페이지 이미지
PDF
ePub

behind the vessels, which had opened into the trachea and esophagus, both of which appeared slightly congested. The opening into the artery was plugged up with a clot of blood. The preparation, whicb had been carefully dissected, was handed round.

The author said, that there was no dispute as to the fact of opened abscesses subsequently communicating with arteries; the only doubt was, whether an abscess which has not been opened could exert that ulcerative power. He himself believed that both events occurred, but the latter much more rarely than the foriner. The history just read lent support to either view. We had two abscesses in close apposition. The larger he had himself opened ; it communicated through a small recent-looking aperture with the smaller abscess, which in its turn was found to have discharged itself into the trachea, esophagus, and the artery. Now, when were these three apertures made ? Subsequently to the external incision, or had they existed for some time previous, producing the spitting and dysphagia complained of? That question he found it very difficult to answer. But, supposing that the involvement of the artery resulted from the opening of the more external abscess, the incision he (Mr Miller) made must still be regarded as the correct practice. The abscess was then so acute that it must speedily have evacuated itself, and thus a delay of a day or so might have been incurred, during which time ulceration would have extended the space of the abscess, exposing the vascular tissues to greater and and greater risk. It might be asked, why make a direct opening, and not rather draw the matter away from time to time by the Abernethian method ? The answer was, that such treatment is never dreamt of, or is altogether inapplicable in the case of acute abscesses. He certainly was of opinion that delay would have been attended with increased danger to the artery, which had a chance of being avoided by the prompt incision. As to the after treatment in such cases, a doubt might arise whether it was to be strictly antiphlogistic, vr whether a moderate allowance of support was to be given, on account of the probably asthenic character of the inflarnmation. In the present case a middle course had been followed ; and he believed that the requirements of each individual case must regulate the practice in that respect. Of course the opening, when made, must be kept free and patent, so as to obviate the confinement of the pus, which was an untoward circumstance. Unfortunately, from the rapid adhesion of the lips of the incision in this case, the discharge, during a few hours, did not get free vent.

With regard to the date of the apertures, he desiderated more precise statements as to the appearance of the sputa. The report which had been read, and which was neagre on the point, was that of his house-surgeon, who had since gone abroad. The opening into the trachea might have been early produced, and supplying the abscess with air, though by a route somewhat circuitous, might account perhaps for the artery's erosion, in the opinion of those who consider the access of atmospheric influence essential to that event : or the artery might have been opened by the abscess, while the latter yet had no communication whatever with air; and then this inner ahscess for a few moments aneurismal-bursting into the outer abscess, which was open, would produce the outward channel to the hæmorrhage. The communications with the larger abscess, with the trachea, and with the oesophagus, might have occurred simultaneously. In the first crisis, we had the blood coming from three different channels at once-wound, trachea, gullet; in the second, we appeared to have it vomited alone. Could anything have been done to check the bleeding? He believed not. He was a little surprised that the carotid had been perforated so high in the neck ; his impression had been, from the situation of the abscess, that the bleeding was to be expected from the subclavian or jugular veins, or the corresponding arteries in the lower cervical region. But, as it was, had the artery been cut down upon, it would have been no easy matter to have thrown a ligature around it in the universal

NEW SERIES.-N0. VI. JUNE 1855.

matting of the parts; and the ligature would have had little chance of long securing a vessel surrounded by unhealthy ulceration. It was interesting to observe, however, that, even in these desperate circumstances, nature was always busy with her plug, which was found, on dissection, obstructing the ragged arterial aperture. The case certainly was not decisive as to whether an external opening was always necessary for the production of false aneurisms in such cases. Liston and Breschet had recorded cases of suspected abscesses, which, on the first incision, gave evidence that arterial communication had taken place. In these cases he agreed with their authors; but it was well known that, in the minds of others, they were still open to doubt and surmise. The great lesson of the present case was, in his opinion, sufficiently clear : to open early in all cases of acute abscess, in whatever situation they might be found, and inore especially in those which bore closely on the neighbourhood of vascular or other important tissues. At the same time, it must be observed that, in this case, the small abscess, which did the mischief, was so situated-iminediately behind the trachea and vessels—as to be inaccessible to such treatment.

