Case 2. "Nicolas Lejeune, aged 41 years; of a middle height, and spare habit; had a Congenital Hernia, which obliged him to wear a truss, as it had several times been strangulated, and was always reduced with difficulty. On the 13th of July, 1826, at ten o'clock, it became strangulated, without any apparent cause. After numerous ineffectual efforts to reduce the hernia, assisted by a surgeon, he was conveyed to the Hospital of St. Louis, five hours after the symptoms appeared. He was then found in the following state:-On the left side, a large, soft tumour descended from the inguinal region, and distended the scrotum. The patient had vomited, and complained of nausea and great thirst; the pulse was small and rapid; respiration frequent and short; great sensibility of the abdomen, with general prostration of the system. The foot-bath, local blood-letting, and the taxis, were employed, without success, and Mr. Cloquet proceeded to remove the stricture with the knife. A transverse portion of the skin, over the tumour, was pinched up, and divided across, for nearly two inches in extent. The fascia superficialis, the cremaster and dartos muscles being divided in the same direction, exposed the hernial sac, a portion of which was raised by the forceps, and a small perforation made into it, and enlarged by a pair of straight scissors. The portion of the intestine included in the hernia, was much inflamed, and distended. While two assistants removed the intestine to the side, Mr. Cloquet passed a bistoury, to divide the stricture, which he had discovered situated in the neck of the sac. He then tried to reduce the gut, but failed, and the bistoury was again introduced, to enlarge the stricture; as he was withdrawing the instrument, a portion of the intestine, held by one of the assistants, escaped, and was divided to the extent of an inch and a half. A quantity of gas and fluid escaped from the wound in the gut, which was found thickened to double its natural size. Two ligatures were passed through the lips of the wound in the intestine, about five lines from its edge, and when tightened, thus brought

the serous surfaces together. The extremities of the ligatures were cut close to the intestine, which was then returned into the abdomen. Simple dressing was applied to the external wound, and secured by a T bandage. All the unfavourable symptoms disappeared; and the patient recovered."

The cases will probably be interesting to practical surgeons. We may add to the foregoing, the following instance of wound of the abdomen, though apparently not of the bowels, which we find related in another part of the same volume.

Mr. Thompson reported to the Medical Society a case of wound of the abdomen, which occurred in a Malay man, at Malacca. The wound was inflicted with a spear, which entered above the posterior spinous process of the left os ilii near the last dorsal vertebra; and came through the body, passing out at the linea semi-lunaris of the right side, two inches above the navel, where there was an opening an inch in length, at which a portion of omentum protruded. Very little blood was effused externally. Six hours after the injury was inflicted, the patient had violent pain in the belly, urgent thirst, vomiting, anxious countenance, a small weak pulse, and cold perspirations. The omentum was reduced, and the wounds closed by sutures. V. S. was attempted, but the man soon fainted: next day he was bled to 12 ozs.; leeches were ordered on account of painful tension of the belly; and a blister was applied to the abdomen. Enemas, and aperient medicines were administered repeatedly, until the bowels were freely opened. The unfavourable symptoms gradually subsided, and by the 16th day after the wound was inflicted, the patient was able to walk from his house, two miles to the hospital; the wounds were then in a good state, and affording every prospect of recovery. As no blood was observed in the stools, or in the matter vomited soon after the wound was inflicted; there seems reason to believe, that the spear passed through the body, quite across the belly, without wounding the intestines or stomach.

LXII.

LIGATURE OF THE CAROTID FOR HEMI

PLEGIA AND EPILEPSY.

