Surgeons ofEngland had recently made use of the following language, as Ireported in THE LANCET of June 10th, 1865 :-" Occasionallysome, under the impression that nothing is being done, willcling to the mysterious-looking black or yellow lotion-to theso-called specific alterative ; even a month of slow poisoningwith mercury may be preferred to the laissez faire system."Such were the words of the renowned Professor Fergusson;and he hoped they would make other able men in high placespause and think. It was but a few years back that anaspirant would have been rejected for a degree at the Collegeof Surgeons if he had said that indurated chancres did not re-quire a course of mercury. These days, he hoped, were gonefor ever.

Reviews and Notices of Books.De l’Ovariotomie. Par E. KŒBERLE, Professeur agrégé (Sec-

tion de Chirurgie) à la Faculté de Médecine de Strasbourg,&c. 8vo. pp. 88. Paris, 1865.

Opérations d’Ovariotomie. Par E. KŒBERLÉ. 8vo. pp. 162.Paris, 1865.IN the first of these works M. Kœberlé has given a brief

account of the history, statistics, and prognosis of ovariotomy,together with a chapter on the various objections which havebeen raised to the operation. As most of the materials forthis essay have been drawn from English authors, we findnothing with which the readers of our literature are not fullyacquainted. The various sections are, however, clearly written;and although full justice is not rendered to all the gentlemenwho have recommended and performed ovariotomy when thisoperation was tabooed, yet on the whole the essay may be re-garded as a tolerably fair compilation.

The second volume is devoted to long reports of those casesin which the author himself was the operator, and whichoccurred between June, 1862, and June, 1864. The historiesare twelve in number ; many of the cases were complicated ;five times both ovaries were simultaneously removed; and oncethe uterus itself was extirpated with success. Nine of the

I operations were followed by recovery. From an examinationof the reports, the following facts may be gleaned :-CASE 1.-Madame J. W , twenty-six years of age, mar-

ried two years. Had observed a small tumour for eighteenmonths. In spite of medicine the growth increased until itfilled the abdomen. The catamenia had been abundant untilsix months before the operation, since which time they hadbeen absent. Ovariotomy was performed on June 2nd, 1862,the patient being under the influence of chloroform. Thetumour was multilocular, and was adherent to the omentum.The pedicle was retained outside the lower part of the woundby the écraseur and ligatures. On July 3rd she was completelycured.CASE 2.-Madame V-, aged thirty-seven years, a widow,

and the mother of four children. Catamenia always regular.The stomach had been enlarged two years; while four monthsprior to the operation of ovariotomy she had been tapped, andsomewhat less than three gallons of fluid taken away. Thetumour was removed Sept. 29th, 1862, eight days after thetermination of the menstrual period. Chloroform was given.The tumour sprang from the left ovary, was multilocular, ad-herent to the omentum, and required a very long incision forits extirpation, while the pedicle was very short, and was withdifficulty retained outside the abdomen by a clamp. The rightovary was of the size of a fowl’s egg, and contained many cysts.A ligature was placed tightly round its pedicle, and the glanddrawn out at the lower angle of the wound, where it was reotained until the ninth day, when it sloughed off. A piece ofthe omentum, as large as the hand, was ligatured "en masse. "

Altogether the operation took two hours, while, wonderful torelate, the pulse, which was previously 95, fell to 72 in a fewhours, never again rose above 90, and after the eighth day reomained at 75. By the twenty-first day she was well.CASE 3.-Madame S-, aged twenty-one, married eighteen

months previously. Had noticed an enlargement of thestomach for eleven months. A multilocular tumour, springingfrom the left ovary, with, probably, recent adhesions in theleft flank and in the pelvic cavity. Her mother died fromovarian dropsy at the age of thirty-eight. On Dec. 4th, 1862,ovariotomy was performed, the patient being under the in-fluence of chloroform. There were adhesions to the omentnmand mesentery, the separation of which produced haemorrhagerequiring two ligatures. The tumour was also firmly attachedto the uterus. The right ovary was diseased, and formed amass of morbid material in conjunction with the rectum,uterus, and tissues at the side of the pelvis. As it was impos-sible to extirpate the ovaries only, the right was left un.touched, while a clamp was passed round the base of thetumour, springing from the left gland, and then as much of itas could be drawn outside the abdomen was cut off. The ope-ration lasted ninety minutes, the loss of blood was great, andthe pulse was almost imperceptible. But in about six hoursthe pulse was only 86; there was little pain, and a slight bleed-ing from the divided portion of the cyst was easily checked.By the sixth day there was abundant suppuration; the tumourwas gangrenous and shrivelled up, and drainage tubes wereintroduced at the chief focus of suppuration. Subsequentlythe condition of the patient varied, though generally it wasgood. The suppuration gradually diminished, and at the endof the month was insignificant. There was then a narrow

fistula, about two inches and a half deep, kept open by adrainage-tube. On examining the pelvic cavity no appreciabletumour could be detected. Eighteen months after the opera.tion the health of Madame S-- was most satisfactory.