Dr W. T. Gairdner addressed himself to the interesting pathological question of abscesses opening into arteries before or after incision. It had been argued that abscesses never, or very rarely, communicate with arteries before incision. The affirmative observations were certainly few in number, and still under challenge. Authors had not, to his mind, given a very satisfactory explanation why the vessel is not so apt to give way to ulceration before as after incision. It had been generally supposed that the alteration of the pus by the air, or some other circumstance acting vitally on the coats of the artery, was the cause of the altered condition after the abscess was opened. Dr Gairdner believed that the real solution of the difficulty was, on the contrary, mechanical. An artery in contact with a closed abscess was supported on every side by equable hydrostatic pressure ; and however much its coats might have been previously softened, they were therefore in the most favourable condition for withstanding the pressure of blood from within. On the abscess being opened, on the other hand, the equilibrium between the external and internal pressure was destroyed, and the weakened arterial tunics were exposed to the whole force of the circulation. The opening in the vessel in the present case, instead of being minute, and with inverted edges, as might have been expected had it been produced ab extra by ulceration, presented an everted appearance, and supported his (Dr Gairdner's) opinion, which was also borne out by direct esperiments. Virchow and others had shown that, when the exterior of an artery is subjected to chemical irritants, the internal coats are found to have undergone no ulcerative action, but lie like a necrosed mass in the very middle of the surrounding pus. They are more amenable, therefore, to forces of a mechanical than to those of a vital character. The present case presented many points of difficulty. On closely examining the preparation, the esophagus bore marks of ulceration on the side opposite to, as well as near, the seat of the aperture : and it was possible that the ulcerative action in the æsophagus had led to its perforation, and thus to inflammation of the neighbouring cellular tissue.

Dr John Struthers referred to the somewhat similar case in which the late Dr M.Kenzie had tied the subclavian artery. With regard to the sequence of events in the interesting case which had been read, he was inclined to take a different view from those advanced by Mr Miller and Dr Gairdner. He (Dr Struthers) thought it probable the smaller abscess has formed first, and forced its way into the esophagus and trachea. Escaping externally, it led to the formation of the external swelling; and, lastly, the coats of the artery gave way after the external opening had been made ; thus accounting for the blood escaping in three different directions at the same time.

Dr Andrew Wood thought that there was no evidence to show that the smaller abscess had first burst into the wesophagus and trachea : indeed, had any air entered by that route, the pus which Mr Miller evacuated would have been more or less fætid. Now, in the record of the case, it was particularly

noted, that the incision let out pus of a healthy quality. He differed from Mr Miller, however, in opinion as to the simultaneity of the apertures in the smaller abscess. He (Dr Wood) thought it more probable that they had formed at different times.

Mr Miller, in reply, could not concur in the theory advanced by Dr Struthers. When the patient was first seen, weeks before she entered the hospital, there was no difficulty of swallowing or cough complained of. The swelling, too, was distinctly lateral. As to the character of the expectoration, nothing particular was noted in the house-surgeon's report, and he (Mr Miller) believed that, if it had been purulent, that circumstance would have been mentioned. Again, the aperture of communication between the two abscesses was not only minute, but also had all the appearance of being recently formed. With regard to the csophagus being the seat of the primary lesion, he could only state that a swelling in the neck was from the first complained of, and at a very early stage was thought a fit subject for excision. At that time there were no symptoms referable to the cesophagus or wind-pipe. The case obviously originated in chronic glandular enlargement, external to the canals and vessels. CASE OF UNSUCCESSFUL TREATMENT OF LOOSE CARTILAGE IN THE KNEE JOINT.

BY JAMES MILLER, ESQ. His object in bringing the unsuccessful issue of this case before the Society, was to make a recantation of a principle of practice which he had inculcated in his text-book on Surgery. Mr Miller read the extract from his work, and then gave the following particulars from the hospital case-book. The patient, a young man aged 14, was admitted March 7th, 1854, with a loose cartilage in his right knee-joint. The symptoms were characteristic, and had existed for six months. After careful preparatory treatment, two hare-lip needles were inserted over the external condyle, and the body was transfixed; not, however, without great difficulty, from the smoothness of its surface.

