Reviews and Notices

1878 BMJ (Clinical Research Edition)  
526 THE BRITISH MEDICAL 7OURNAL. [April 13, 1878. tion followed, but soon subsided. The salivation then completely subsided. Large Nzvoid Growth on the Cheek: Ligature and Sutures.-An infant presented a nevus as large as a couple of walnuts nearly in the centre of the left cheek. It was congenital, of the sebaceous variety, and increasing rapidly in size. It was tied in halves subcutaneously, the ligatures being secured with running points, so as to allow of their being tightened up as
more » ... . A few setons were subsequently used. Suppuration was thus freely established, and then healing advanced rapidly. After remaining in the hospital a month, some of the mass remained unabsorbed, but the naevus appeared to be cured; and the subsequent account given by the mother is confirmatory of this opinion. Compound Fracture of the Tibia: Rapid Recovery.-A girl ten years of age presented a very oblique fracture of the tibia a little below its centre, the sharp end of the upper fragment protruding through the skin. Lint steeped in blood was applied, and on this a pad soaked in friars' balsam; and the limb was placed in the ordinary fracture-box of the hospital. The wound gave no trouble. The little patient was dismissed with a perfectly sound and well-consolidated limb in twentyfive days. Spontaneous Gangrene of Toes: Separation:. Recovery.-In a man aged 42, the little toe of the right foot and the outer surface of the fourth toe were in a state of sphacelus, and the whole foot was extremely inflamed. The patient attributed the mischief to cutting his corns with too sharp a knife. The little toe sloughed off entirely at its proximal articulation. After this, the inflammation of the foot subsided; the wound became clean, and healed by cicatrisation. Early Operation for Ruptured Perinaum. -A woman aged 25 had sustained an extensive laceration of the perinaeum, opening into the anus, at her confinement, three weeks previous to the operation. On admission, the wound was but slightly healed, the greater portion of its surface on both sides was granulating freely. The operation was planned so as to make broad strips of raw surface, corresponding to each other in breadth, on the opposite sides. Where there was mucous membrane, this was dissected back and saved ; but the major portion of the field of operation was in a condition of granulation, and this was dealt with by transfixing these structures with a sharp knife and shaving off the face. The very moderate haemorrhage soon subsided, when four deep quill-sutures of strong silk and four superficial stitches of carbolised catgut were inserted. The former were removed after eight days; with the latter it was not necessary to interfere at all. The entire wound healed soundly, and primary union occurred, except a very small hole at the posterior extremity; this granulated kindly, and soon closed in. At the time of the operation, the woman was pale, anaemic, and alto. gether in a condition of depreciated health, a circumstance which adds to the interest of the operation, performed as it was at so exceptionally an early period after the confinement. Hydrocele of the Neck.-This occurred in a small child, two years of age, and was complicated with further deep-seated disease. The growth occupied the right inferior triangle of the neck, and was as large as the closed fist. It was translucent, and presented the other characters of the affection named. The fluid was drawn off by a drainage-tube, and, as it came away, it was evident that a bunch of enlarged glands occupied the deeper portions of the cyst. Some days subsequelntly, the cavity was injected with tincture of iodine. Much suppurative action of a most unhealthy type followed, numerous abscesses formed and had to be opened, and through the apertures ill-formed pus and sometimes fragments of broken down glands extruded. The child's health was for a time much depreciated, and at one time there were symptoms of blood-poisoning. Eventually, however, respirative action became established, both locally and constitutionally. After a stay in the hospital of nearly two months, the child was allowed to return to his country home, apparently in a fair way to do well. Some of the inflammatory swelling of the matted tissues still remained, and was being slowly absorbed. ASTON MANOR.