Chapter 23

45. _Hæmorrhage from Lithotomy._--In the London Med. and Phys. Jour. for Jan. Mr. JOHN SHAW has published an account of a patient, who unfortunately perished from hæmorrhage, in consequence of being cut for the stone. The parts being injected after death, it was found, that the bleeding proceeded from the _unusual distribution_ of a branch of the pudic artery, which traversed the neck of the bladder, and lay directly in the way of the incision. The pudic artery was uninjured.

46. _Extirpation of the Parotid Gland._--The best surgical writers have condemned this operation, if not as absolutely impracticable, nevertheless, as too dangerous to be ever attempted. Successful cases have however been reported, and Mr. A. COOPER, in a letter to the operator in the following case, avers, that he twice removed the parotid gland in one year. Mr. KIRBY, late president of the Royal College of Surgeons in Ireland, in a work published in 1825 at Dublin, on hæmorrhoidal excrescences, has given the details of a diseased parotid, and of the operation for its removal. We condense from Johnson's Review for April, 1826.

The patient was a poor female, aged 40, who had a tumour extending from above the zygoma downwards on the neck, two inches below the angle of the jaw, stretching as far forwards as the anterior edge of the masseter muscle, forcing the ear backwards, and raising it outwards from its natural position. Above the surface, it was about the size of a goose-egg; immoveable; painful when handled; irregular on the surface, and of a deep livid colour over the prominent points. Pains of a lancinating character, extended over the head and neck, producing sickness and want of sleep.

The operation was performed chiefly by the fingers and the handle of the knife, after dividing the integuments by a crucial incision. The branches of the portio dura were of course divided, and great embarrassment arose from a copious hæmorrhage, caused by the bursting of the tumour, while Mr. K. was rooting it out from between the pterygoid muscles. The bleeding was restrained by the finger of an assistant, and the complete extirpation of the diseased gland was effected. Mr. KIRBY says, "the space between the pterygoid muscles was void--the auditory tube was fully exposed--the articular capsule of the jaw was brought into view--the finger could trace the length of the styloid process, and on sponging the wound of its blood, it could be seen by those who surrounded the chair." The hæmorrhage was restrained by a sponge firmly lodged at the bottom of the wound, covered by compresses of lint, and the whole secured by a double-headed roller.

The patient was much exhausted, slept tolerably well the next night, complaining of thirst and inability to swallow. On the 2nd day, inflammation, swelling, and fever followed--erysipelas appeared on the neck--patient lethargic--pulse small and frequent. Fourth day, suppuration--symptoms improving--no relapse. The patient completely recovered, without any regeneration of the tumour.

In FERUSSAC'S Bulletin Universel for Jan. 1826, we observe the following notice, from a German Medical Magazine, conducted by M. D. Schmidt.

A female, aged 33 years, had suffered for 9 years from a diseased parotid gland, which had gradually attained a large size. It was extirpated by Dr. PRIEGER, and the patient soon returned home in good health, and little disfigured. The tumour measured 8 inches in circumference, and weighed three and a half pounds. (Livres.)

Dr. PRIEGER had previously extirpated a scirrhous parotid successfully. M. WIENHOLD affirms, that he has extirpated three parotids; the details of these operations are published. M. SCHMIDT, however, suggests some doubts, as to the _nature_ and _seat_ of the tumours removed.