THERE is a curious paper on this subject by J. R. Preston, in the volume of the Calcut a Transactions, from which the preceding article was taken. We say curious, for the reasoning does appear to us to be extraordinary. It amounts to this, that ligature of the carotid is likely to be serviceable in cases of inflammation, congestion, irritation within the cranium, in our author's own words, in "apoplexy, phrenitis, hydrocephalus, many cases of injury of the head, palsy, epilepsy, and insanity." All this practical induction appears to be bottomed on the principle, that ligature of the carotid diminishes the volume of the b'ood sent to the head. Now this principle seems to us most futile. The cranium cannot be emptied, nor can the quantity of its contents be diminished. If we take blood out, something else must be sent in. But there is nothing else to supply, on the emergency, the place of blood. Therefore, if we tie one carotid, blood must pass in increased quantity by the other carotid and vertebrals, or, supposing these channels obstructed, it must flow back into the cranium by the veins, or remain stationary in them. This seems to us to be as clear as any demonstrable truth. The principle, therefore, on which Mr. Preston sets out is a false one. We may alter, and by our medicinal and surgical operations, we do alter, the disposition of the blood in the brain, the energy, or the rapidity with which it circulates, but its actual quantity, other things being the same, we do not, and we cannot alter.

There are other considerations to deter us from expecting benefit from ligature of the carotid in inflammation, congestion, or irritation of the brain. The operation itself is not a slight one, but, in a certain number of cases, would itself be the cause of death. We have no just grounds for concluding, that irritation of any part is removed by diminishing the quantity of blood sent to VOL. XVIII. No 35.

it. Is depletion useful in tic douloureux, or those nervous symptoms that occasionally follow amputation? Irritation, on the whole, is not benefitted by depletion, general or local, and yet it is on the principle (we have shewn its erroneousness) of lessening the quantity of blood sent to the brain, that Mr. Preston proposes ligature of the carotid for epilepsy.

After tying the vessel of a limb, we not unfrequently find that inflammation is set up in the limb below the ligature. After ligature of the femoral artery, we have seen a low inflammation, like chilblain, attack the foot. Numbness and nervous pain are frequent consequences of such an operation, and they often remain for a considerable time. Here, then, we see both inflammation and irritation the result of the ligature of an artery in the extremities. As we never saw the converse experiment made, that of tying the vessel for inflammation or irritation in an extremity, we cannot speak to its results. Now, then, if Mr. Preston

Case 1.-Ligature of the Common Carotid Artery for Hemiplegia.

Peter Rochford, æt. 50, king's pensioner, was admitted into hospital, Oct. 25th, with hemiplegia of the left side-some pain in the paralytic leg-circulation unaffected-skin cool. The symptoms came on during the preceding night. He had been a hard liver.

He was ordered a blister, calomel, iodine. On the 28th, the mouth was slightly affected -on the 29th, a seton-on Nov. 1st, the mouth sore, and the calomel omitted. On the 5th, sensation had returned in the arm 23

and leg, and there was much pain in the knee. On the 8th, more difficulty of speak ing. Croton oil. On the 9th, better; he now took tinc. iodin. 1ηxviij. 6tis horis. On the 13th, much the same. Nux vomica. On the 17th, some uneasiness in the liver, for which leeches were employed. On the 21st, much the same-pulse 72, and intermitting more frequently on the left than on the right side; an ulcer on the sacrum, from pressure.

On the 23d, Mr. Preston tied the right common carotid artery. He commenced the incision, three inches long, at the thyroid cartilage, and carried it upwards. He found the artery very deep, and tied it. Mr. Preston appears to have made his incision somewhat too high. This artery usually bifurcates at the upper border of the thyroid cartilage, and, therefore, an incision commencing opposite this cartilage, and carried upwards, must have had the common carotid quite at its inferior extremity, instead of near its centre. The common direction for securing the common carotid, in the upper part of its course, is to prolong the incision downwards to near the lower border of the cricoid cartilage.

On the 23d there was slight fever, some cough, and difficulty of swallowing. On the 24th, slight uneasiness in the side of the head, On the 25th rather more cough and uneasiness of the chest. Castor oil and opiated sudorifics. On December 1st, he was put on half diet. On the 4th, he could draw up the leg a little. He had much pain in the paralytic arm. On the 12th, he could walk about with the assistance of a stick. On this day the ligature came away. On the 21st, he "could walk about pretty well with the assistance of a stick." The arm seems to have continued paralysed, and he had much pain in it. On the 22d, the report ends.

