experience was disregarded, and what was the consequence ?-that cholera arrived, as it had arrived elsewhere, and that in addition to its ills, we had the depression of commerce and stagnation of trade dependent upon quarantine restrictions. In France -in Holland it has been the same. Now look to Spain d Portugal. In Spain quarantine is rigidly enforced, and the priests of despotism in every form, the Camarilla, have sagely, as wiser men in this land of freedom did before them, disregard all experience, and hoped to keep out cholera by law. In Portugal the force of events has been stronger than the force of prejudice, and the thunder of artillery has choked the cholera cry. Yet, in spite of all the unrestricted tagious, even though we felt inclined to suspect that it were not so. But there is another sophism that happens is in far more general use. to have been applied to cholera, although it It is a common observation that if one cause be adequate to explain a circumstance in medicine, it is unphilosophical to look for another. No remark can be more shallow, more absurd. Do we not find in life that there are many and very opposite obvious causes of disease? Will not a very high temperature produce Is pleurisy always brought on by cold? inflammation, and will not a very low one do the same? Nature abhors those petty ligatures that fools would fancy, and philosophers would forge, and she will not be trammelled by these logical refinements and scholastic subtleties. Our readers know that we are not of the class that sneer at communication that exists between infected London and Glasgow, and uninfected Oporto-in spite of the volunteers from our poorer and therefore cholera-loved ranks, that enrol themselves for problematical philosophy, and see in vigour of expression, liberty, and still more problematical pay— in spite of all this, there is yet no cholera at Oporto, whilst the obstinate and well-quar antined Dutchmen are affected with it. It is just a toss up which gets it first-Portugal or Spain. What we mean to say is thisthat supposing cholera to be highly conta gious, quarantine has been proved, by the experience of Asia, Europe, America, to be useless, and if useless, to be pernicious. We care not, for the sake of the argument, what may be the cause-whether the contagion be too subtle to be restrained by quarantine or whether so many means of breaking through quarantine exist, that it becomes inefficient in that way-whether in short it be too little for the disease-or whether man by fraud, or force, or gold be too much for it--whether cholera come in by the smuggler, or Jove-like be conveyed in a shower of gold-it matters not whether any of these reasons be valid or none-the general result is against quarantine, against this the first and last of " tionary" measures, and practice has eternally damned it, if theory has not. precau We hold it then to be a sophism in the case of cholera, to act as if it were con or exact discussion, nothing but rhetorical flourishes or useless refinements. But we would not willingly lay hold of the eel of science by the tail, nor would we substitute the scholastic forms of reasoning, for the substance of rigorc us and inductive reasoning itself. LIX. LIGATURE OF THE SUBCLAVIAN ARTERY FOR SUBCLAVIAN ANEURISM. THIS case is related in the Lancet, for Nov. 17, by the operator, Mr. Nicholls, senior surgeon of the Guardian's Dispensary, Norwich. Early in April last, Miss N. æt. 21, residing near Norwich, consulted him respecting a pulsating tumour in her neck, which had commenced after a sudden exertion of her left arm. On examination (says he), I found a tumour the size of a hen's egg, situated in the left side, occupying the triangular space which is bounded below by the clavicle, on the inner side by the clavicular portion of the mastoid muscle, and on the outer side by the anterior fibres of the trapezius, evidently the result of some injury done to the subclavian artery, in that part of the canal which stretches from the edge of the scalenus muscle towards the axilla, before it has passed under the clavicle; indeed, so near the edge of the scalenus was the injury, that I was not able to compress the vessel with my thumb, between the muscle and the tumour." Mr. M. ordered rest and some aperient medicine, and, having obtained the young lady's consent, performed the operation of tying the subclavian, immediately external to the scalenus anticus, on the 30th April. As there are some peculiarities in the mode in which the operation was performed, we must give the operator's own descriptio.. "The patient was placed in a horizontal position on a table about three feet in height, having her head hanging over the end, and supported by an assistant. The integuments being drawn down, an incision was then made through the skin and platysma myoides, along the clavicle, three inches in length, from the outer fibres of the clavicu. lar portion of the sterno-cleido-mastoideus, outwards: another incision