54

discarded; for it is a question of life and death. The open,disorderly-looking order of march, however slovenly it mayseem to the lieutenant-colonel, must here be used, the closeorder being nothing short of stifling and sickening the men"by Piegulation. " While on the march, the face and handsshould be frequently bathed; and on such halts, which shouldbe ordered every hour, the men should be urged to refrainfrom drinking the impure waters so general in the hot season.It is hardly necessary to say that the ordinary march shouldbe conducted slowly, and always during the night, when theservice will admit of it.In the French as in the British army, the newly-arrived

soldier from Europe has been observed to be the most subjectto attacks; and this circumstance would indicate the necessityfor an especial precautionary regard to the new-comer and theplethoric. Here, indeed, in the words of Marshal Ney, theattentions of all classes of officers to their men should be unre-mitting.

In a letter from a distinguished staff-surgeon serving inIndia in the hot-weather campaign of 1858, I am informedthat in his force they lost in a month one hundred or moreBritish soldiers by sun-stroke. The men at length becameabsolutely terrified of the overwhelming power of the sun,though " not at all of the enemy, for whom they had a greatcontempt. But all dreaded the sun, and the hospitals becamecrowded, as well with men really ill as with men ailing butlittle, and anxious only to escape solar exposure." Herethe moral and military effect of the protective helmet of Dr.Julius Jeffreys" would be almost of as great value as its admi-rable chemical action: it would not only save the lives of sometwenty men on the long day’s march under an Indian Julysun, but it would impart new courage to the drooping bat-talion. Its influence, small though it looks, would stand in faircomparison, in moral and military power, with that caused bythe first sight of Larrey’s ambulances on the grenadiers of theFrench revolutionary armies: "Behold," said they, as theyascended the breach, " we shall no longer be neglected in ourwounds and our sickness." Dr. Jeffreys, speaking of his ownadmirable suggestions, says: "We know too well what theclimate of India can do while imperfectly opposed; we haveyet to learn what may be the immunities conferred by themost perfect protection at our command."The protective influence of temperance in diet, as against

the dangers of insolation, was never so thoroughly demonstratedas during the recent siege of Delhi, and indeed throughout thehot-weather campaigns, everywhere, against the great Bengalmutiny. Officers before Delhi describe themselves as march-ing all day in the sun of June, July, and August, and servingin the burning trenches for weeks together; and yet they pre-served their health, under a temperature of 130° or more,through temperance, to a wonderful extent.

Grosvenor-street, 1858.

REPORT OF A CASE OF

ALLARTON’S OPERATION FOR STONE:RECOVERY.

BY FREDERICK J. BROWN, M.D., Chatham.

CEPHAS P-, aged six years, residing in Chatham, wasoperated upon for stone by me, on the 8th of June last, athalf-past ten A.M. The child was put under the influence ofchloroform, and a stone was removed from the bladder by themethod designated after Mr. Allarton. A No. 3 staff wasused, and Poland’s forceps (altered in form by being lengthenedand narrowed) answered remarkably well. The stone was

oval, weighed 125 grains troy, and consisted of phosphate oflime. There was no haemorrhage. The boy slowly recoveredfrom the effects of the chloroform during the afternoon. Therewas some tenesmus in the rectum in the evening.June 9th.-The boy passed a good night; the urine flows

freely by the perineal wound on attempting to micturate, butit does not dribble away at other times; free from tenesmus untilnoon, when he experienced it slightly the countenance has

* The British Army in India: its Preservation by Appropriate Clothing,Housing, Locating, Recreative Employment, and Hopeful Encouragement ofthe Troops. With an Appendix. By Julius Jeffreys, F.R.S., Staff-Surgeon atCawnpore, and Civil Surgeon at Futtehgurh. London, 1858. This admirablework, by my distinguished friend, should be in the hands of all naval and’l’YBi.l;t,1"" QBl1"O"PfBY’lQ

recovered its colour, having been pale from the effects of thechloroform; tongue clean; eats bread-and-butter and sponge.cake.