Now we really see nothing whatever in this case to recommend the operation. Is it not common, we speak to practical men, is it it not common for patients affected with hemiplegia so mildly as this man was, to recover gradually some use of, not only the lower, but also the upper limb ? To be

sure it is. Hemiplegiacs may be seen creeping on with a stick in any of our public streets, in any of our public hospitals; and yet, after undergoing the pain and the risk of a formidable operation, Mr. Preston's patient is only reported to be "walking pretty well with a stick," his arm continuing paralysed. We venture to say that, with regular cathartics, slight mercurial action, and judicious and consistent counter-irrita. tion, the man would have been as well, if not better, on the 22d of December, where Mr. Preston's report left him.

CASE 2.-Ligature of the Common Carotid Artery for Epilepsy.

Michael Cox, pensioner, æt. 25, had for five years been subject to severe epileptic fits, which generally recurred about once in a fortnight. He was first attacked while on duty at Burmah, after having been much exposed to the sun, and undergone extreme fatigue. Since the first seizure, the fits had generally occurred without assignable cause, but were occasionally induced by intemperance; he was unable to drink as much liquor as European soldiers usually do, a very small quantity producing giddiness, &c. He had frequently been bled, but no other treatment appeared to have been adopted.

Mr. Preston performed the operation on the 4th February, and was obliged to bleed him during its performance, in consequence of a threatening of an attack. On the 24th he was discharged the hospital, the wound being healed, with the exception of the part through which the ligature hung out. the 5th March, the ligatnre came away. The report ends on the 13th April. He had had no fit, allhough he had returned to his work, and had drunk hard.

On

Thus, in this case there was no epileptic fit for upwards of two months from the performance of the operation. If there is none after the expiration of two years, the evidence will assume a satisfactory appearance; but Mr. Preston will excuse us from attaching much importance to it yet. In conclusion, we recommend these cases to our readers' notice. Let them discard all theoretical notions, and look to the facts. Mr. P.

might be utterly wrong in his reasoning, and yet the operation founded on that reasoning might be good. Its value is only to be tested by the cases in which it was performed. If our readers are satisfied with them, it is well

-we are not so.

LXIII.

SURGICAL ANATOMY OF THE ARTERIES, WITH PLATES AND ILLUSTRATIONS. By NATHAN R. SMITH, M.D. Professor of Surgery in the University of Maryland, and one of the Surgeons of the Baltimore Infirmary. Baltimore, 1832.

NOTHING affords us more sincere gratification, than any opportunity of directing the attention of medical men in this country to the labours of their brethren in America. Sprung, we may say, from our loins, speaking the same language, cherishng the same customs, actuated by the same love of political liberty, and displaying the same energy of individual purpose as ourselves, what Englishman but must look with pride upon their growing greatness-feel an interest in their welfare-and offer his best wishes for their success. It may be, that in the changes ominously impending over Europe, Britain, the modern nurse of freedom, science, and the arts, may fall a prey to despotism or to anarchy, and her name be blotted from the list of nations. Should that day arrive, and such a fate has overtaken far mightier empires, we shall live in our offspring stil!, and America will shew what Britain was.

Americans may be assured, that the feeling entertained towards them by the mass of the liberal and enlightened here is one of unmixed good will. We know how important it is, that kindly sentiments should take root and flourish in either land, and we look upon the attempts of fools or knaves to sow disunion with deep indignation and bitter contempt. This spirit pervades our scientific, as well as our political relations, and the paltry scribbler hardly exists, who

would dare insult the public taste by such a tirade against American literature as once was penned in Scotland. The Review which contained that ill-advised criticism has since made ample and honourable amends to America, and few can read its notice of Mrs. Trollope's book, without applauding its manly and liberal tone.

The volume before us is calculated to be highly serviceable to students in surgery, old or young. The object of Mr. Smith, the able author, is to place before his countrymen a native work, which shall satisfy their wants in this department of science. We think he has succeeded, and, as children of a soil where patriotism is not altogether uprooted, we can fully appreciate Mr. Smith's motives, and not only appreciate, but approve.

