Imatges de pÓgina
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with bloody expectoration; headach; nausea; retching; and occasional vomiting; pulse 92, small and soft. In the progress of the disease, the pain became general over the left and lower parts of the heart; the retching continued; the pulse became quick, feeble, and intermitting; and delirium came on. The bloody expectoration was for a short time suspended, and then increased so as to amount to hæmoptysis. At first he complained of want of sleep; afterwards he slept or dozed a great deal. His cough and dyspnoea fluctuated, but increased towards the close of his life, which took place on the fifteenth day from the attack.

These cases seem to me to form a valuable addition to our knowledge of this interesting disease. In Baxter we have an example of chronic and occult carditis, without any symptom occurring to indicate the affection of the heart; while after death the effusion of coagulable lymph, both into its cavities and into the pericardium, and the change its substance had undergone, left no doubt as to this important organ having been generally affected with inflammation. In Rickman and Macleod, we have cases of acute or subacute pericarditis: the former, accompanied by effusion of coagulable lymph, would have produced, if the patient had survived, a general adhesion of the pericardium, and the latter terminating in an enormous, and necessarily fatal, effusion of pus. The symptoms during life were no less different than the appearances after death; but any attempt to connect the one with the other would be premature.

IX.

Case of Inguinal and Popliteal Aueurism, cured by tying the External Iliac Artery. By WILLIAM Newbigging Esq., President of the Royal College of Surgeons, Edinburgh.

WHI HILE in attendance upon A. B. in August 1814, for sciatica of the left lower extremity, which confined him to bed, he remarked to me one morning that the disease was surely of a severe nature, as it had excited swelling in the groin. On turning down the bed-clothes, I found a tumour seated in the right groin, which pulsated strongly. This tumour had every character of aneurism.

In tracing the large vessels in their course through the limbs, I was surprised to find another aneurism existing in the ham of

the same limb; but there did not appear to me, at that time, evidence of any other of the blood-vessels being similarly affected.

The tumour in the groin was about the size of a walnut; circumscribed; without pain; and the pulsations in it were strong, and corresponded with those of the artery at the wrist. Its upper part occupied the crural arch.

This tumour was first observed by the patient about five or six weeks before, but was not considered to be of any consequence.

The swelling in the ham was somewhat larger, but, in every other respect, resembled that in the groin, and was not discovered by the patient till I pointed it out to him.

The patient was about 30 years of age, five feet five inches high, well made, but laboured under considerable irritability of the vascular system. He had complained of the sciatica for a considerable time, which for four or five weeks had been so severe as to confine him much to bed. His pulse was never under 100. Skin was warm; he had some thirst; appetite was impaired; B. slow. He was prevented from sleeping by the pain of the sciatica.

Friction with stimulating liniments; blisters; opiates; occasional laxatives, and a mercurial alterative course, were employed to remove the sciatica, with no very marked benefit, though the complaint afterwards became less severe.

After the discovery of the aneurisms, a strict attention to the antiphlogistic regimen was recommended; and the patient was particularly enjoined to keep in bed, and to avoid animal food and other stimulating substances,

In January 1815, the tumour in the groin had made very little if any progress; but that in the ham had evidently, though slightly, increased. At this time I applied a roller moderately tight from the toes to the groin, over compresses laid upon each of the tumours, About the same time it was observed, that the pulsations of the abdominal aorta, and of the left external iliac artery, were stronger than natural, which gave rise to doubt respecting the sound state of these vessels.

In February, the tumour in the ham became larger and painful, with increase of heat.

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The use of the roller was desisted from, and a solution of the acetite of lead was applied with some effect in allaying the heat and pain. His general health, which had not improved, be came now rather more affected, and he continued to be more or less distressed by the sciatica..

Though the aneurism in the groin appeared to be stationary, yet that in the ham was now progressive in its increase, had acquired a large size, and the skin began to be smooth and shine ing on its surface, and the heat and pain to be considerable,

In this state of eircumstances, it was agreed, in consultation with my friends, Messrs Andrew and William Wood, Mr Law, Professor Thomson, Dr Gordon, and Mr Turner, that the operation of tying the external iliac artery should be had re

course to.

On the last day of February, I accordingly met these gentlemen at the patient's house to perform the operation, when, on examining the ham, we found, to our surprise, that the pulsation had stopped. The patient, who was aware of this, had remarked, that the cessation followed a particular uneasiness and pain in the tumour during the night. It was therefore deemed proper to postpone the operation, in the hope that a spontaneous cure of the popliteal aneurism might possibly take place. The pulsation, however, after having been absent about two days, returned, but continued less strong than it had been before.

The swelling in the ham now became larger; the heat and pain increased, with great tension of the skin, which had a slightly livid appearance. There was starting of the limb, and a sensation as if some burning hot liquor had been poured upon the leg. Pulse rose to 120, and other febrile symptoms were present. He was bled to 10 ounces without relief.

