" Introduction of Air into the Veins. I have met with this occurrence only once in my practice, and that was in this Hospital about ten years since. I was in the act of removing the last of several of the deeper chain of lymphatic glands of the neck, which had become enlarged so as to interfere with the functions of deglutition and respiration, and was cautiously using the knife about half an inch on the outer side of the internal jugular vein. After a slight escape of venous blood, I heard a noise like that produced by drawing up with a syringe the last drop of water in a vessel. I immediately placed my finger over the spot from which the blood had issued, not being able to discover any orifice; and looking the patient in the face, asked him how he felt, he answered, ' very well.' Marks of consternation were visible around me, and many suggestions were made which I did not heed, but calling for an eyed probe, I directed a ligature to be passed through it. I applied to the internal jugular vein two ligatures,-one above, the other below the wound, directing them to be successively tightened. I then removed my finger, and proceeded with the operation. No bad consequences followed the application of the ligatures. The wounded vein appeared to be a branch of the internal jugular, but I did not think it safe to pass a ligature directly round the divided vessel, not liking to run the hazard of removing the pressure of my finger." Dr. Stevens objects naturally to operating on a female about her menstrual period. He recommends the operator to have the instruments he wants within his own reach. He likes, in great operations, to have the assistance of a judicious medical practitioner, a personal friend, if possible, of the patient, to console, to watch, to support him. "An adult, with ordinary powers of endurance, will, generally, sustain an operation of the average severity, during protracted suffering of one hour's duration, rarely much more than this. A clammy skin, with coldness of the extremities, and a soft, thready pulse, indicate alarming exhaustion of the vital powers. But an experienced surgeon will judge most accurately from the expression of the countenance, from the eye and mouth especially :—the former partially loses its lustre, the latter becomes relaxed, until, finally, the eyes are turned upward, and the jaw falls, indicating an almost hopeless condition. The voice, also, is an index of the degree to which the vital powers are sunk; its tones become more and more feeble, until, at length, the patient can only speak in a low whisper, like one in the collapsed stage of cholera, and finally ceases to articulate at all. On the first approach of this state of things, I would advise you to give your patient a few minutes' respite. I give you the above indications, as being the only ones that occur to me as capable of being conveyed by language; your own observation will hereafter enable you to determine their real value. It is also important for you to know that a patient will endure a long operation much better by being allowed two or three short intervals in which to rally during the progress of an operation, it being more easy to prevent him from sinking, than to raise him from extreme prostration." Finally Dr. Stevens counsels the surgeon never to undertake an operation against his own judgment, nor if possible assist at one. DR. LAW ON DISEASE OF The Brain, dePENDENT ON DISEASE OF THE HEART.* M. Legallois first drew attention to the fact, a striking and, practically, an important one, that hypertrophy of the heart disposes to apoplexy. Legallois * Dublin Journal, May, 1840. has been followed by others, and the doctrine has for some time been firmly established. The object of Dr. Law, is to extend the proposition, and to lead us to believe that disease of the brain may not only be occasioned by too great, but also by too little an impetus or quantity of blood, the result of cardiac disease. He lays down the following propositions, which he supports with several cases and with much ability. For the facts and arguments we refer to our esteemed contemporary. The propositions themselves are sufficiently intelligible in their naked form. They are as follows: 1st. The pathology of the brain is in many instances intimately connected with, and dependent upon, pathology of the heart. 2nd. To limit the pathological relation existing between these two important organs to apoplexy, the result of hypertrophy of the left ventricle of the heart, is to narrow it much within its true limits. 3rd. Ramollissement of the brain occurs in connexion with diseases of the heart, whose effect is either directly or indirectly to diminish the flow of blood to the head. 4th. This cerebral lesion may be connected with either disease of the aortic or mitral valve. 5th. Hypertrophy of the left ventricle of the heart, in order to produce apoplexy, must depend upon some impediment to the circulation, placed at a greater distance from the heart than the origin of the vessels which convey the blood to the brain. 6th. When ramollissement of the brain occurs, in connexion with an imperfect or patulous condition of aortic valves, the close analogy that we trace between the physical signs and constitutional symptoms of this lesion and hemorrhage, as well as the results of treatment, render it very improbable that the disease of the brain is the result of too much blood driven to it, and with undue force. 7th. When ramollissement of the brain occurs, in connexion with disease of the mitral valve, the state of the pulse, which, as a diagnostic mark of this lesion, is habitually small, precludes the idea that the cerebral lesion is produced under the usual conditions of inflammation. 8th. While ramollissement of the brain occurs as a result of inflammation, hyperemia, &c., it occurs also under diametrically opposite circumstances. 9th. To confound such opposite modifications of disease, and to apply to them the same treatment, must necessarily lead to the most mischievous practical results. 