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P.S.—I would compare the process of coagulation in an aneurism to those instances of crystallization which occur when the slightest disturbance of the conditions of solution determines the immediate solidification of dissolved matter, where a sudden movement, a rough surface, &c., are enough to induce the formation of crystals—vice versa, the completely arrested current seems to assume the solid form at once and decidedly as soon as the conditions of the solution of fibrin are disturbed : we are still uncertain as to the exact nature of those conditions, but we can disturb them in an aneurism by the compression treatment.- Medical Times.
LIGATION OF THE THE SUBCLAVIAN.
By Charles F. Bullen, M.D., formerly Apothecary to the Montreal General
Hospital, Acting Assistant Surgeon U. S. Army. (Extracted from Dr. A. R. Becker's Fiske Fund Prize Essay on Gun-shot wounds.)
Adam Grignun, private, Co. D. 7th Conn. Vols., aged 21, was wounded before Petersburg June 9th, 1864, by a rifle-ball, which fractured the acromion end of the right clavicle, passed beneath the scapula and out below its lower border. On admision to the Hospital, three days after the injury, some fragments of bone were removed. The wound looked healthy, and continued discharging laudable pus and granulating till June 28th, 11 A.M., when secondary hæmorrhage occurred. He then lost about six ounces of blood before it was checked by pressure.
June 29, 10, A.M.—Hæmorrhage again occurred, more severely than before, losing from fourteen to sixteen ounces of blood. The cavity of the wound was by this time much enlarged. The hæmorrhage was again apparently checked by plugging the wound with lint saturated with perchloride of iron. But in two hours the whole of the tissues between the wound and the neck where engorged with blood, the swelling rapidly increasing, thus showing that he was still bleeding. After consultation, it was decided to stimulate freely and give narcotics to relieve pain, and let him remain till morning.
June 30th, 11, A.M., being in about the same condition--the tongue dry and glazed, pulse 120 and very weak, and with the engorgement gradually increasing--the subclavian was ligated successfully in the first part of its course.
Coagula were then removed from the cavity of the wound, and it was syringed out with ice-water, no bleeding being apparent. Immediately after the operation he rallied; the tongue became moist; pulse at left wrist 110, at right wrist none. The temperature of both arms was the same, and continued so throughout.
July 1st, 10, A.M.-- Left pulse 110, right barely perceptible. Patient in good spirits ; takes nourishment freely, but complains of pain in swallowing. 10, P.M.-Left pulse 112, right same as in the morning. Ordered R. Liq. amon. acetat., 3 i.; tinct. aconit. M v.; to be taken every four hours.
2d.-Left pulse 110, right increasing a little in strength ; no pain in swallowing, and improving.
3d.—Left pulse 108, right same as yesterday.
4th-Left pulse 100, right same as yesterday ; takes nourishment freely, and both wounds looking healthy and well.
5th—Left pulse 96, right same as yesterday.
7th-Left pulse 90, right same as yesterday. Complains of pain in the region of the heart, but no abnormal sounds heard.
8th-Left pulse 120, right same as before ; tongue dry and glazed. At 9, P.M., he had a rigor.
9th, 7, A.M.-A slight hæmorrhage from the point where the artery was ligated. The wound was plugged and pressure employed. At 10, A.M., the hæmorrhage recurred more severely than before. From this time until evening there were repeated hæmorrhages ; the patient gradually sapk, and died at 8, P.M., remaining sensible to the last.
Autopsy.-- Both the suprascapular and posterior scapular arteries wers found to be in a sloughing condition, which was apparently the cause of the last hærmorrhages. The subclavian was ligated about half an inch from its origin. The ligature had come away, and the coats of the artery were ulcerated through. On the cardiac side a slight clot had formed, but on the distal side the clot was larger, firmer, and more perfectly organized.
This case is exceedingly interesting, both on account of the infrequency of the operation and because the man lived so long after its performance-nine days and eight hours; and at one time it really seemed as if he would recover.
PERFORATING ULCER OF THE STOMACY. Dr. Hayden exhibited, before the Pathological Society of Dublin, a specimen of perforating ulcer of the stomach. The subject was a man, æt. 34, a patient in the Mater Misericordiæ Hospital. About two years ago he for the first time complained of uneasiness in the stomach, acid eructations, and uneasiness after taking food. These sensations occurred about two hours after meals, and generally ended in vomiting, which completely relieved him of the sensations. He went on in this state for about two years, during which time, however, the uneasiness
became converted into absolute pain. He was continually attacked with vomiting, and on three or four occasions threw up a quantity of dark grumous matter, evidently consisting of altered blood. He likewise passed a quantity of this matter from the bowels. He was admitted into the hospital on the 13th February. His appearance was then pale and anæmic; his pulse was quick, but in other respects normal. His tongue was clean. There was pain about two hours after taking food, whether liquid or solid, and acid eructations. The bowels were constipated and distended with flatus. There was no tenderness over the region of the stomach, and no evidence of disease of the organ could be detected by external examination. The pain after food extended to the lower dorsal spine; it was not of a very aggravated character, being very little more than uneasiness. On the morning subsequent to his admission, I found that during the night he had vomited a quantity of dark
grumous matter, it was a good example of what is termed “coffeegrounds vomit;" it was manifestly altered blood, perhaps three or four
I accordingly made up my mind that I had to deal with one of two things—either some form of latent aneurism finding an entrance into the stomach, or (still more probable) gastric ulcer. I treated the man on this assumption. On the following day, in my absence, he was attacked while at dinner with a severe excruciating pain in the abdomen. At four p. m., Dr. Cruise, who happened to be in the hospital at the time, saw him and prescribed for him, but he obtained very little relief. He took a dose or two of morphia, and continued to suffer till nine p.m., when he died exhausted. I should add, that though exceedingly avamic, he was not at all wasted, and had a very good coating of flesh.
