(Fig. 1), which I owe to Dr. J. Hughlings Jackson, representing that knife nearly in its full length. The blade was about six inches long, and has been shortened a few lines by being sharpened. There was blood upon it in all its length except about 1 inch. It is, of course, impossible to know exactly what was the greatest injury to the spinal cord in this case. The patient is, I believe, still alive, and if an autopsy were made at this late day (the wound was inflicted in October, 1853-i.e., fifteen years ago), it would not reveal what was the lesion which existed at first. But in the actual state of our knowledge, as regards the physiology and pathology of the spinal cord, it is easy to explain inost, if not all, the details of that case. If something must remain doubtful, it is, at any rate, certain that the nervous centre was wounded in the cervical region, and that its two lateral halves were injured, but the right one very much more than the left. Judging, on the one hand, from the symptoms and on the other hand from the shape of the blade of the knife, from the location of the scar and from the very small angle that would be formed by the line of the scar and a line parallel to the longitudinal axis of the spinal cord the knife must have followed an oblique course from above downwards, from the left to the right, and from behind forwards. It must have divided, or otherwise injured, at least a part of the left side of the spinal cord (the posterior column), and a very large portion of its right half (its grey watter chiefly, but other parts also). Blood effused in the right side of the cord, in the part where the number and size of blood vessels are the greatest-i.e., the grey matter-has produced a pressure which most likely was the cause of the paralysis of the four limbs which existed for some time after the stabbing. The study of this case leads to the following remarks: 1st. There was fever only for a short time. It is so usually in cases of incised or punctured wounds of the spinal cord. 2nd. As usually also in such cases, there have been only a few symptoms of inflammation of the spinal cord. 3rd. The patient fainted away twice: at first when he was stabbed, and again nine days after. His pulse remained very weak for a long time. A syncopal state (or at least a weak pulse) is not rare after an injury to the spinal cord, in the cervical region, especially in cases in which that nervous centre has been completely or almost completely crushed by a broken piece of bone. In experiments on animals, I have ascertained that crushing or dividing suddenly a good part of the cord, in the cervical region, acts on the heart in the same way as similar injuries to the medulla oblongata. This influence ceases to exist when the experiments are made after the division of the par vagum. 4th. A convulsive affection, resembling that which I produce in certain animals by the section of a lateral half of the spinal cord, soon appeared in the patient after his wound. This must be a very rare effect of an injury to the cord in our species, as I have vainly looked for it in all the cases I know of a punctured or incised wound of that organ, and I have only found one other case of injury to the cord in which there were general convul cervical nerve; 2ndly, partly also the fact that some part of the right side of the spinal cord remained uninjured. sions. In this case there was pressure by an exostosis; it was published by Dr. E. Geddings ("North Amer. Arch. of Med. and Surg. Science." Baltimore, 1835, vol. i. p. 110). On the other hand, it is well known that tubercles in the spinal cord usually cause convulsions. If in limbs that are not paralysed, convulsions are very rare, in cases of incised or punctured wounds of the spinal cord, local spasmodic movements, lim-tary movements. I will only say now on this ited to the paralysed limbs, such as F often had, are, on the contrary, almost constant in cases of spinal hemiplegia due to such wounds or to other causes. 5th. The increased sensibility to the various kinds of impression (tonch, tickling, heat and cold, pricking, &c.) on the right lower limb is quite remarkable on account of its intensity and its long duration. I pointed out long ago (in 1849), at the time I introduced in the practice of medicine the use of Weber's means of measuring tactile sensibility, the possibility for that special kind of feeling to become considerably increased, as much, in fact, as we know that sensibility to 9th. It may surprise many persons that the power of voluntary movement in this case returned to a greater extent than the power of feeling. When a nerve is divided, it is well known that sensibility returns much quicker than volunsubject that cases of injury to the spinal cord prove, like that of F, that the reverse takes place for this organ-i.e., that wounds of the spinal cord allow of a much less rapid return of sensibility than of voluntary movements. (To be continued.) Clinical Lecture ON painful impressions can increase. In the case of SIX CASES OF ANEURISM. F-, we find that the tactile sensibility of the big toe and the leg on the right side was three or four times as acute as in health. 