10th. The circumstances under which we have seen ramollissement of the brain to take place, seem to identify it with gangrene, or death of a part consequent upon a diminution of its due supply of blood. HOSPITALS OF MALTA. There are four hospitals in Malta, one naval, one military, and two civil. One of the last is in Valetta, and the other in Citta Vecchia or Notabilé, near the centre of the island. There is a civil hospital, also, in Gozo. At Floriana, adjoining Valetta, there is an asylum for the insane, and the town last mentioned is furnished with a public dispensary. The civil hospital in Valetta is as well furnished and as neatly kept as most of the institutions of the kind in England and France. A University was established in the island, by the Jesuits, in the year 1592. It has included a medical department ever since its commencement. The Medical Faculty is composed of five Professors. The chairs are, 1st. Anatomy and Surgery; 2d. Physiology and Pathology, including Theory and Practice; 3d. Botany, Medical Jurisprudence, and Natural History; 4th. Obstetrics; and 5th. Chemistry and Materia Medica. At the commencement of the year 1839, the organisation and discipline of I the University were remodelled, and some changes were made in the Medical School. The medical students receive constant instruction in the hospitals. These particulars are extracted from a paper by Pliny Earle, M.D. in the American Journal of the Medical Sciences, for February, 1840. SECTION OF THE HAMSTRING TENDONS, FOR CONTRACTED Knee-joint. By DR. BURLEIGH SMART.* CASE. A Scrofulous boy nine years old. The knee of the left leg began to enlarge, on each side of the ligament of the patella, six years ago, accompanied with a slight lameness in walking,-no pain, tenderness or redness. At this time there was a perceptible tightness of the tendons in the ham, and a disposition to flexion of the limb when in a recumbent posture. This thickening of the integuments of the joint, was followed by an apparent enlargement of the articular extremities of the bones of this joint. The enlargement, however, never became very great, sufficiently so, to render it distinctly perceptible at sight. About two years since, the boy was found to be affected with an angular anterior curvature of the spinal column, at the junction of the lumbar, with the sacral vertebræ; and the knee-joint more flexed, other appearances of the joint remaining the same. At this time the general health, always good before, appeared to be affected—some loss of flesh and strength, and restless nights. By the use of moxa and caustic issues, each side of the angular projection, kept open for about eight months, and the internal use of sarsaparilla, soda, and the hydriodate of potassa, the disease of the spine was apparently cured. But now there was a considerable degree of stoop, or inclination forward, given to that portion of the trunk above the pelvis. In this state Dr. Brown, of Boston, being consulted, advised the application of a mechanical apparatus, to be constantly worn, together with the use of an inclined plane; which seemed to afford important aid in rectifying the forward inclination of the trunk. But as the straightening of the spinal column progressed, an increase of the flexion of the knee was observable. For the period of about five years, this lad, in walking, has been able to bring only the toes and ball of the foot to the ground; the heel not coming to the ground, in the ordinary step, by the distance of between two and three inches, the latter part of that period of time. The leg has been a little smaller than the other, below the knee, ever since the commencement of the distortion. On the 15th of November, the tendons of the biceps flexor cruris on the one side of the popliteal depression, and of the semi-tendinosus and semi-membranosus on the other, were divided, about two inches above their insertion. The operation was performed with a slightly curved and sharp-pointed bistoury, which was introduced with the flat surface parallel and close to the inner side of the tendons, with the point upwards, and penetrating sufficiently deep to hook the point of the instrument under the tendon, by gently depressing the handle and turning the blade of the bistoury on its own axis, until it revolved a quarter of a circle, and the edge was presented transversely to the tendon. Then, by a gently sawing motion, depressing the handle, and at the same time elevating the point of the instrument, the parts were divided with but very trifling pain. The punctures were accurately closed by court and adhesive plaster, and a * American Journal of Medical Sciences, Feb. 1840. compress and bandage were applied, with a crooked splint outside the bandage; the limb having been extended about two inches, measured at the heel, before the dressings were applied. The flexion of the leg previous to the operation was about 40 degrees. The 8th day subsequent to the operation, no pain or troublesome inflammation having supervened, a carved wooden splint, with its cavity padded, and having a hinge joint at the knee, by which the two parts were connected, was applied and confined with broad padded straps passing from one side of the splints to the other, fastening with buckles above and below the knee. On the posterior surface of the splints was fixed a screw, connecting the two splints; by the daily turns of which, the limb was gradually extended until it became very nearly straight, which was effected in a fortnight after the extending apparatus was applied, and three weeks after the operation. This patient commenced walking as soon as the extending apparatus was applied. He is now able to walk with or without it, bearing his weight on the entire length of the foot; he can place the heel on the ground at every step, which he had not been able to do for about five years. OBSERVATIONS ON THE EMPLOYMENT OF CIMICIFUGA IN THE TREATMENT OF CHOREA.