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ANEURISM OF THE EXTERNAL CAROTID ARTERY.
271 which I think that the method of amputating with the aid of the elastic constrictor affords a still greater advantage. I refer to the cases of women who have had children, in whom there is procidentia of the uterus, associated with hypertrophy both of the vaginal and the supra-vaginal portion of the cervix. The starting-point of the mischief is then usually injury received by the cervix in parturition, and consequent hyperæmia and chronic hyperplasia. The procidentia, however, adds greatly to the effect by producing strangulation of the cervix and venous congestion. In these cases it is generally desirable to remove as much as possible of the vaginal cervix, although not to incur the risks of hæmorrhage and of injury to the bladder or peritoneum involved in the operation proposed by Huguier for the excision of the supra-vaginal cervix. Usually, however, there is much difficulty in ascertaining exactly the extreme point at which the wire of the écraseur may with safety be applied. In the procident uterus the mucous membrane of the cervix is so loosened from the muscular tissue beneath that the point of vaginal reflection becomes indefinite, and it may appear at first sight that there is no lengthening of the vaginal, but only of the supra-vaginal portion, when an exploration by the sound of the position of the bladder shows that the vaginal portion is really considerably
elongated.
If the elastic constrictor be used for the amputation in a state of things, it would seem desirable, to avoid any risk to the bladder or peritoneum, not to transfix the cervix by two pins at right angles, but to pass two parallel pins transversely. If one transverse pin only be used, the constrictor may tend to slip off at the front or back. There is then no risk of injury, even if the pins be passed somewhat above the vaginal reflection, since experience shows that the bladder and pouch of Douglas suffer no harm from the moderate compression which they may undergo from the constrictor. The operator has then ample time at his disposal, and the opportunity of seeing exactly the relation of parts as he proceeds. And since anterior and posterior flaps are cut from the cervix itself, there is no likelihood of opening the bladder or peritoneal cavity by the knife. It need scarcely be said that the method which I have described is applicable only to cases in which the cervix can be drawn down externally without the use of undue force. This comprises, however, by far the greatest number of cases in which operation is desirable, since it is generally as producing real or apparent prolapse that hypertrophy of the cervix calls for interference. Some cases, however, occur, especially in women who marry, having congenital hypertrophy of the vaginal cervix, in which the enlarged cervix causes irritation or inflammation while it remains at its In them the galvanic cautery ecraseur proper level. appears to be by far the best means of removal. In conclusion, the points in which it appears to me that amputation with the aid of the elastic constrictor compares favourably with the use of the galvanic cautery may be summed up as the following :-1. It requires no implements except those which any practitioner has always at hand. 2. Although the operation itself takes somewhat longer, the patient, if the flaps unite, is saved from the necessity of protracted suppuration and cicatrisation. 3. There is no danger of contraction or obliteration of the cervix being produced. 4. The operator is able to ascertain more precisely the exact extent to which amputation may with safety be carried.
such
ANEURISM OF THE EXTERNAL CAROTID
On admission, a large tumour of about the size of an orange was found occupying the upper part of the neck on the left side; there was well-marked pulsation and a loud bruit. The patient complained of constant pain, which he described as shooting into the ear, and of being unable to sleep on that side. From the time of his admission to Nov. 14th the tumour increased rapidly, by that date occupying two-thirds of the neck, and also showed signs of pointing, its walls having evidently thinned in one direction. A few days after admission the man complained of the pain becoming more acute, giving him no rest by day or night, were freely administered. On Nov. 14th he complained of being unable to swallow anything except fluids. As the tumour was now evidently pressing on the œsophagus and the prognosis ws mot unfavourable, on the 15th of November, after consultation with Surgeon-Major Ross, H.M. 4th N I., and Surgeon Brodie, who agreed with me on the absolute necessity of the operation, I ligatured the common carotid one inch above the clavicle, that space alone being available owing to the encroachment of the tumour. The ligature used was the ordinary silk one, no carbolised gut being in store. Immediately after the application of the ligature the tumour became cold and all pulsation ceased. Temperature after the operation, 95°. — 4 P M: Temperature 99°; difficulty of swallowing increased, a great deal of saliva flowing from the mouth. Hypodermic injection of morphia (one-twelfth of a grain) at night, and to be continued every night. Nov. 16th.-Slept tolerably; saliva flowing in less quantities ; difficulty of swallowing as before. Temperature 1000. 17th.—Swallows with somewhat more ease, being able to take a little gruel. Temperature 99°. 18th.-All pain disappeared, but complains that his head feels cold. Morphia injection to be discontinued. 19th.-Complains of pain in the head, which prevented him sleeping at night. Injection of morphia to be continued at bedtime. 20th.—Pain in the head has disappeared; swallows fluids without difficulty. From this date to that of his discharge the case progressed most favourably. By the 25rh he could swallow solid food. On Dec. 3rd the ligature came away. The tumour has had no return of pulsation, is smaller and hard, all fluctuation having disappeared. The man himself has perfectly regained his health and spirits, and states that the tumour causes him no inconvenience whatever. Dec. 22nd.-Discharged.