47. _Aneurism from a Wound, cured by Valsalva's method._--This interesting and valuable case, is condensed from Le Propagateur des Sci. Med. for March, 1826. M. Antouard, a healthy female, æt. 18, was wounded on the 18th of June, 1825, by a poniard, in the left carotid artery, below the superior extremity of the sternum; the instrument passing obliquely inwards and downwards. The anterior and lateral portions of the neck, were enormously distended with blood, and syncope supervened. Four days after the injury was received, an aneurismal tumour was observed at the edge of the sternum, the surrounding effusion being greatly diminished by absorption; and at the expiration of a month, when she was first seen by Dr. SOUCHIER, it was of the size of the two fists of the young female. The pulsations at this time, were nearly equal over the whole surface of the tumour; but rather more distinct over the orifice in the vessel. The surrounding blood was entirely absorbed. No pain was experienced, unless from the pressure of the swelling; from which cause also, resulted a troublesome and continued headach. Dr. SOUCHIER, not believing an operation adviseable, during the warm season of the year, and on a tumour, situated so much under the sternum, determined to fulfil the following indications: 1st. To lessen the quantity of blood; and thus, to diminish the stimulus to the heart, the projectile force it exercises, and consequently, the rapidity with which the blood escaped from the ruptured vessel, and the impulse hence imparted to the sides of the tumour, preventing, in some degree, the coagulation of the blood. 2nd. To increase the effect of general and local bleeding by the use of _cold_, of _pressure_, and especially, of the digitalis purpurea: that thus the force of the circulation may be lessened, the blood allowed to coagulate, and a radical cure be accomplished.

Mademoiselle Antouard, determined to yield herself to this plan, and was directed: 1st. Rice-water, acidulated with lemon-juice, and an infusion of mallows, for _food_ and _drink_. 2nd. To employ frictions on the abdomen, and on the insides of the thighs, morning and evening, with eight grains of the pulverized leaves of digitalis, previously macerated for 24 hours in a sufficient quantity of saliva. 3d. To apply every day 12 leeches, near the aneurismal tumour, and after favouring the flow of blood by emollient fomentations, to cover the part with compresses, wet with a saturated solution of the acetate of lead, to be frequently renewed, so as to be kept below the temperature of the skin. 4th. The effect of these means to be augmented by pressure, made by means of the base of a glass tumbler, fixed by the hands of assistants; and 5th. To be kept at rest, and in perfect silence.

_Fourth day of treatment_, being 2nd of Aug. 1825. Pulsations more central; tumour very sensibly diminished; pulse less strong and reduced from 86 to 74 in the minute; the menses, which had been suppressed for two months, appeared on the 31st ulto. and still flow. _Prescription_, V. S. [Symbol: ounce]xviij. next day, twelve leeches, on the lateral parts of the tumour; gr. xxiv. of digitalis in three applications through the day. Continue ut supra.

Aug. 8th. Patient tranquil; pulse 60, full, not active; face not flushed, but preserving a delicate tinge of red; headach now slight; no nausea; menses continued until the 6th inst. _Prescription_, V. S. [Symbol: ounce]xij.--fifteen leeches to-morrow; increase digitalis to gr. xxviij. daily; the rest, ut supra. The tumour has diminished at least one-fourth.

Aug. 12th. Tumour reduced to 3-5ths of its former volume; pulse at 56; her nights are comfortable; has some headach, and lately, cardialgia; complains of hunger and weakness, and from the fatigue of her assistants, the pressure was made with a bandage less effectually than before. This was allowed, as the pulsations are weakened, and more and more central, while the elevation of the tumour is trifling. For fear her health might be injured, she was permitted to rise a little from bed, and to add to her rice water, some light jellies, (crémes) made from the same grain. V. S. [Symbol: ounce]x. and every 2nd day, eight leeches around the tumour; digitalis increased to 32 grains daily; warm pediluvium for one hour, morning and evening; silence as complete as possible.

Aug. 18th. No tumour visible; pulsations can yet be felt; the skin is thickened; pulse at the wrist is at 50. V. S. [Symbol: ounce]viij.--six leeches every 4th day until menstrual period; digitalis reduced to gr. xx. and still to the same parts; continue the pressure; allow some rice jelly, vermicelli soup, gentle exercise; silence to be preserved, continue pediluvium, and relieve constipation by simple enemata.

In 15 days, Dr. SOUCHIER again visited his patient. It required an experienced hand to distinguish, at the spot where the artery was cicatrized, an elevation rather more evident, than over the rest of the artery. Pulse 48 per minute; hunger great, and the remedies now unpleasant. Most of them were suspended, and fruit and the white flesh of poultry added to her diet list. The digitalis reduced to 12 grains a day. Compression, silence, and moderate exercise, to be continued as before. The menses appeared at the expiration of twenty-five days, and were more abundant than at the last period.