Post-mortem Examination. On opening the abdomen we found a quantity of dark coffee-grounds matter diffused through the abdominal cavity. There was not a trace of inflammatory action—no peritonitis. On raising the liver from the surface of the stomach we found a good example of perforating ulcer, the aperture being exceedingly well defined, larger than a large goose quill, and perfectly circular. The stomach was much thickened in the neighbourhood of the opening. The edges of the aperture and portions of the surface in the vicinity were discoloured, manifestly with bile, the gall bladder lying immediately over the opening. In the neighbourhood of the perforation we found a quantity of exuded lymph in flakes on the surface of the stomach. On opening the stomach we found an ulcer in the immediate neighbourhood of the pylorus on the interior wall. On the inner surface this ulcer was about one inch in diameter. Immediately behind this, and upon the posterior wall of the stomach, we found a second ulcer of much greater magnitude, being 2.) inches in its long and about 14 inches in its short diameter. The floor of this latter ulcer was formed by the adherent pancreas which was closely attached to the posterior wall of the stomach. Another ulcer, smaller than either of the former, was in the immediate neighbourhood of the cardiac opening of the stomach. This ulcer had not penetrated the walls of the stomach; it was about the size of a large pea, and its edges well defined. There was no evidence of inflammatory action around it; it was just as if the mucous membrane had been punched out. In front of the ulcer which passed through th. walls of the stomach we, on closer examination, detected an old cicatrised ulcer, which penetrated only through the mucous membrane.
This case possesses interest in one or two points.-—1st, as affording a satisfactory explanation of the absence of epigastric tenderness on pres
The right lobe of the liver lay over the perforation, and hence there was no tenderness evinced on pressure, as the liver lay between the hand of the examiner and the diseased portion of the stomach. 2nd. The immediate cause of death was not exactly perforation, but the detachment of a very frail adhesion between the fundus of the gall bladder and the peritoneal surface of the stomach. On the surface of the gall bladder there was a layer of lymph corresponding to the portion of the stomach it lay in contact with. It is probable the lymph, which served as a bond of cohesion between the gall bladder and the stomach, was of a frail character, owing to it being mixed with bile by transudation from the gall bladder. The presence of this lymph in the immediate neighbourhood of the opening, and there only, further tends to confirm this view. 3rd. The case is of interest in respect to the condition of the patient, who, as already stated, was not at all emaciated, although the disease had lasted for two years. Of this we have an explanation in the fact that though the pyloric extremity was thus diseased, the remaining parts of the organ were in a tolerably healthy state, and in this way the man, who retained the food for some time, was capable of absorbing and appropriating various aliments at all periods since the commencement of his illness.- Medical Press.
MONTREAL, JULY, 1865.
A LUNATIC ASYLUM.
We have not yet received a copy of the report of the Board of Inspec. tors of Asylums, Prisons, &c.; but, from what we have seen in the daily press, we are convinced that this report demonstrates most fully the necessity which exists of constructing a proper building in this section of the Province, for the care and treatment of those affected with mental diseases.
It appears to us, the Government are bound either to entertain the report and act upon it with promptitude, or they must, by continued neglect of the reiterated necessity, treat the report of their commissioners with silent contempt,-a course of action which, in any other country, would bring about the resignation of the entire body of those constituting the board.
The thrice told tale of over-crowding, which has been dinned into the governmental ears, by doctors, journalists, and the entire press, comes at last from those appointed by the executive to visit and report on the sanitary and other conditions of these institutions. We say, at last, for it does seem that the necessity has become too glaring to be over-looked, even by well-paid inspectors. We speak thus strongly because it will be found, on reference to the report for the year 1863, a controversy started between one of the Board of Inspectors and Dr. Workman of the Toronto Asylum on this very subject. The doctor states that his asylum is already too full, but, in spite of his remonstrance, we find Mr. Inspector Taché recommending the addition of fifty extra beds in the asylum, which, according to Dr. Workman, is, or was at the date of his letter, July 17, 1863, "full enough, and that the beds cannot be increased without risk to the health and lives of the present inmates.” How the case stands at the present date in Toronto, we are unable to say, not having seen the report. But, in reference to the Beauport Asylum, it does appear that they are in a sad state for want of space, with the expectation, or rather the daily necessity, of extra room. But to go to figures. We