though anodynes
Sattara.
A Mirror HOSPITAL PRACTICE, OF
BRITISH
COLSON, M.R.C.S.,
SURGEON,
BOMBAY ARMY.
ROWJEE BIN Essoo, aged about forty-eight years, a cultivator by caste, was admitted into the Civil Hospital, Sattara, with an aneurism of the external carotid artery. The previous history of the case, as given by the patient, is as follows. At the beginning of August last, he noticed a small hard swelling situated about the angle of the inferior maxillary bones. This at first gave him no inconvenience, but as it increased in size it caused him considerable
pain.
FOREIGN.
Nulla antem est alia pro certo noscendi via, nisi quamplnrimas et morborum dissectionum historias, tum aliorum, tum proprias collectas habere, et iuter se comparare.—MORGAGNI De Sed. et Caue, Morb., lib. iv. Prooeminm.
et
UNIVERSITY COLLEGE HOSPITAL. FRACTURE OF CERVICAL SPINE ; STRICTURED URETHRA PUNCTURE OF BLADDER; POST-MORTEM APPEARANCES.
(Under the
ARTERY. BY E.
AND
FoR the
down
of Mr. CHRISTOPHER HEATH.) notes we are indebted to Mr. Gould;
care
following registrar. P-, aged thirty-six, a very intemperate man, fell twelve steps while drunk on Sept. 2nd, 1876. He was
surgical G.
;
rendered unable to move his arms or to walk, and carried to bed. After about half an hour he " fainted," and remained unconscious for about fifteen minutes. He then continued restless and sleepless until the date of his admission, Sept. 3rd. On admission he was quite conscious. He was found to have complete motor paralysis of the left leg and of the extensor muscles of both arms and forearms, his respiration
! at
once
was
elongated.
If the elastic constrictor be used for the amputation in a state of things, it would seem desirable, to avoid any risk to the bladder or peritoneum, not to transfix the cervix by two pins at right angles, but to pass two parallel pins transversely. If one transverse pin only be used, the constrictor may tend to slip off at the front or back. There is then no risk of injury, even if the pins be passed somewhat above the vaginal reflection, since experience shows that the bladder and pouch of Douglas suffer no harm from the moderate compression which they may undergo from the constrictor. The operator has then ample time at his disposal, and the opportunity of seeing exactly the relation of parts as he proceeds. And since anterior and posterior flaps are cut from the cervix itself, there is no likelihood of opening the bladder or peritoneal cavity by the knife. It need scarcely be said that the method which I have described is applicable only to cases in which the cervix can be drawn down externally without the use of undue force. This comprises, however, by far the greatest number of cases in which operation is desirable, since it is generally as producing real or apparent prolapse that hypertrophy of the cervix calls for interference. Some cases, however, occur, especially in women who marry, having congenital hypertrophy of the vaginal cervix, in which the enlarged cervix causes irritation or inflammation while it remains at its In them the galvanic cautery ecraseur proper level. appears to be by far the best means of removal. In conclusion, the points in which it appears to me that amputation with the aid of the elastic constrictor compares favourably with the use of the galvanic cautery may be summed up as the following :-1. It requires no implements except those which any practitioner has always at hand. 2. Although the operation itself takes somewhat longer, the patient, if the flaps unite, is saved from the necessity of protracted suppuration and cicatrisation. 3. There is no danger of contraction or obliteration of the cervix being produced. 4. The operator is able to ascertain more precisely the exact extent to which amputation may with safety be carried.