March 18.- The needles, having now been inserted for a week, were withdrawn to-day. They had given rise to no pain or constitutional disturbance. A little exudation was observed at their points of exit.

March 24.–The loose cartilage had slipped from its position, in consequence of the knee having been incautiously handled by a student. It was, however, again transfixed, but with only one needle.

April 14.-(Twenty-one days since the date of the last transfixion). The needle was removed. The patient got up, was in the habit of moving about the ward, and expressed a wish to return home.

May 2.—The cartilage had now been fixed for eighteen days, when this morning, on the patient pulling on his boots preparatory to his leaving the hospital, it started from its place, and again entered the cavity of the joint.

May 3.-Next day Mr Miller once more transfixed it; but, on the 5th, violent inflammation set in, resisting the most active and prompt local and general treatment; and, after a narrow swim for his life, the poor lad left the hospital with an amputated limb.

This was the first case in which he had put the principle he had advocated to the test of practice. The theory was feasible enough, and for a while, no doubt, all goes well ; but to the questions, Is the operation a safe one? Is it efficient, even supposing it somewhat dangerous ? a decided negative must be given; though, as had been stated, the needles were again and again introduced, and retained with perfect impunity.

Dr John Struthers said that the needle, however little annoyance it might occasion, could only be regarded as a foreign body. With regard to the difficulty experienced in retaining the loose cartilage in a fixed position, the late Dr Mackenzie had made many experiments upon the subject, and found it a matter of extreme difficulty to force the cartilage into the wound of the synovial membrane, which had been made by the ordinary subcutaneous operation. And this Dr Mackenzie accounted for by the extreme laxity of that membrane. Mr Syme's

latest plan, which had been found so successful, consisted in making a wound in the synovial membrane, and fixing the body in contact with it. This plan was found so safe and simple, that it was unnecessary to have recourse to any other.

Dr Alexander Wood was of opinion that the tbanks of the Society should be awarded to Mr Miller, as a tribute to his candour in bringing this unsuccessful case before their notice. He (Dr Wood) only wished that the practice of giving unsuccessful as well as successful results was a little more common, not only among surgeons, but also among physicians. Nothing, he believed, would tend more to the establishment of true principles, and the advancement of their common profession. UPON THE USES, MEDICAL AND SURGICAL, OF THE BARK OF THE AMERICAN

SLIPPERY ELM. BY HORATIO R. STORER, M.D., OF BOSTON. This elm, the ulmus fulva of Michaux, grows in great abundance throughout the northern and north-western states of America. The bark, when of good quality, is perfectly loaded with mucilage, which it readily parts with to water, and as a demulcent is much used by our trans-Atlantic neighbours in dysentery, diarrhea, and diseases of the throat and urinary organs. As an external emollient it is also very useful, the bark or its powder being formed into a poultice with hot water. So long ago as 1837, in a paper entitled “ Elm-bark Surgery,” Dr Macdowall, of Virginia, had drawn the attention of the profession to the application of the bark to the manufacture of surgical instruments, as bougies, catheters, tents in fistulæ, etc., etc.; frankly, however, stating a danger attendant on the use of such instruments, when seasoned and in a dry statenamely, their liability to break from their brittleness. Such an accident, occurring in the urethra or bladder, would be very troublesome; and the fear of such occurring prevented the general use of the bark for such purposes, though Dr Macdowall's paper received due notice in the British and Foreign Medical Review for July 1838. This objection to its use in the formation of catheters was, in Dr Storer's opinion, fatal, and as yet had not been surmounted. Dr Storer, however, proposed to use it as a tent, either for opening up the os uteri, or for preserving the patency of the cervical canal. By bruising the bark, an abundant supply of fibrous tissue was obtained, of great flexibility and toughness, and admitting of being moulded into any shape or size. The tent, with a little glazing, was complete. Not only on the score of cheapness did it competo successfully with the sponge-tent; but, from the important property which the bark possessed, of freely parting with its mucilage, it applied a bland lubricating fluid to textures which were often from disease destitute of any such protection, and which resented the contact of such an irritating substance as sponge. Again, the expansion of these tents, though not so speedy as that of sponge, was not so annoying : it was entirely lateral, and not productive of any recoil. Specimens of the tents and of the bark were handed round.