On the 13th of March I performed the operation in the presence of the above named gentlemen. I began by making an incision parallel to the linea alba, through the skin, of three inches in length, about an inch and a half from the anterior and superior spinous process of the os ilium, and extending to within half an inch of the inguinal tumour. I then divided the tendon of the external oblique, cut through the internal oblique, and across the fibres of the transversalis muscles of the abdomen, in the direction of the external wound. With my fingers I cautiously separated the peritoneum from the subjacent parts, until I felt the artery distinctly; and I detached it from the surrounding substance with my fingers for about half an inch, and then passed a ligature under the vessel by means of an eyed hook. Immediately on tying the ligature, the pulsation entirely ceased in the popliteal tumour. The strong pulsation, too, was instantly stopped in the tumour in the groin; it became softer and more compressible; and, although a feeble beating could still be per

* In this expectation I was the more sanguine, as two cases had occurred in Edinburgh a short time before, in both of which a spontaneous cure took place: the one a case of Popliteal Aneurism, under the care of Messrs A. and W. Wood, which I saw along with them; and the other, a case of Femoral Aneurism, under the care of Mr Caird, which was seen by Professor Thomson and Mr Turner,

ceived in it, there seemed no doubt that this depended upon anastomozing vessels. Very little blood was lost.. The wound was closed by two stitches, and adhesive plaster applied between them. These were covered by a pledget of simple ointment, and the patient was replaced in bed.

He behaved with uncommon firmness and composure during the operation, but seemed much fatigued by it. He felt at times, during the operation, severe pain stretching from the wound to the thorax.

Hora 8va, P. M.-Pulse 140, neither full nor strong; skin cool and soft; tongue clean and moist; no thirst. He has pain in the wound, stretching to the thorax, impeding free respiration and the discharge of the urine. No general pain of the belly, and he can bear it to be pressed without any uneasiness being excited. Slight oozing of blood under the dressings. The pain in the ham ceased about three or four hours after the operation. The limb remained cold and numb for several hours after; but warmth was applied, and the heat of it is now nearly natural, and the numbness almost gone. Some starting of the limb. Little sleep.

14th.-Hora 8va, A. M.-Puls e126, soft; skin cool; sensation of cold and numbness of limb almost entirely gone, and its temperature seems natural. Pain of wound abated; breathing easy; urine voided freely; tumour in the ham free from pulsation, and less tense; that in the groin little changed, and the beating in it still felt but faintly; serous oozing from the wound.

Hora 8va, P. M.-Continues easy. Pulse 120; skin cool; tongue clean and moist; some thirst through the day, and slight perspiration; is distressed with sciatica.

15th.-Hora 11ma, A. M.-Took 25 grains of the pil. opiat. at two doses last evening, and spent an easy night, with some sleep. Pain of sciatica gone; pulse, which was at 110 this morning, is now at 116.

Pulsation is more perceptible in the inguinal tumour, but none in the popliteal; the last still less tense. Heat of the limb natural.

Ten grains of the pil. aloet. taken this morning.

Hora Sva, P. M.-Pulse 144; skin rather hot and dry; tongue whitish; no stool. Has taken two tea-spoonfuls of artificial Cheltenham salt.

16th. Hora 1 Ima, A.M.-Other two tea-spoonfuls of the salt were given last night, one at nine and the other at twelve. Has had frequent stools since, with gripes and flatulency; no sleep; pulse at eight this morning 132, now 124; skin cool and soft; tongue clean and moist; slight thirst; appetite tolerable; takes a basin of tea night and morning, and about half a pint of panada at dinner.

. Pulsation of inguinal tumour more distinct; but it continues, notwithstanding of compression being made upon the course of the iliac artery, above the tumour. Tumour in the ham evidently smaller, and free from pulsation. Skin over its surface slightly wrinkled. Slight oedema of this foot. Wound dressed, and looks well. Took ten grains of pil. opiat. at four this morning, on account of gripes.

18th.-Purging ceased on the 16th, and he has continued easy since, except the pain of the sciatica, which was allayed by ten grains of pilula opiata on the evening of the 16th. Pulse from 100 to 110; tolerable nights.

Popliteal tumour diminishing; oedema of foot continues; matter from the wound good.

20th.-Has been much distressed since last report by the sciatic pain, and has slept ill, on account of which he has taken ten grains of the pil. op. two or three times a day. Pulse 112; skin cool; tongue clean; a copious stool last night from an injection; edges of the wound do not adhere, though it appears clean; the lower stitch cut out; has had his shirt and flannel vest changed.

21st. Had sensation of cold, and tendency to shivering yesterday after changing his linen, followed by heat and sweating in the evening, when the pulse was at 150; has had a good night, however, and to-day the pulse is at 110, soft, and of good strength.

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23d. Had a tendency to rigor yesterday, which was checked by thirty drops of laudanum; pulse to-day 116; skin soft; tongue clean; no tendency in the wound to adhere, and it appears flabby; discharge pretty copious, and viscid; one copious stool by injection on the 21st. Sciatica still distressing, but it is relieved by taking thirty drops of laudanum, which he does two or three times in 24 hours. Popliteal tumour continues to diminish, and the natural furrows of the skin are now evident upon its surface; inguinal tumour appears somewhat diminished, and the pulsation continues. To have rice and milk to dinner, and a pound of wine-whey in the day.

25th.-No return of rigor; wound appears less soft, and discharge is more purulent; granulations appear at the upper part of the wound, around the ligature; one copious stool on the 23d by injection; pulse 96; skin soft, sometimes covered by sweat; tongue clean; relishes his food and wine-whey; sciatica continues to distress him, but is always relieved by the laudanum.

28th. One stool by injection last night; some griping and tenesmus since; pulse more frequent; wound as last reported. Wine whey stopped. To take a dose of castor oil.

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