was carried from the inner point of the former one, upwards along the clavicular portion of the sterno-cleido-mastoideus for four inches; this incision passed between the fasciculi of the platysma myoides, which, in this case, were remarkably large. The triangular flap formed by the two incisions was dissected back, carrying with it, imbedded in its substance, the external jugular vein, as far as the tumour would allow of its being done; and a little dissection now brought into view the omo-hyoideus at the upper part, passing obliquely upwards to its insertion. This muscle was divided, and a small artery passing across the wound immediately below it, was secured; the deep fascia of the neck was here exposed, having on the inner side the anterior scalenus beautifully distinct, and passing to its insertion into the tubercle of the rib. By slightly rotating the head, the different direction of its fibres from those of the sterno-cleidomastoideus, became remarkably apparent, shewing how important at this stage of the operation it is, that this muscle should be your guide. The fascia was then cautiously, divided along the outer edge of the scalenus, and the transverse artery of the neck drawn upwards by a blunt hook, whilst the large vein which accompanied it, but which crosses the wound considerably lower down, was secured by two silk ligatures, and divided. This enabled me to pass my finger along the scalenus to the tubercle of the rib, and to compress the artery where it leaves the chest, about half an inch above that process. The space, however, be tween the aneurismal tumour and the scalenus was so small, that it was thought advisable to divide a few of its fibres, in order the more readily and securely to tie the vessel. This having been done, a strong blunt aneurismal needle, armed with a silk ligature, was very readily passed under the artery from below, and its blunt extremity having been pressed upwards, I cut through the cellular tissue upon it, and thus passed the instrument without detaching the vessel from its connexions. The ligature was tied with great ease, and the tumour immediately subsided. All pulsation ceased from that time; the edges of the wound were brought together by means of a suture and some adhesive plaster, and the patient returned to her bed. She bore the operation with remarkable firmness throughout.” There is little in the subsequent occurrences to deserve notice. On the 5th day, the wound was dressed for the first time, and was partially healed. On the 12th day two of the ligatures came away-on the 14th the radial pulse returned-on the 21st day, the ligature on the subclavian separated-and, on the 24th, she is reported as eured. We are told that, up to the present time (November), she continues to enjoy good health, and feels no inconvenience from the operation. The circumstances to which Mr. Nicholls would direct attention are-1, the position of the patient during the operation-2, the turning back of the jugular vein, imbedded in the flap-3, the non-division of the clayicular origin of the sterno-cleido-mastoid muscle-4, the drawing upwards of the transverse artery-5, the division and ligature of the transverse vein without bad consequences-and, 6, the ligature of the subclavian, beneath the outer fibres of the scalenus anticus. To these memorabilia, we would add the circumstance of so young a lady having an aneurism at all, and regret that the state of the tumour, subsequent to the operation, has not been more particularly noticed by Mr. Nicholls. We are told that, after tying the vessel, the tumour "immediately subsided." Did it subside entirely, or partially? This we are not told, and yet, to say the least, it would be interesting information-because, if the former, there could have been no coagulum in the aneurismal sac, and it must have been a dilatation only of the artery-if the latter, we ought to be acquainted with the final result. We throw out these hints to Mr. Nicholls, believing him sincerely desirous of benefitting science by the publication of the case, and we think he will agree with us, that facts, to be really serviceable, should be perfectly explicit. LX. DEATH AFTER THE INTRODUCTION OF THE CATHETER. THIS case is related in the same Number of the Lancet which contains the preceding. We notice it for more reasons than one. A sailor, æt. 45, had for some time been troubled with stricture, the difficulty of making water being greater at one time than another. In the morning of Sept. 10, he was brought into the London Hospital labouring under retention of urine, with urinous extravasation into the cellular membrane of the scrotum. The introduction of the catheter being impracticable, Mr. Scott "determined on laying open the membranous part of the urethra." The patient was placed in the position for lithotomy, and an incision, as in that operation, was made in the perinæum. A quart of urine was evacuated with relief. There was troublesome bleeding "from the corpus spongiosum," and