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crural nerve.

As the skin soon threatened to give way, the operation of tying the common iliac was determined on.

"The tumor now occupied the whole of the left iliac fossa, extending from below Poupart's ligament to within little more than an inch from the umbilicus; the vertical diameter was six inches, the transverse six inches and a half; the swelling also projected at least three inches from the plane of the abdomen. It presented all the usual characters of aneurism. The patient was placed on a mattrass, inclining somewhat to his left side, and his shoulders moderately raised.

"I commenced the operation by an incision which reached from about two inches and three quarters above the umbilicus to the base of the tumor, being about six inches in length, and moderately curved; this was afterwards extended by an angular continuation an inch and a half in length; it was also exactly three inches to the left of the median line. The fibres of the external and internal oblique and transversalis muscles were successively divided; and the transversalis fascia having been readily raised with a director, was carefully opened, to an extent equal with that of the external incision. The peritoneum now protruded, but being greatly depressed and drawn towards the opposite side, I was enabled slowly to insinuate my fingers behind it, so as to separate it from its cellular attachment to the adjacent parts. The common iliac artery was easily reached, and its compression with the finger instantly stopped the pulsation in the tumor. A little time was occupied in scratching through the sheath of the artery; a common silver aneurism needle was now passed under the artery, armed with a double ligature of staymakers' silk, waxed. By holding aside the peritoneum and viscera, a momentary view of the artery was now obtained, and its complete isolation ascertained. The ligature was then tightened with the fingers close down upon the artery, when the pulsation entirely and finally ceased. The situ ation of the ligature was I believe an inch below the bifurcation of the aorta, or very little more." 329.

The time occupied in the operation was 25 minutes. The patient was much exhausted, notwithstanding the little blood lost. The wound healed favourably and the ligature came away on the 28th day. The author notices a source of anxiety in the after-treatment, viz. distension and violent spasm of the bowels accompanied with obstinate costiveness. This was found to proceed from the bowel being distended with an enormous mass of dry and hard fæces, the pressure of the aneurismal sac on the colon having prevented the contents of that viscus from descending into the rectum. The mass was with difficulty broken down and the pa

tient relieved.

We sincerely congratulate the author on the result of his surgical skill in this case. It must undoubtedly tend to maintain the fame which has so long attached to the name of Hey.

XXIII. Two CASES OF TUBULAR EXPECTORATION FROM THE BRONCHI, IN THE ADULT. By James Reid, M.D.

The author, after noticing the rarity of this disease and that few cases of it are placed on record, describes two cases. In one, a married woman, æt. 28, after an attack of bronchitis followed by a chronic cough, expectorated several arborescent membranous substances, resembling casts of the minute bronchial tubes, for three days, the quantity gradually dimin

ishing. She suffered from a recurrence of the attacks five or six times, at intervals varying from one to three weeks in extent, but each attack being preceded by a sense of suffocation. The patient lost flesh and strength, but recovered her health on removing to Devonshire in the summer. On her return to town in the winter she had a return of the complaint, which was again relieved by the expectoration of the arborescent tubular substance. There was no further relapse, and the patient died the succeed. ing winter of a disease unconnected with the chest. The second case was that of a barrister, æt. 44. who, after several attacks of cough, expectorated several portions of tubular substance, resembling plastic casts of the extreme bronchial tubes, accompanied with hemorrhage. The expectoration of this solid matter and blood recurred at intervals, but subsequently ceased, and at the end of nearly two years there had been no return of the disease. It is a curious coincidence, that the brother of this patient was afterwards affected with the same complaint. The case is related by Dr. Watson in his published Lectures. The bronchial concretions seemed with few exceptions, to be hollow, and to contain both air and blood. In the first case there was great dyspnoea, but in the second the cough was never accompanied by a feeling of suffocation. The author we think, rightly attributes the bleeding to the partial detachinent of the plastic substance from the turgid mucous membrane. He considers the disease to be chronic inflammation of the mucous membrane of the bronchial tubes of a specific kind, and that the exudation does not depend on the intensity of the inflammation, but on some peculiar action of the parts producing it. It may attack both lungs, or be confined to one, as in the author's second case. He thinks the prognosis favourable, provided the malady is not complicated with phthisis or other serious disease. The higher the plastic formation takes place in the air-tubes, the more severe will be the symptoms. Dr. Reid does not recommend active treatment, but is disposed to rely more on the employment of ipecacuanha, squills, and other mild expectorants, conjoined with light diet.

XXIV. A TABULAR VIEW OF THE SEAT OF TUBERCULE IN ONE HUNDRED AND EIGHTY CASES OF TUBERCLE OF THE LUNGS IN Children, WITH REMARKS ON PULMONARY PHTHISIS IN THE YOUNG SUBJECT. By P. Hennis Green, M.B.