6th. In this case, as usual in cases of spinal hemiplegia, there was some anaesthesia, particularly to tactile impressions in the arm and neck on the side where the lower limb and other parts were hyperesthetic. This I have already explained in the beginning of this lecture, and I will only say that this loss of feeling is of importance, in conjunction with the hyperesthesia and paralysis and also the facial and ocular symptoms, all on the same side, to prove that the spinal cord was chiefly injured on that side (the right). 7th. There was in this case a symptom which I did not mention in the list I gave of the symptoms of spinal hemiplegla: there was some degree of hyperæsthesia in both sides of the neck above the limits of anesthesia, and in parts receiving their nerves from the spinal cord above the injury. Mr. G. Busk found, long ago, in a case of complete paraplegia (reported by Dr. W. Budd in the " Medico-Chir. Transactions." 1839, vol. xxii., p. 179), a circular zone of hyperesthesia at the limit of anaesthesia and paralysis. In 1856, an eminent physiologist, Dr. Aug. Waller ("Comptes Rendus de la Société de Biologie," 1856, p. 138) found that in guinea-pigs, in which he had divided transversely the spinal cord, there was a narrow circular zone of hyperesthesia on the upper limit of the anesthesia. I have ascertained that a division of a lateral half of the spinal cord in the cervical region, in rabbits, produces hyperesthesia in the same side in a small zone animated by nerves arising from the cord above the section; and that if the posterior column, with perhaps a very small part of the grey matter of the other side, are also divided transversely at the level of the first operation, there is hyperæsthesia also in a similar zone on this last side. This is most likely what occurred in the case of F. 8th. The persistence of respiratory movements in the side of the principal injury to the spinal cord, as well as in the other, was due-1st, partly to the fact that that nervous centre was wounded below the origins of the phrenic nerve, excepting perhaps the small branch given off by the fifth Delivered at University College Hospital. By JOHN ERIC ERICHSEN, ESQ., F.R.C.S., GENTLEMEN,-I wish to-day to direct your attention to several cases of aneurism that have either been lately in the hospital, or that present some points of interest in connexion with cases which have recently been under our care. The first three of the cases to which I will direct your attention are cases of aneurism of the lower extremity that were mistaken for abscess, and for a time treated as such, their aneurismal character having been overlooked till they came under observation here. By the treatment to which they had been subjected, in consequence of that error of diagnosis, their condition was, I need scarcely say, rendered materially worse; and it became necessary, in two cases at all events, to depart from the treatment of aneurism which is usual under ordinary cir cumstances. CASE 1.-The first case to which I shall direct your attention is that of a man named Samuel H, sixty-four years of age, who was admitted into the hospital August 7th, 1861. The history of the case is, that on July 30th, eight days be fore admission, he tired himself by a walk of about five miles, but he could not recollect any blow or sprain. After the walk he first noticed a lump on his thigh, about the size of a hen's egg. The swelling gradually got larger, and was poulticed. Four days before admission-Aug. 3rdsome discoloration came on in the tumour. He was afterwards seen by a medical man, who ordered a continuation of the poultice, and sent him to the hospital. On admission, a large tumour was observed on the front of the right thigh. This was tense and shining, and of the natural color of the skin. It had a distinct eccentric impulse, and, on applying a stethoscope, the aneurismal bruit could be heard. Above the tumour there was considerable ecchy mosis and fullness, not reaching above Poupart's ligament, and chiefly on the inner part of the thigh. The limb was cold, but not oedematous. On compressing the external iliac artery, the pulsation ceased, and the tumour diminished soinewhat in size; on taking off the pressure, the pulsation returned, and the tumour resumed its former dimensions. It was evidently an aneurism, which was on the point of becoming dif fused, if it had not already become so. There was no alternative but to tie the external iliac artery, which 1 did forthwith in the usual manner and at the usual place. The artery at the spot was perfectly healthy. Without troubling you with the details of the case, the patient went on