* The cimicifuga, known in America under the common name of black snake root, has been recommended by Dr. Young of Pennsylvania, as a remedy for chorea. Dr. Kirkbride has just published seven cases in which he tried it. He concludes them by observing : "We feel satisfied of the value of the cimicifuga, in the treatment of chorea, and disposed to attribute to it powers in some other affections in which we have not yet had an opportunity of giving it a satisfactory trial. After the details we have given, it is hardly necessary to say, that we do not look upon it as a specific in chorea. We have scarce ever met with a case where the primary treatment was not plainly indicated by the disordered digestion, the loaded bowels, the pain or heat of the head, and the languid circulation of the skin. But it is also right to state, that where these symptoms have been properly treated, the involuntary muscular movements, have often continued unchanged, until after the employment of the black snake root. Purging we have always used before the cimicifuga, and general frictions with salt or the flesh-brush, and pustulation with croton oil over the spine, we have believed to be of much value in the chronic cases. Of the two preparations we have employed, we are disposed to give the powdered root the preference, and now regret that we did not administer large doses in that form in our fifth case, where the decoction certainly had no effect." CURE OF SQUINTING BY DIVISION OF THE RECTUS INTERNUS MUSCLE. This operation is beginning to attract attention, indeed it may be looked on as already an established one. Proposed, and first, we believe, executed by Dieffenbach, it has been taken up by Dr. Franz, and by several surgeons in town, and the cases in which it has been resorted to are respectable in appearance and number. As Dr. Franz's cases have had the priority of publication, we think it only fair to notice them. We shall select the first case. • American Journal Medical Sciences, Feb. 1839. CASE.-Louisa M'Cleish, aged 18, affected with squinting since the age of two years. "On examination, I found the left eye slightly inverted, but the right eye so much turned inwards, that one third of the cornea was hidden by the inner canthus. She stated that the right eye was larger than the left, having been frequently told so by others; but this I found to be an error, probably arising from the circumstance that so little of the cornea was visible, whilst a large portion of the sclerotica presented itself. With considerable exertion of will she was scarcely able to direct the right eye so as to look straight before her, and could not in the slightest degree move the globe towards the exterior angle. When not under the influence of the will this eye instantly returned to its usual position inwards. On closing the left eye she could only distinguish large objects, and was not able to read even the largest print. Having provided myself with three assistants, the patient, whose left eye was closed by a bandage, was seated facing the light with her head inclined backwards, in which position it was retained by an assistant, who at the same time fixed the upper eyelid with a retractor. A second assistant kneeling before the patient, fixed the lower lid by means of a retractor, held in his right hand the eyelids being by these means well secured and drawn asunder, I perforated the conjunctiva at the inner corner of the eye close to the eye-ball, with a small and very sharp hook, and gave it to the second assistant to hold with his left hand, with which he was, by means of this hook, to draw the globe outwards. I next made a semicircular incision with a scalpel through the conjunctiva, about six lines in length; then dissecting through the subjacent cellular tissue, exposed the internal rectus muscle, and terminated the operation by dividing it close to the sclerotica with a very small pair of curved scissors, the one blade of which was passed beneath the muscle. The duty of my third assistant was to hold the patient's hands, reach me the instruments, and attend to the bleeding, which in this case was very inconsiderable. On the removal of the hook from the conjunctiva, the eye-ball was no longer inverted, but stood in the proper position, the pupil occupying the centre of the eye. The edges of the wound in the conjunctiva were brought together by the motions of the eye itself, which were perfectly free in all directions, except inwards. Cold water dressings were ordered, and a common draught. The patient then walked home."* Mr. Mayo, Mr. Liston, and others, have performed this operation. It is probable that the simple division of a single muscle will be found inefficient in some, if not in many, cases, and no doubt experience will suggest modifications in the method. STUDENTSHIPS IN ANATOMY.-COLLEGE OF SURGEONS. It is with great gratification that we publish the following. The President and Council have great pleasure in announcing to their members, that three Studentships in Human and Comparative Anatomy have been instituted by the College, to be held respectively for the term of three years, with the annual stipend of one hundred pounds attached to each studentship; and that, at the instance of the Director-General of the Medical Department of the Army, the Physician-General of the Royal Navy, and of the Chairman of the Honourable East India Company, the General Commanding the Army in Chief, the Lords Commissioners of the Admiralty, and the Court of Directors, have, with the view of promoting the objects of the College, been pleased to place at the disposal of the President and Council an Assistant-Surgeoncy, in each service, once in three years, for such of the said Students as may be considered worthy of these honourable distinctions. The President and Council have also the pleasure to announce, that, with the view of * Med. Gaz. April 17, 1840. |