such
ANEURISM OF THE EXTERNAL CAROTID
On admission, a large tumour of about the size of an orange was found occupying the upper part of the neck on the left side; there was well-marked pulsation and a loud bruit. The patient complained of constant pain, which he described as shooting into the ear, and of being unable to sleep on that side. From the time of his admission to Nov. 14th the tumour increased rapidly, by that date occupying two-thirds of the neck, and also showed signs of pointing, its walls having evidently thinned in one direction. A few days after admission the man complained of the pain becoming more acute, giving him no rest by day or night, were freely administered. On Nov. 14th he complained of being unable to swallow anything except fluids. As the tumour was now evidently pressing on the œsophagus and the prognosis ws mot unfavourable, on the 15th of November, after consultation with Surgeon-Major Ross, H.M. 4th N I., and Surgeon Brodie, who agreed with me on the absolute necessity of the operation, I ligatured the common carotid one inch above the clavicle, that space alone being available owing to the encroachment of the tumour. The ligature used was the ordinary silk one, no carbolised gut being in store. Immediately after the application of the ligature the tumour became cold and all pulsation ceased. Temperature after the operation, 95°. — 4 P M: Temperature 99°; difficulty of swallowing increased, a great deal of saliva flowing from the mouth. Hypodermic injection of morphia (one-twelfth of a grain) at night, and to be continued every night. Nov. 16th.-Slept tolerably; saliva flowing in less quantities ; difficulty of swallowing as before. Temperature 1000. 17th.—Swallows with somewhat more ease, being able to take a little gruel. Temperature 99°. 18th.-All pain disappeared, but complains that his head feels cold. Morphia injection to be discontinued. 19th.-Complains of pain in the head, which prevented him sleeping at night. Injection of morphia to be continued at bedtime. 20th.—Pain in the head has disappeared; swallows fluids without difficulty. From this date to that of his discharge the case progressed most favourably. By the 25rh he could swallow solid food. On Dec. 3rd the ligature came away. The tumour has had no return of pulsation, is smaller and hard, all fluctuation having disappeared. The man himself has perfectly regained his health and spirits, and states that the tumour causes him no inconvenience whatever. Dec. 22nd.-Discharged.
though anodynes
Sattara.
A Mirror HOSPITAL PRACTICE, OF
BRITISH
COLSON, M.R.C.S.,
SURGEON,
BOMBAY ARMY.
ROWJEE BIN Essoo, aged about forty-eight years, a cultivator by caste, was admitted into the Civil Hospital, Sattara, with an aneurism of the external carotid artery. The previous history of the case, as given by the patient, is as follows. At the beginning of August last, he noticed a small hard swelling situated about the angle of the inferior maxillary bones. This at first gave him no inconvenience, but as it increased in size it caused him considerable
pain.
FOREIGN.
Nulla antem est alia pro certo noscendi via, nisi quamplnrimas et morborum dissectionum historias, tum aliorum, tum proprias collectas habere, et iuter se comparare.—MORGAGNI De Sed. et Caue, Morb., lib. iv. Prooeminm.
et
UNIVERSITY COLLEGE HOSPITAL. FRACTURE OF CERVICAL SPINE ; STRICTURED URETHRA PUNCTURE OF BLADDER; POST-MORTEM APPEARANCES.
(Under the
ARTERY. BY E.
AND
FoR the
down
of Mr. CHRISTOPHER HEATH.) notes we are indebted to Mr. Gould;
care
following registrar. P-, aged thirty-six, a very intemperate man, fell twelve steps while drunk on Sept. 2nd, 1876. He was
surgical G.
;
rendered unable to move his arms or to walk, and carried to bed. After about half an hour he " fainted," and remained unconscious for about fifteen minutes. He then continued restless and sleepless until the date of his admission, Sept. 3rd. On admission he was quite conscious. He was found to have complete motor paralysis of the left leg and of the extensor muscles of both arms and forearms, his respiration
! at
once
was