-The population is estimated at 46,462; the birthrate at 43.2 and the death-rate at I7.5 per I,OOO inhabitants. Mr. May having expressed his conviction that the building by-laws should be strictly enforced, an assistant-surveyor has been appointed to see them carried out. Mr. May says that this is absolutely necessary, as he has found families in rooms where the paper would not stick, and the plaster was running down with water; so that it is a wonder that the death-rate was so low. The mortality of infants under one year was 13 per cent. of the births, and the zymotic death-rate was 3.4 per I,ooo. Sanitary work appears to have been actively carried out, and some new sewers have been constructed. OUR profession is often twitted with the haphazard way in which its most successful weapons against disease have been discovered; and, in truth, the data for rational therapeutics have as yet scarcely emerged from their concealment in obscure or inaccurate physiology. We know this so well, that remedies suggested on physiological grounds are still looked at askance, although the time has at last come when this reproach is passing away from us. The operation of ligature of the carotid artery for aortic aneurism will not suffer discredit, however, from having been suggested by any a priori reasoning. No remedy in medicine or surgery has ever originated from observations less premeditated. On the one hand, the association of consolidated aortic aneurism with occluded left carotid had been more than once observed in the dead-house and the dissecting-room; on the other, ligature of the same vessel had been successfully performed for the cure of what had been erroneously diagnosticated as carotid aneurism, but which proved to be an aortic sac. It is to Dr. COCKLE that the credit is undoubtedly due of having suggested to Surgery an operation which, based upon post mortem findings and the clinical errors of the past, has yet so far been justified by practical results. It is a good feature of the pamphlet before us that, near its commencement, the author boldly observes that he has no theory to offer us as to the exact manner in which the measure he strongly advocates brings about the consolidation of the aneurismal sac. Dr. Cockle is, indeed, not satisfied with any of the suggestions that have been offered. He does not find in the facts of cases that diversion of blood-current will suffice to explain the occlusion of the aneurism ; for it would appear that the left carotid need not spring directly from, or even very near to, the aneurism, for the effect to be observed; the operation having proved useful in cases in which the disease involved the ascending or right portion of the aortic arch. And, for this same reason, it cannot be held that extension of clot downwards from the tied vessel is essential for the cure. That an influence should be transmitted to the lining membrane of the sac is a supposition sufficiently indefinite to be beyond criticism. It may be that the true rationale of the treatment includes all these, and, in addition to them, that absolute repose which an important surgical operation entails. But we are for the moment assuming more than is, perhaps, yet permissible; viz., that the operation is to be commended as a method of treating aortic aneurism. And this is the very question with which the pamphlet before us deals as fully and fairly as present experience will allow. In answering this question, Dr. Cockle refers to three sets of observations: firstly, those in which the occlusion of the artery, coinciding with the formation of laminated clot, has been effected by a natural process-cases which have for the most part come to our knowledge from post mortem inspections ; secondly, cases in which the artery has been tied for supposed carotid aneurism, which has, however, turned out to be aortic aneurism ; thirdly, cases in which the vessel has been successfully tied with the definite purpose of causing consolidation of an aneurism affecting the arch of the aorta. Several cases of this latter kind have now been published. Mr. Christopher Heath first adopted the treatment at Dr. Cockle's suggestion in I872, and has subsequently repeated it on two occasions. Mr. Holmes and Mr. Maunder and other surgeons have also more recently performed the operation. The results of this operation must, like those of any other surgical measures, be compared with those of other treatments of a disease which no pathologist can admit to be curable. The important question is, When is this severe measure to be adopted ? Dr. Cockle is scrupulously careful in pointing out the place ligation should hold in the treatment of aneurism; viz., that of a dernier ressort, " last on the list of therapeutic means". But, be it remembered, this in no way sanctions the postponement of the question of operation to a period when the patient is too exhausted for its adoption. Here lies, indeed, the great practical difficulty in deciding upon this procedure. The operation itself is by no means free from dangers; secondary haemor. rhage, cerebral anaemia, and possible cardiac syncope, being those apt to arise. But the sufferings from the disease are so terrible, and the relief has in some cases proved so prompt and long enduring, that the fear is lest, as the operation becomes better known, it may be too eagerly adopted, without very careful consideration of the merits of each case, and before a fair trial has been given to other measures. A careful perusal of the pamphlet before us, however, will tend to lessen
doi:10.1136/bmj.1.902.526 fatcat:m7dka3av6zau7gvn7kfs56ubjm