10th.—Passed a good night; he is free from pain, and hasno pyrexia ; bowels open once, without occasioning much suf-fering ; he is amusing himself with toys, sitting up in bed.

llth.—Passed a good night; part of the urine passes throughthe extremity of the urethra, occasioning smarting; the urinehas never dribbled away through the wound, consequently thebed has been dry, and the child’s skin unirritated.12th.-The child awoke at three A.M., crying; pure blood,

to the amount of a teacupful, passed by the wound and alongthe urethra; he complained of pain in the nates and in theright hip; cold chills, with hot skin. Ordered oranges, as

an agreeable substitute for saline mixture; fomentations.-Three P.lII.: Passed urine through the wound and along theurethra; has pain only at intervals, and feels better; he ate a,piece of chop for dinner.

13th.-Passed a good night; has only slight pain occasionally;the urine passes principally along the course of the urethra;bowels open once; a small quantity of blood escaped from thewound during defecation; the pyrexia has disappeared, andhis appetite is good.14th.-Bowels open twice ; some blood escaped from the

wound during defecation; the wound is healing.15th.—Doing well; bowels twice open; no bleeding, and,

no pain.16th.-Wound healed to the size of the tip of the little-

finger ; some urine still passes through the wound.17th.-Sitting up.19th. -Out of doors; no urine has passed through the wound

since the 17th (the tenth day).25th (eighteenth day).-Wound quite healed, and the child

active and running about. Discharged cured.,

This child’s father was drowned four years ago, at the ageof thirty-six years. He had a calculus at the age of twenty-one months, which was extracted by forceps from the extremityof the urethra. He was never again troubled by the complaint.The child (young Cephas) suffered from symptoms of stone

from the age of a fortnight: for instance, he screamed on pass-ing urine. At the age of nine months, he passed a calculusper urethram. Between the ages of nine months and fiveyears, he passed four calculi, making five calculi in all. Bloodin considerable quantity escaped with the stone on one occa.sion. The calculus that was removed by operation is thesixth in number, and it was probably of one year’s concretion,since no stones escaped from the bladder after the age of fiveyears.Chatham, 1858.

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 interse com-parare.—MORGAGNI. De Sed.et Caus.Morb.lib.14. Proœmium.

ST. THOMAS’S HOSPITAL.

RECENT AXILLARY ANEURISM IN A HEALTHY MAN;DELIGATION OF THE SUBCLAVIAN ARTERY IN THE THIRD PART OF

ITS COURSE.

(Under the care of Mr. LE GROS CLARK.)THE important operation of deligation of the subclavian

artery in the third part of its course, immediately external tothe scalenus anticus muscle, we saw performed by Mr. Le GrosClark on the 5th inst. This was the second time he had doneit. In the course of the operation the external jugular veinwas seen very prominent, and it was carefully drawn towardsthe inner side. The omo-hyoid muscle was not once observed.The subclavian artery was readily reached by careful dissec.tion, and the aneurism needle was passed under it from before

55

backwards, when it was tied. The ligature was not, however,tightened until it was ascertained, by very slightly elevatingthe vessel, that the influence of pulsation was lessened in theaneurismal tumour, and then that important proceeding wascompleted.The difficulties to be encountered in the living subject are

much greater than can be supposed by a contrast with theoperation on the dead body; for in the former the shoulder isnot uafrequently elevated, and the vessel is almost whollycovered by the clavicle, which may be partly due to its beingpressed upwards by the tumour itself. In Mr. Clark’s patientthese conditions seemed to be present, and much care andattention were requisite before finally securing the vessel,which was accomplished within the half hour. There was nohaemorrhage worth mentioning; a little blood had now andthen to be sponged away, but nothing unusual from what wehave several times witnessed in placing ligatures on this part ofthe subclavian.The operation was performed without chloroform, and the