The work is in quarto, contains 104 pages of close letter-press, and 18 lithographic plates, the arteries in which are coloured. The three concluding plates represent the mode of exposing and tying the carotid, subclavian, brachial, ulnar and radial, inguinal, popliteal and anterior tibial arteries. The fifteen preceding these are devoted to the anatomy of the arterial system. They are copies of the excellent plates of Cloquet, and well executed. In justice, however, to Mr. Knox, our valued friend, the able translator of Cloquet, we must confess that they are inferior to the engravings of the same vessels which he has published, and is selling at a very cheap rate. We think that if Mr. Smith had an opportunity of seeing these engravings, he would candidly admit the inferiority of his own.

Mr. Smith has adopted a method of shewing the absolute size of the arteries which he describes, which appears quite new. Thus, the arteria innominata is marked in this manner:

The diagram is coloured red, and the numbers mark the branches, as well as the spots whence they arise.

In a journal of the nature of ours, it is in

compatible with our plan to notice elementary works at length. We cannot, therefore, analyze or review Mr. Smith's. When we say that it comprises all the information of the day on the subject to which it is devoted, we only render a due tribute of praise to the able and industrious author. But there is one part to which we can allude, and to which we are, indeed, pleased at having the opportunity of alluding. Our readers will see, in another part of this Number, the experiments of Mr. Hawkins on hæmorrhage from arteries. Now it happens that Mr. Smith has been following up the experiments of Dr. Jones, and while Mr. Hawkins has been employed in confirming them, Mr. Smith has been equally profitably occupied in extending them. The process adopted by Nature to arrest bleeding from lacerated arteries was not thoroughly investigated by Dr. Jones. He himself confessed it. Since his time, as before it, a degree of discreditable mysticism has hung over the subject. Mr. Smith has, we think, gone far to dispel it. We cannot compress, with advantage, the experiments and conclusions of Mr. Smith. We, therefore, give them entire; and we do this the more readily, as they will necessarily be new to the majority of our English readers.

Cause of the Spontaneous Cessation of Hæm

orrhage from Lacerated Arteries.

"It is a well known fact, that when a limb is torn from the body, or when organs involving very large arteries are rudely lacerated by obtuse instruments, hemorrhage will often spontaneously cease, even from vessels which always bleed fatally when smoothly cut. Cheselden's case, in which the arm, with the scapula, was torn from the body, will occur to the reader, and perhaps others of a similar character. Such a case fell under my own observation some years since, in the state of Vermont. A young man was caught by the arm in the drum wheel of a factory, and the limb, together with the scapula, was rent from the body. I saw the boy a week after the accident, and witnessed the dressing of the

stump. I was informed that a very small quantity of blood had been lost, although no arteries had been secured. No secondary hemorrhage ever took place, and the patient recovered with surprising facility. The case was treated by the intelligent Professor of Surgery in Dartmouth college, Dr. Mussey, who has given an interesting account of the case in the New England Journal of Medicine. Many similar cases are on record.

Mr. Jones paid but little attention to the subject of lacerated arteries, and does not appear to have performed any experiments particularly for the purpose of comparing such injuries with others, in relation to hemorrhage. In one instance, however, he lacerated the carotid of a horse, and the animal bled to death. In another instance, he did the same, but arrested the bleeding by pressure on the artery. He reports that, in these cases, the internal coat was lacerated in many places, and that there were formed internal coagula, large enough to fill the artery, and that they were attached to it by lymph effused from the fractures in the internal coat. Although he seems to think the internal coagulum a more perfect barrier in this case, yet he does not appear to have ascertained its comparative influence in suppressing hemorrhage, indeed, he says that 'the natural means of suppressing hemorrhage, the peculiar state of the coagulum excepted, were the same in these cases of lacerated arteries, as in ordinary wounds of arteries, but I am not solicitous of pressing this opinion.'

The opinions which have been stated by various surgeons, relative to the spontaneous cessation of hemorrhage from lacerated arteries, are exceedingly vague and contradictory. From this we may infer that the subject has not been thoroughly investigated by experiment. M. Richerand* states that large arteries, when ruptured, become closed (se reserrent) partly in consequence of the chill which they suffer, producing