At the end of a month, no trace of the tumour was discoverable. The young lady had carefully increased her nutriment and exercise without inconvenience, and all remedial measures were now omitted.

During the months of December and January last, she remained free from any inconvenience from the tumour, and the union of the parietes of the artery was therefore regarded as complete.

In the above account, we have only to regret that the state of the artery above the tumour, before and after the treatment, had not been noticed. Perhaps this may be supplied by Dr. SOUCHIER, in the commentary, which he proposes publishing on the above case.

48. _Protrusion and Wound of the Stomach._--Mr. TRAVERS, in the Edin. Journ. of the Med. Sciences, for Jan. 1826, relates, that a female, aged 53, and the mother of _nineteen_ children, inflicted on herself a wound in the abdomen, three inches in length, and in a transverse direction. When admitted into St. Thomas' Hospital, at the expiration of six hours, the greater part of the large curvature of the stomach, the arch of the colon, and the entire large omentum, were protruded and strangulated in the wound. The omentum was partially detached from the stomach, which organ was wounded in two places; one, half an inch long through the peritoneal coat; the other, a perforation of all the coats, admitting the head of a large probe, and giving issue to a considerable quantity of mucus. Patient faint; pain slight; pulse 102, and irregular; some hiccup. A silk ligature was placed round the small puncture in the stomach, and the displaced viscera returned, after enlarging the external wound. This last was closed by the quill suture. Warm fomentations and abstinence from food and drink enjoined. 2nd day, some re-action; had been sick in the night from some drink given; is free from pain; pulse 120; pain on pressure; an enema ordered. _Evening_, a dose of castor oil, and twenty leeches to the abdomen. 3d, much fever; V.S. [Symbol: ounce]xviij. and 20 leeches to the abdomen; bowels not opened. 4th day, two stools; pulse 98; tension of the abdomen; three more stools during the day. 5th, sutures removed; wound united, except at its right extremity, where a serous fluid is discharged in considerable quantities. On the 6th day, was allowed food, and on the 23d of Dec., about two months after the accident, was discharged cured.

49. _Oesophagotomy._--This operation has been objected to, not only on account of the dangers attending its performance, but from the alleged difficulty of promoting the union of the wound in the oesophagus; as it is seldom at rest, the lips of the incision being often separated, and the mucous coat adhering with difficulty under any circumstances. Hence we are induced to notice the following case, in which the operation was successfully executed on an inferior animal, by M. FELIX, a veterinary surgeon of Bergelac. The account is published in the Feb. No. of Le Propagateur des Sci. Med.

A _Cow_ was threatened with immediate suffocation from the lodgment of a potato in the oesophagus. It had shortness of respiration, an incapacity of swallowing even its saliva, which flowed from the mouth, was in great distress, and covered with a cold sweat. Being properly secured in a horizontal posture, an external incision was made on the inside of the sterno-mastoid muscle, and a cautious dissection practised until the tumour was completely exposed. The oesophagus was divided by "an incision extending the whole length of the foreign body, which was extracted without any force, _which is almost always fatal_. I immediately made two close sutures; and also two others in the skin, on each side, adapting to them two pieces of packthread, more easily to fix the dressings. I dressed the wound with brandy, filling the opening with hemp soaked with brandy." The animal was kept on very little food or drink. On the third day the wound was dressed for the first time, and a digestive ointment applied.

In the course of the 2nd week, the cicatrization of the oesophagus occurred; the part was dressed with lint; and by the 20th day after the operation, the animal was quite restored.

This case would have been more useful, if more precision had been employed in describing the dressing and subsequent treatment of the wound. It would seem that the sutures were passed through the parietes of the oesophagus only, and that the external wound was kept open by being filled with tow. Certainly, union by the adhesive inflammation ought to have been attempted in all parts of the wound; but whether sutures in the oesophagus are advantageous, or whether the uniting bandage be preferable, is not so easily determined. In the two cases described in 3d vol. of the Mem. de l'Acad. de Chirur. the uniting bandage was alone employed, and with success.