only discomfort to the patient was the distressing sensation inhis arm and shoulder, from their having to be retained in oneposition. Judging from his appearance, together with an ab-sence of any disease whatsoever, and considering the nature ofthe origin of the aneurism, the case may be pronounced as oneof the most favourable on record for the operation chosen.The result to be feared in these cases, as Mr. Fergusson

shows in his "Practical Surgery," is subsequent suppuration inthe tumour, a frequent occurrence in the history of axillaryaneurisms; but it does not invariably end badly. In some 47- cases, given in a tabular form by Mr. Erichsen, of ligature ofthe subclavian in the third part of its course, he found 23 curesagainst 24 deaths; of the latter, 10 were from inflammation ofthe chest, &c., 6 from suppuration of the sac, 3 from heemor-rhage, 1 from gangrene of the hand and arm, 1 from generalgangrene, and three from causes not stated.

* Suppuration ofthe sac, however, is the most common result, though it is notthe most fatal one ; it occurred in 14 out of the 47 cases men-tioned by the latter writer, or nearly 1 in 3 instances.Up to the present moment appearances are favourable for

.the patient; but we shall not fail to lay the ultimate result be-fore our readers.A good example of recovery after this operation, by Dr. Cac-

,cioppoli, of Naples, communicated by Mr. A. M’Laughlin, ofLiverpool, is briefly given in vol. ii. of this journal for 1853,.p. 164.

The notes of the following case were taken by Mr. CharlesSmith, the dresser of the patient.

Horatio D-, aged forty, an engineer residing at Green-wich. Has never had illness of any kind. About four or fivemonths ago, he says, while occupied in boring holes in a cylin--der (he was boring an upper hole, which required him to havehis arms at a great stretch; the operation as he describes itappears to call for immense exertion, requiring usually threemen, and at this time one man had been called away, so thathe and another only were engaged at the work), just as hewas exerting himself to the utmost, and had " got the leverhalf way down," he felt something give way with a " click"immediately below the clavicle. There was no pain, so hewent on working as usual. This occurred early in the day--teno’clock; he ceased working at half-past five. After he returnedfrom dinner, he found that when he raised his arm there wasaching and stiffness in the shoulder-joint. After the first dayall pain ceased, and he forgot the circumstance of the "strain"until about a week afterwards, when he felt a "lump" (hedid not notice if there was pulsation) just in the spot where hetad felt the "click." Apparently, the size of the tumour wasabout that of a large horsebean. There was no pain exceptaching in the arm itself, nor this in any particular spot. Thetumour increased in size till it became as large as a walnut, andafter a month disappeared. The man says that he put his handupon the place, and it was gone. He did not notice if there werepulsation at this time. At the time of the disappearance hehad taken to lighter work ; but when he resumed heavy work,some two months afterwards (in November), the swelling re-turned, being about the same size as before; and he had painand swelling in the axilla. The aching was then worse. Thetumour commenced gradually to increase, and continued up to-the present time. When the tumour recurred, he felt slight-pulsation, and this likewise has increased with the growth.He consulted some medical men about it, and was ordered to’rub it with liniment. He was told that if he did light workthe tumour would go away.On the 31st December he was admitted as an in-patient.

* Science and Art of Surgery, second edition, p. 571.

He has an anaemic aspect, and speaks with hoarseness, which,he says, followed a cold contracted while at sea some years ago.He has a quiet pulse. The tumour extends from beneath theclavicle to about the fourth or fifth rib, and from below theinner third of the clavicle into the axilla. Tongue anaemic;pulse 75. If his arm is allowed to hang down, he feels anaching all along it; if he raises it, there is pain in the axilla.He has been addicted to drinking : "frequently tipsy, butnever drunk." Dr. Barker has examined him, and can detectnothing abnormal in the thoracic viscera.On Jan. 5th, Mr. Clark stated in the operating theatre that