sufficiently well for the first fortnight; but from the twelfth to the fourteenth day pyæmic symptoms began to develop themselves, and he died, four weeks after the operation, with abscess in the pelvis and general pyæmia. On examination after death, a cylindrical dilatation of the superficial femoral was found, and there was a diffused aneurism, containing a large, hard clot; the aperture in the artery communicating with the diffused aneurism was small in size, about that of a threepenny-piece. It would appear, then, that it was an aneurism that was rather suddenly formed-a diffused aneurism,-supervening upon a cylindrical dilatation of the superficial femoral, forming through a small aperture, and without any distinct circumscribed aneurism preceding it. CASE 2.-The second case is also an aneurism of the groin, which was mistaken for an abscess, treated as an abscess by being poulticed, and eventually punctured by a surgeon, and then brought to the hospital. The case is as follows: William S, aged twenty-nine, admitted into the hospital Sept. 11th, 1867. For about eight months before admission he had noticed a tumour in the upper part of the thigh. When first observed it was as big as a walnut. It was painful, and seemed to throb or pulsate distinctly. He remembers no blow or strain in the situation of the tumour. Under the direction of a medical man it was poulticed for some months, and the skin beginning to get discolored, on the morning of the day of his admission the surgeon introduced a lancet into the tumour, on the supposition that matter was present. On admission, a tumour was found, about the size of the clenched fist, immediately below Poupart's ligament, in the upper part of the left thigh. It pulsated freely, and the conical top of the tumour was ecchymosed, and presented the mark of a recent puncture. There was no hæmorrhage. The patient was somewhat faint and excited, but otherwise well. In a consultation between Mr. Heath and myself, it was agreed that the best thing would be to open up the aneurism completely, and tie the artery above and below it. This was accordingly done by Mr. Heath, who, as I was not on duty at the time, would have the subsequent charge of the case. Lister's abdominal tourniquet was applied to the abdominal aorta, so as to completely arrest the pulsation in the tumour. Mr. Heath then made a puncture in the upper part of the sac, and immediately introduced his finger, which he applied to the opening that could be felt in the artery. The sac was then slit up on a director, the coagula turned out, and the interior sponged. A double ligature was next passed round the artery, above and below the opening into the sac. This was a work of some difficulty for reasons which I shall immediately mention; but at last, by introducing a large probe into the open mouth of the artery, Mr. Heath passed the ligatures round the vessel, and all danger of hæmorrhage was put a stop to. The patient rallied fairly well from the operation, and with the exception of slight restlessness during the first few days, he went on very well till the 20th, the wound suppurating very freely. On that date-nine days after the operationsecondary hæmorrhage came on to a small extent, which was arrested by the pressure of a pad. Slight hæmorrhage occurred again early the next morning (21st), also easily arrested by a pad and spica bandage, Lister's tourniquet being kept on the aorta, ready for application. The patient's pulse became softer and more frequent, and the wound continued to suppurate freely. Early the next morning there was again free oozing, which soon became more copious. Compressors having been applied to the aorta and femoral above the wound, the dressings were removed by Mr. Berkely Hill. It was found that the ligature, which had included a quantity of thickened tissue connected with the walls of the vessel, had sloughed through this, and so had ceased to compress the artery itself, which was quite patent. Free hæmorrhage took place to about twelve ounces, ultimately arrested by another ligature round the vessel. No further loss of blood took place, but the patient, who had become very anæmic, rapidly sank, and died about midday, eleven days after the operation. CASE 3.