50. _Retention of Urine, caused by a Stricture of the Urethra, relieved by a forcible but gradual Injection._--The editor of Le Propagateur des Sci. Med. in the No. for Feb. 1826, introduces the following case, by observing, that it reflects great honour on M. AMUSSAT, and that his discovery merits the greatest praise. M. D... aged 70 years, of a plethoric constitution, had suffered about 30 years before from three attacks of gonorrhoea; since which period he has had a difficulty in urinating, and can never discharge more than one or two ounces of urine at a time.

At eight o'clock, P. M. of the 1st of Feb. he tried to urinate, but could not succeed. He suffered great pain. Pulse agitated; face flushed; belly swelled, and globular at its inferior part; the subcutaneous abdominal veins distended, and the penis in a state of semi-erection. All attempts to urinate were painful and ineffectual. At ten o'clock, A. M., on the 2nd, M. AMUSSAT visited him, and passed a bougie. This was arrested by a contraction near the bulb of the urethra, and caused the discharge of some blood. No urine had been passed for 14 hours, while ordinarily he urinated 12 or 16 times through the night. The obstruction was so great, that none of the usual means of relief remained, except _the forcible introduction of the catheter_, or the _puncture of the bladder_. M. AMUSSAT resorted to the following plan which he had devised, and which completely succeeded. He injected warm water forcibly, but gradually, into the urethra, which, dilating the orifice of the stricture, forced backwards the thickened mucus which had obstructed it. As soon as the liquid injection met the urine, the patient cried out that he was saved, and immediately was able to urinate as formerly. At two trials, he discharged nearly two pints of thick urine. There was no return of the retention, the patient continuing well.

Should subsequent experience confirm this experiment of M. AMUSSAT, this simple measure will be a most valuable substitute for those dangerous measures hitherto resorted to for retention of urine, in cases where the obstruction arises from thickened mucus, from small calculi closing the orifice of a stricture, from inflammation, or from what are termed, (justly or not,) spasmodic strictures.

51. _Tracheotomy._--In the Amer. Med. Review for April, Dr. JOHN ATLEE, of Lancaster, mentions that on Wednesday, Aug. 11th, he was consulted by a child ten years old, who had that morning, while running, put a button-mould into his mouth, which during respiration was drawn into the trachea. He complained of uneasiness in respiration, with a slight rattling, and pointed towards the upper part of the sternum, as the situation of the button. On coughing, a rattling was heard, and immediately after, a sudden check to expiration, from the lodgment of the button near the rima glottidis, requiring a sudden and violent effort of inspiration to remove the sense of suffocation. An emetic was given with no advantage. During the night, he had two or three spells of coughing, threatening suffocation.

An operation was urged, to avoid immediate and subsequent dangers from the lodgment of this extraneous body, and was agreed to by the parents, and by Dr. HUMES, who was called in consultation. It was performed on the 14th of Aug.; a cathartic, and afterwards an opiate, having been given.

An incision, one inch and a half long, was made through the integuments, extending downwards from above the cricoid cartilage, and exposing the sterno-hyoid and thyroid muscles, which were then separated. After exposing the trachea, a longitudinal incision, about three-quarters of an inch in length, was made through its parietes at the third ring. This was held open, and the patient requested to cough. This was ineffectual. The wound being closed, the button was, by coughing, thrown up against the rima glottidis. A probe passed into the trachea, produced a violent effort to cough, by which, as soon as the instrument was withdrawn, the button was thrown through the wound, to some distance from the patient.

The wound was dressed with two sutures and adhesive strips. Most of it united by the first intention: and in a few days the patient completely recovered.

52. _Fistula Lachrymalis_--At the session of the Royal Academy, on the 15th of December, M. J. CLOQUET related the case of a female, who, three years previously, had submitted to the operation for fistul. lachrym. according to the method of M. FOUBUT. The canula which had been allowed to remain in the nasal canal, had ulcerated through the floor of the nose, and presented its inferior extremity on the inside of the mouth.

A practical commentary on this mode of operating, which is still recommended by able surgeons!