the tumour occupied the sub-clavicular space in the first andsecond divisions of the course of the axillary artery. This gavea more diffused character to the swelling, and made it appearlarger than it really was. There was sufficient space between theaneurism and the external border of the scalenus muscle toapply a ligature. On raising the arm, the tumour could betraced beneath the great pectoral muscle. There was no diseaseof the heart, and, the patient being a quiet man, all circum-stances were favourable to the operation. He accordingly tiedthe subclavian artery in the third division of its course,-viz.,external to the scaleni muscles,-in the usual way, the patientlying quiet on a table without chloroform. Mr. Clark pro-ceeded cautiously, so as to avoid a plexus of veins. There wasvery little bleeding; the omo-hyoid muscle was not seen duringthe operation. A sharp-pointed aneurism needle was cautiouslypassed around the artery, which was then tied. The vesselappeared quite sound, and unaffected by atheromatous deposits,nor was there dilatation of its calibre. At half-past three,Mr. Clark ordered a hot-water bottle and cotton-wool to be

applied to the limb, and an anodyne at bed-time if required.Tongue coated with yellow fur; pulse 65; arm aching; patientvery cheerful. The temperature of the limb was taken: thethermometer, being at 57° before use, rose to 79° when graspedin the hand, and when placed in the axilla, to 98°; whilst inthe left hand it indicated 89°, and in the left axilla 95°.6th.-There was a good deal of aching in the arm last even-

ing, and, the patient being restless, the opiate was exhibited.He slept soundly for three or four’hours, and expresses himselfmore refreshed than he has been since his admission. Thetumour has subsided, and there is not the slightest perceptiblepulsation. Arm much relieved from pain; tongue clean; pulse75, very good. To have fish, and a pint of porter. Thermo-meter, 57: right axilla 97°, bend of elbow 97°, hand 93°; leftaxilla 93°, bend of elbow 94°, hand 80°.7th.-The patient says he has not had a good night’s rest;

complains of a slight burning pain in the back part of the arm,with aching in the axilla and occasional shooting pains downthe arm. He is in excellent spirits, and has a good appetite.Wound healing healthily and rapidly; tongue rather furred;bowels not opened since the operation; pulse 78, soft and full.Thermometer 55°: right axilla 99°, elbow-joint 94°, hand 89;left axilla 95°, elbow-joint 92°, hand 70°. To have a drachmof castor oil to-morrow morning; half-a-grain of morphine, ifnecessary, at night; and a mutton chop.8th.-Passed a very comfortable night without the morphia.

The arm is tolerably easy, painful only now and then, espe-cially if it be moved. Tongue much cleaner; bowels openedtwice, freely; pulse 80. Hot-water bottle to be discontinued.Ordered two eggs, arrowroot, and an ounce of brandy. Ther-mometer 48°: right axilla 96°, elbow 95°, hand 84°; left axilla.95°, elbow 92°, hand 78°.10th.-Has slept very comfortably. Arm quite free from

pain, except when he dozes and happens to move it. Tongueclean; bowels opened yesterday; pulse 84, full and good. Tohave two mutton chops. Thermometer 56° : right axilla 94°,elbow 91°, hand 90°; left axilla 92°, elbow 91°, hand 81°.llth.-Has had a good night’s rest, is quite free from pain,

and eats well. Tongue clean; pulse 80; wound lookinghealthy. Thermometer 56° : right axilla 93°, elbow 89°, hand88°; left axilla 91°, elbow 89°, hand 84°.The patient is going on as satisfactorily as can be desired.

ST. BARTHOLOMEW’S HOSPITAL.

AXILLARY ANEURISM OF SEVEN MONTHS’ GROWTH IN A

SOLDIER;DELIGATION OF THE SIYBCLAVIAN ARTERY IN THE THIRD

PART OF ITS COURSE; DEATH ON THE THIRD DAY.

( Under the care of Mr. STANLEY.)V4 E take advantage of the present occasion to record another

I example of aneurism of the axillary artery, which has not been