Dr Priestley had used the tents, and could speak favourably of them. He had no reason to complain of their brittleness ; they had been generally expelled as a mass of mucilage. He had stated to Dr Storer that tents of this material would be more useful in cases of mechanical dysmenorrhæa, where there was great contraction of the cervix.

Dr Matthews Duncan was inclined to think very favourably of elm-bark tents. He only feared that their power of expansion was not great ; and he should like to hear from Dr Storer if he had made any experiments upon the subject. This expansion, however, was of little importance in the class of cases - viz., of mechanical dysmenorrhea-in which Dr Priestley had suggested their employment, as a great dilating power was not required, but merely some innocuous substance, sufficiently coherent to maintain a free channel of exit, and by its presence to induce enlargement of the canal by vital dilatation.

Dr Douglas Maclagan said, that the bark was well known to him. From the specimens before the Society, he doubted whether the substance, in the form of uterine bougies or tents, could be obtained of sufficient strength to admit of forcible insertion into a tight stricture.

Dr Storer stated that the bark expanded to five or six times its size. He was still engaged in experimenting on the subject.

The President thanked Dr Storer, in the name of the Society, for his very interesting communication, and expressed his opinion that the introduction into common use of a mild demulcent, which would sit light upon the stomach, would be attended with great benefit in the treatment of disease; and such a desideratum he hoped might be supplied by the bark of the slippery elm.

VARIETIES. Death of DR MARTIN BARRY.-It is with regret that we make the above announcement, which has taken the scientific world by surprise. Dr Barry died at. Beccles, in the house of his brother-in-law, on the 27th April. In our next number we hope to present our readers with a short account of his life and labours.

ASSISTANT-SURGEONS IN THE ARMY.— The Royal College of Surgeons of Edinburgh, at a meeting on May 16, unanimously adopted the following resolution, and directed a copy of it to be transmitted to Lord Panmure :-" That the appointment by Government to the local rank of assistant-surgeon in the army, of persons not possessing a surgical diploma, or any other public testimonial of fitness for the office, and who have merely passed through the rudiments of medical education, is calculated to prevent the individuals so employed from acquiring a proper knowledge of their profession, to compromise the interest of the sick and wounded committed to their charge, and to lower the character of the medical department of the army.”

Sir William Burnett.—By a Treasury minute, dated April 3d, 1855, the late distinguished Director-General of the navy has been awarded a retiring allowance of £1000 per annum. Special reference is made to his thirty-three years of distinguished services on sea and land, and to his presence at the battles of St Vincent, the Nile, and Trafalgar.

MILITARY TRAINING OF YOUTH.—A small pamphlet has been published on this subject by H. Lawson, Esq., F.R.S., in which, urging the expediency of military training, he says :-" The absolute necessity for early training, and the result of its neglect, is strikingly displayed in the authentic tables published in the years 1833, and onwards to 1837 inclusively, the recruiting parties who visited the cities of Edinburgh, Dublin, London, Manchester, and Liverpool, refused one half of the men who offered themselves, as being incapable of bearing arms ! and this lamentable circumstance appeared to arise in many, or most, instances, from diseases engendered in their youth, particularly pulmonary complaints, and the ill condition of their limbs, from neglect, and the want of mental alacrity in obeying comipand.” Mr Lawson's suggestions are as follow: 6 Schoolmasters should have no choice in this important branch of discipline. The details may, indeed, be left to schoolmasters, but there should be no impediment to their insuring to all their pupils a regular course of military training. If the scholars be the children of poor parents, and the schoolmasters cannot tax them with the extra charge for paying a drilling-master, means must be provided to relieve those poor scholars from the necessity of contributing towards the expense. In almost every town and village throughout the land there are old soldiers, many, if not all of them, enjoying pensions ; these invalided soldiers are very generally employed by the masters of such establishments as can afford to remunerate them. I venture to suggest, that those pensioners should be suitably recompensed, and have regular appointments from government to attend schools, and, under the direction of the schoolmasters and tutors, insist upon every scholar being taught manual exercise,”

« 이전계속 »