it was only arrested by including in the ligature a portion of that structure. By this, and the application of cold water, the bleeding was arrested. The volatile alkali was given, and no further bad symptoms occurred. The urine flowed exclusively through the wound in the perinæum till the 2nd October, when a small quantity issued through the urethra. So matters continued till the 19th, when Mr. Scott, after much difficulty, passed a catheter into the bladder, and ordered it to be retained by tapes. At 11, a.m. of the 20th, it slipped out, and, on the 21st, the catheter was re-introduced. Early in the morning of the 23d, symptoms of "acute peritonitis" came on. The patient was ordered castor-oil and leeches, and the bowels not being opened, Mr. Scott directed house-medicine every half hour till they should be so, with calomel and Dover's powder every four hours. In the evening, leeches were again applied. On the 24th he felt much easier, but there was distressing and constant sickness. The bowels had not been opened since the preceding evening, and he was again ordered house-medicine every half hour till they should be so, to be succeeded by blue-pill and opium, and leeches. The greater portion of urine was passed by the urethra. Next morning he was extremely low, and at 3, a. m. of the 27th he died. The friends would not allow the body to be examined. It would, perhaps, be idle to throw out many conjectures on the cause of death, certainty on that point being unattainable. But we may be permitted to express a doubt of the existence of peritonitis, to the extent imagined by the reporter. At least, the symptoms were very similar to what we see after lithotomy, and it is now pretty well ascertained, that diffuse inflammation of the cellular membrane of the pelvis is more frequent after that operation than pure peritonitis. Besides, we have seen a case very similar, in many respects, to that before us, in which dissection shewed no peritoneal inflammation. The case was that of an elderly man, with a bad stricture. An instrument was with much difficulty passed, and the urine flowed. On the same evening, or next day, tenderness of the abdomen, with rapid pulse and hot skin, came on. The patient became worse, had vomiting and hiccup, but no rigor. It was thought that there might be mischief in the perinæum, and an incision was made there, but without any result. The man died. On examination, it was found that the instrument had made its way through the side of the urethra, into a cavity behind the neck of the bladder, containing pus. Whether this was, or was not, an old abscess, we cannot say, but certainly the pus thus locked up was the cause of the symptoms and death. Now we do not say that such was the case in Mr. Scott's patient, but we point out the similarity of the cases, and the probability, or, at all events, possibility, of a nearly similar state of things existing in both. We entertain no doubt that the introduction of the instrument, in Mr. Scott's case, was the exciting cause of the mischief, whatever that may have been. But supposing peritonitis, as was thought, to have existed, we question the propriety of administering a drastic purge, like "house medicine," every half-hour, until it should operate. Are inflamed parts usually the better for such disturbance as this must necessarily have created? If Mr. Scott's patient had inflamed leg, would he set him to run about the ward for some five or ten minutes, in order to answer some end in view? We think not, and, though we may be wrong, we do not approve of the practice to which we have adverted. A word on the operation at first resorted to, when the patient was affected with retention of urine. As it was determined to cut into the membranous part of the urethra, in the perinæum, might it not have been better to have finished the business, by endeavouring to establish the urethral channel at once? Mr. Scott might have commenced by introducing the staff, or other instrument, as far as it would go, cutting upon it, and following up the incision by dividing the strictured part of the urethra, and opening into the dilated membranous portion. Subsequently a catheter would have been retained in the bladder, and the fatal risk which the patient ultimately ran would have been avoided. It would have been avoided had the operation succeeded, and that would have been quite as likely to have done so, as the operation which Mr. Scott actually performed with temporary success. The procedure to which we have adverted is not merely a speculative one; Mr. Mayo has adopted it on several occasions with success, and we do think that surgeons should give it a trial, to establish fairly its merits or its faults. LXI. WOUNDS OF THE INTESTINES. DR. WISE has inserted a paper on this interesting subject in the fifth volume of the Transactions of the Medical and Physical Society of Calcutta. We shall notice some facts related by Dr. Wise. "In many cases of Hernia and Introsusception, in