In this paper the author proposes to indicate a few of the peculiarities which distinguish infantile consumption from the phthisis of adults. He gives a table of 180 cases of thoracic tubercle for the purpose of furnishing data for the history of pulmonary consumption in children. He remarks, "the main character which distinguishes the phthisis of children from that of adults is this,-in children, the tubercular deposit occupies a much larger surface of the lung, is more rapidly secreted, and is complicated with tubercular disease of other organs more frequently than in the adult. Hence children often sink under phthisis before the complaint has arrived at its third stage; while on the other hand, the modifications produced by an extensive diffusion of tubercular matter often render the diagnosis of the disease obscure and difficult. In addition to this character

we have the peculiarities occasionally induced by excessive tuberculization of the bronchial glands, giving rise to bronchial phthisis, a form of disease altogether confined to the child."

The author notices an important modification which should guide the practitioner when he seeks to determine the existence of cavern in young children, viz., that under five years of age, the cavernous excavation is generally seated in the lower or middle lobes, and is almost always confined to one side of the chest. To show that the general diffusion of tubercular matter forms a striking characteristic of phthisis in children, Dr. Green compares some of M. Louis' results with those deducible from his table.

"In 358 cases of phthisis in adults, M. Louis mentions the existence of tubercular matter in the brain or its membranes only once. In the bronchial glands, tubercles were found in about one-fifth of the cases; in the mesenteric glands, in one-fifth; in the liver, only twice; in the kidneys, five times in 170 cases; on the other hand, ulceration of the larynx existed in one fourth,-ulceration of the bowels in five-sixths of the cases.

"The history of phthisis in children presents us with very different results. The brain was affected in one-ninth of the cases; the bronchial glands, in 100 out of 112; the mesenteric glands, in one-half; the liver, in one-ninth; the kidneys, in one-eighteenth ; but ulceration of the larynx occurred only once; ulceration of the bowels, sixteen times in the 112 cases." 356.

The physical signs are rarely as well marked as in the adult, and the young child frequently dies before the practitioner is able to decide whether the lung be actually the seat of cavern or not. The cause of this is that, in children, "the tubercular matter is widely diffused, and has implicated many important viscera; in the brain, it may excite hydrocephalus or meningitis; under the serous membrane of the chest, pleurisy; in the abdomen, peritonitis; in the intestines, tubercular ulceration. These complications rapidly undermine the resisting power of the little patient; diarrhoea sets in, and death ensues long before the period at which a fatal termination takes place in the adult."

Infants and children under five years of age hardly ever expectorate. They swallow every thing that comes up into the mouth from the lungs. Hæmoptysis is an exceedingly rare symptom. The symptoms which constitute hectic fever in adults are seldom present together in any marked degree.

The bronchial glands were more or less affected in one hundred out of one hundred and twelve cases. In a few of these cases only were the glands sufficiently enlarged to produce symptoms through their mechanical effects, or by communication with caverns in the lungs and the bronchi, and in such cases the term bronchial phthisis should be confined. Understood thus, this form of phthisis is peculiar to children, and attended with very characteristic symptoms; but it is not, as some writers assert, of frequent occurrence.

"The enlarged bronchial glands may act mechanically on the neighbouring organs contained in the chest, or they may perforate them. Hence a variety of symptoms, depending on the position or function of the injured part. "The aorta and pulmonary artery, the vena cava, or the pulmonary veins, may be compressed by the tuberculated glands, and the flow of blood more or less impeded. M. Tonellé has related a case in which the superior cava was com

pletely obstructed, and I have seen one where the pulmonary artery was perfectly flattened between two enormous glands. From the compression of vessels may arise pulmonary apoplexy, fatal hæmorrhage, effusions of serum, or symptoms closely resembling those of organic disease of the heart. The trachea, bronchial tubes, and lungs, may be compressed, and in such cases the symptoms will vary considerably, according to the seat and extent of the mechanical lesion. When the ganglions act on the lower portion of the trachea, MM. Rilliet and Barthez have noticed the existence of a loud, sonorous ronchus, which persists for a considerable length of time. In other cases, the pressure on the large bronchial tubes causes more or less feebleness of the respiratory murmur, which is remarkable in being intermittent.

"Pressure on the eighth pair of nerves or its branches is often attended by very peculiar modifications of the voice and cough. The former is hoarse or occasionally subdued, and even lost; or the hoarseness and loss of voice may alternate. The cough, also, is frequently hoarse, or occurs in fits which bear a close resemblance to those of hooping-cough, but are not followed by vomiting; or the fits may simulate accesses of asthma, with great oppression of breathing, anxiety, agitation, congestion of the head, and cold, viscid sweats.