53. _Aneurisma Herniosum._--This form of aneurism is supposed to consist of a dilatation of the internal and muscular coats of the artery; the external cellular having been destroyed. It is termed by ARNAUD, and by Dr. WILLIAM HUNTER, _aneurisma herniam arteriæ sistens_. Its existence in any case has, however, been denied by a large majority of surgeons; and perhaps the only cases reported are those of DUBOIS, in 1804, found in the thoracic and abdominal aorta of a dead subject.

The reporter of the following case, quotes also MONRO, as having cited examples of this kind of aneurism. But what MONRO termed a "mixt aneurism," arose from the rupture of the coats of a "true aneurism," by which it was reduced to the state of a "false aneurism;" very different from that here contended for. SABATIER and BOYER, also, deny the existence of this hernia of the artery, and a good summary of facts and arguments is given by BOYER in his Surgery, in support of this opinion, (vide article Aneurism, tome i.) which it would be difficult to invalidate, especially by cases analogous to the following. The reporter, M. BONNET, of the late French army, considers this case as proving a hernia of the artery in a vessel of medium diameter; those of DUBOIS having been noticed in the largest arteries.

A Prussian soldier was wounded over the femoral artery by a musket ball. No hæmorrhage ensued, and the wound cicatrized. In this state, M. BONNET visited him for a mortification of the foot of the same limb, which had been frozen. Amputation of the leg was performed, the stump healed readily, and in 12 days the ligatures came away. On the 13th day, (being six weeks since wounded in the thigh,) the patient perceived a tumour at the original cicatrix on his thigh, which had appeared during the preceding night. On the 14th, it had enlarged to three times its former size: it was painful; fluctuation was evident; but there was no pulsation, not even the thrilling noise, which is evident in the last stage of aneurism. A consultation was called, to determine whether it was an abscess or an aneurism. The question could not be satisfactorily answered, and it was determined to open it, after having made the necessary arrangements to secure the artery, should the tumour prove aneurismal. As soon as the integuments were punctured, the jet of blood evinced the nature of the complaint; and the artery was secured by ligatures above and below the tumour. The coagula were numerous, and the superficial ones, quite hard and cartilaginous. The patient did well, and there was every prospect of his recovery on the 1st day, when M. BONNET was forced by the movement of the armies to leave him at Meaux.

Such are the facts, from which the Reporter infers, that the aneurism consisted of a protrusion of the internal and middle coats of the artery. The _reasoning_, founded on them, appears to us inconclusive; but we have not space to insert it, and must refer to the March No. of Le Propagateur des Sci. Med.

54. _Extirpation of the Two Dental Arches, affected with Osteo-sarcoma._--Dr. GIORGI REGNOLI, physician at Pesaro, performed this operation on a female 35 years of age, who had from infancy, been troubled with pain and diseases of the teeth and jaws. When Dr. R. visited her, both dental arches were enormously swelled; red and sanguineous tumours had formed over their whole surface, and covered the teeth. The alveolar processes were entirely softened. The diameters of the mouth were greatly lessened; but by the touch, it was evident, that the disease was confined to the alveolar processes of the two ossa maxillaria. A foetid odour exhaled from the mouth. Lancinating pains continually tormented the patient; especially on attempting to masticate. The slightest touch was very painful, and was always followed by an effusion of blood. There was also an alteration of voice; a disgusting deformity of the mouth, with emaciation, fever, &c. The operation was performed on the 18th May, 1825.

The patient was seated opposite to a window; her head being supported against the breast of an assistant, who, at the same time, pressed upon the labial arteries. The inferior lip was divided perpendicularly, and detached laterally from the inferior jaw, so as to expose the whole extent of the carcinoma. Some strokes of the saw were made on the anterior and most prominent part of the bone, and into the groove thus formed, the blade of a very strong knife was inserted, by means of which, aided by some slight strokes with a mallet, all the diseased portion was removed. The soft parts had been previously detached from the internal surface of the jaw. The last left molar tooth, not being diseased, was alone left. The hæmorrhage from the dental artery was arrested by the actual cautery.

The dental arch of the upper jaw, was then completely removed in the same manner. The bleeding was here more profuse, but was arrested by a hot iron. The alveolar processes thus removed, were enlarged, and of a lardaceous colour, and the fungous growths had the appearance and consistence of indurated albumen.