which the persons recovered, after portions of the intestine had sphacelated, it has been found that an adhesion took place between the parts of the peritoneal sac, naturally in contact with each other. By this mean, extravasation of the contents of the gut, and its fatal consequences, were prevented. In a case of strangulated Hernia, Mr. Hunter found that organized coagulated lymph had formed 24 hours after the operation had been performed. To set free the strictured portion, recourse is sometimes had to the same principle, for the cure of other diseases, as of hydrocele; but it appears that it might be employed with advantage in many cases, in which it is at present neglected. To prove this, experiments on the inferior animals have been instituted; and Dr. Thomson found, that a ligature may be passed round so as to encircle a piece of intestine, and drawn tight with impunity. This is found to be in consequence of the ligature dividing ligatures short, and returned the whole into the abdomen, an abscess subsequently formed at the umbilicus, and by it the pieces of ligature were discharged. In the case of the intestine there is this great difference, that the ligature may, and in all probability often does, separate into the cavity of the gut. In an instance of wounded intestine Sir Astley Cooper included the wound in a ligature, cut both ends short, and returned the whole with success. The following two cases were similarly fortunate. Case 1. A man, æt. 60, was brought to Bartholomew's Hospital, while Dr. Wise was house-surgeon with strangulated inguinal hernia, of large size, soft, and the seat of great pain in the neck of the tumor. Seven hours after the commencement of strangulation Mr. Lawrence operated, various means having been employed in the interim to produce reduction. On opening the sac about a foot and a half of small intestine, of a chocolate colour, was exposed. A small hard stricture was found high up in the sac, admitting the director with much difficulty. The stricture was removed, and the gut pulled down a little for the purpose of examination, when a gush of brown fluid took place from a small wound in it, ap the internal coats of the intestine, producing an adhesive inflammation between the two sides of the serous membrane, immediately above and below the ligature; and a slow ulcerative process, by which the ligature passes into the gut, and is discharged. In Introsusception the same adhesive process takes place between the two serous surfaces, at the commencement of the included portion, which is removed by a slow ulceration at the part where the enclosed joins the included portion. Mr. Jobert, an expert and judicious surgeon of Paris, performed a number of experiments on dogs, to discover to what extent this principle could be relied on. I assisted at some of these experiments, and as I believe they are not generally known, shall now relate the results obtained. Part of the stomach, and different portions of intestines, were exposed, and incisions made in different directions. The lips of the wounds were inverted, or if the Epiploon was near, a piece of it was placed between the lips and several stitches of the interrupted suture were made, including a small portion of the serous and submuscular coats, near the edges of the wound, so as to keep the two serous surfaces in contact; the gut was then returned, and the external wound closed. The dogs were killed at different periods after these exper-parently produced by the director. The iments, when the wounds were found healed, without any extravasation having taken place of the contents of the gut. In other experiments, the gut was divided across; the serous coat of the inferior portion inverted, and the superior portion passed for a short distance within this. It was secured in this situation by the interrupted suture. The catgut ligatures divided near the knot, and the gut was returned into the abdomen. In these cases, adhesion took place in a few hours, and the animals quickly recovered without any unfavourable symptoms." It is important to observe that the presence of the ligatures in the abdomen was productive of no ulterior inconvenience. Our readers may probably be aware that in a case in which Mr. Earle, we think, tied some vessels in protruded omentum, cut the wounded part was pinched up with a pair of small forceps, a fine ligature passed round beyond the points of the instrument, tied tight, and the extremities cut close to the knot, and the intestine returned into the abdomen. As there was a large mass of omentum slightly adherent, much of it was removed, and the rest left in the wound. Laxatives were given half an hour after the operation, and repeated till the bowels acted. The patient recovered without a bad symptom. When the wound is more extensive the same principle is applicable. The next case occurred to M. Jule Cloquet, and is related by M. Jobert.* * Memoire sur les Plaies du Canal Intestinal. Par A. Jobert, Paris, 1926. |