"The enlarged or softened glands give rise to another order of symptoms, by perforation of the neighbouring parts. Thus fatal hæmorrhage may arise from perforation of the pulmonary artery; pneumo-thorax from perforation of the lung; difficulty of deglutition and accesses of cough on swallowing from perforation of the œsophagus; but we should observe that these symptoms may equally depend on the presence of tubercular matter or of a cavern in the lungs." 365.

On the subject of diagnosis of this form of phthisis, the anthor remarks: "Whenever a child presents several of the rational symptoms of consumption, without our being able to detect any physical signs of the presence of tubercles in the lungs or abdomen, we have good reason to suspect that the bronchial glands are tuberculated. As long as the case continues to present this simple aspect we cannot go beyond suspicion but it rarely happens that the glands acquire a considerable degree of development, without acting on the surrounding parts or tissues. As these become successively involved, we have a series of varying symptoms, which could not arise from any other source. The eyelids become edematous, and in proportion to the degree of pressure on the vena cava, the œdema extends to the whole of the face, which is sometimes pale, sometimes tinged with venous injection. This œdema will appear and disappear several times during the course of the disease. The cough suddenly changes its character, and occurs in fits, like those of hooping cough; the voice gets hoarse, and for days may be altogether lost; fits of asthma or of suffocation, as if the heart were diseased, occur. On examining the chest, we heard a loud sonorous ronchus, which persists for a length of time, and then disappears, or is replaced by other râles of an anomolous characWhen these symptoms are superadded to the rational signs of phthisis, we can have little hesitation in deciding that they arise from tubercular enlargement of the bronchial glands." 366.

ter.

We find nothing new on the subject of treatment. Dr. Green objects to emetics, lest irritation of the abdominal viscera hasten the deposit of tubercle in the abdomen, to which the patients are already too prone.

We much regret that we have been compelled to give so condensed an analysis of this excellent paper. Much, very much as Louis has done, it is evident that he has not exhausted the subject of phthisis, and the accurate information presented to us by Dr. Green will be received as a valuable addition to our history of the disease at the period of infancy.

XXV. CASE OF TUMOR IN THE RIGHT HYPOCHONDRIUM, OCCURRING AFTER INJURY, FROM WHICH A LARGE QUANTITY OF FLUID RESEMBLING BILE WAS REPEATEDLY WITHDRAWN BY THE OPERATION OF TAPPING. By William Robert Barlow, Esq.

On the 28th of August, a strong healthy man, aged 54, a thatcher, injured himself by lifting a heavy ladder. He complained of so much pain in the region of the liver, that the author apprehended a rupture of that organ. He was faint, in a cold perspiration, and the pulse was scarcely to be felt. He recovered sufficiently to be removed home. By depletion, calomel and opium, &c., the pain was relieved, but his motions presented no appearance of bile. Sept. 15, a swelling, the size of a walnut, was observed over the region of the liver. This gradually increased; he suffered great pain from distention; and from the swelling being limited to the right hypochondrium, and no bile having yet passed by the bowels Mr. Barlow felt confirmed in the opinion, that a rupture of the liver, involving the biliary ducts, had occurred. Oct. 9th. He tapped the swelling and drew off seven quarts of fluid, which from the colour and taste, appeared to be pure bile. The patient was relieved, but the fluid recollected, and on the 21st, six quarts more of fluid were removed. This on analysis was found to be a serous fluid mixed with bile. He was again tapped, and the whole six times, the last occasion being on the 26th of November. On the following day, after a dose of castor oil, some bile was observed in the motions. The swelling subsided, the stools became natural, and by the commencement of the February following he had completely regained his health. The editor has appended to this very interesting case the particulars of another bearing a close resemblance to it, related by Dr. William Thompson of Edinburgh.

XXVI. PECULIAR CASE OF GELATINIFORM CANCER, IN WHICH NEARLY ALL THE ORGANS OF THE BODY CONTAINED COLLOID TUMORS; WITH THE APPEARANCES ON DISSECTION. By John C. Warren, M.D.

The author states that colloid cancer is described by authors as occurring in one single mass, usually of considerable size, but in the case here described, the disease was diffused through nearly all the textures of the body, without presenting any one considerable mass. The case is also remarkable in exhibiting a union of the three admitted forms of malignant disease, scirrhoma, cephaloma, and gelatinoma. The patient was a young man, aged 25, but as the chief interest of this case is connected with the pathological appearances, it will be sufficient to mention, that on examination of the body-its surface was studded with sub-cutaneous tumors about the size of a hazel-nut. They were composed of small granulations, constituted by sacs containing a substance which appeared at first view to be wholly gelatinous, but which, on being divided, discharged a small. quantity of viscid fluid. The colour was a mixed grey and red; they were slightly transparent. Similar tumours were found in the thyroid gland, diploë of the skull, ribs, muscles, mediastinum, heart, lungs,

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