-The third case is one of popliteal aneurism mistaken for abscess. James Laged thirty-seven, brewer's drayman, was admitted April 15th, 1862. He stated that nine or ten weeks before admission he first observed the right ham to be somewhat swollen. The swelling spread down the leg, but did not at that time involve the foot. He noticed no particular difference between the two feet. About a fortnight after first noticing it he assisted his fellowlaborers to lift a heavy cask of beer; and about the middle of the next day he felt a sudden pain in the ham, with a peculiar numbness. On the Tuesday he applied at an hospital, which need not be mentioned, and received some medicine and was told to keep quiet. The next day he was admitted into a public institution, where the swelling in the ham was poulticed. It continued to be poulticed till the day before his admission here, when a puncture was made into the swelling. Hemorrhage followed the puncture, and the swelling increased in size. The following day hæmorrhage returned, and two pints of blood were lost. A tourniquet arrested the bleeding, and he was brought to this hospital. Soon after his admission he was in a very depressed state, with an obvious popliteal aneurism. In the centre of this was an incision, through which a mass of coagula protruded. I immediately amputated the limb above the knee by double lateral flaps, and the patient did perfectly well. On examining the limb, it was found to have been a popliteal aneurism, which had become diffused, and had been opened in the way just mentioned. Without going further into the details of these cases, you will see that here were three cases, two of aneurism of the groin and one of aneurism of the ham, all of which were mistaken for abscess before admission into the hospital, two of which were actually punctured by a surgeon, and two eventually terminated fatally, no doubt in great measure owing to this mistake having been committed; and in the third it necessitated amputation of the limb, instead of the aneurism being treated by compression or by ligature of the femoral artery. Now before we proceed to discuss more fully these cases, which I have very briefly related to you, I may say a word or two about this point of diagnosis between aneurism and abscess. In the majority of cases of aneurism nothing is easier than to make the diagnosis. When an aneurism is thoroughly formed, is pulsating eccentrically, and has a distinct bruit; when the pulsation and the bruit are arrested by compression of the artery leading to the tumour; when the size of the tumour diminishes when the vessel leading to it is compressed; when the pulsation and bruit both return on the pressure being removed; when the tumour increases in size on the pressure being removed; when that increase in size is evidently eccentric, and the pulsation eccentric from the interior of the tumour-a dilatation as well as a pulsation,-there can never be any serious difficulty in distinguishing an aneurism from everything else. But when an aneurism has become diffused; when the pulsation in it is becoming very feeble; when the bruit in it has become obscure; when the tissues that are infiltrated with the blood that has been effused feel somewhat sodden and brawny; when there is perhaps, here and there, an indistinct feeling of fluctuation, one can understand that, unless care is taken in investigating the early history of the case, and unless care is taken in making a minute, prolonged, and what may be called a skilled manual examination of the tumonr, it may possibly, in an off-hand manner, be supposed to be an abscess, a chronic abscess, in the region in which it occurs. But when you find a tumour presenting more or less of the characters that I have just described occurring in a situation in which aneurisms are likely to occur as the groin, the ham, or the axilla,-it is only proper to institute a very careful examination; and if you make such an examination, with the hand to the tumour, with the ear to the tumour, and with the finger applied to the artery above the tumour so as to control the flow of blood through it, there is very little danger indeed of your falling into the most serious and probably fatal error of mistaking an aneurism for an abscess. Now, with regard to the treatment that was adopted in these three cases, you will observe that in each case we had recourse to a different method of treatment. In the first case the artery leading to the tumour was tied. In the second case the tumour was laid open; the old operation for aneurism was performed. In the third case the limb was amputated. Why were three different methods of treatment adopted in these three cases? For this reason. Each of the cases differed from the others in very important particulars, and they only resembled one another in all having been mistaken for abscess. In the first case, the case of aneurism in the upper part of the thigh occurring rather rapidly in an old man, the tumour fortunately had not been punctured; it had only been poulticed; and the aneurism was sufficiently below Pouparts ligament to admit of the ligature of the external iliac artery above Pouparts ligament with every prospect of success; and therefore, although the aneurism had been mistaken for abscess, yet the ultimate and fatal termination of that mistake, the puncture of the sac, had not actually occurred, and there was therefore no reason whatever to depart from the usual treatment of such casesviz., the performance of the Hunterian operation, the ligature of the artery at a distance above the sac, and that was accordingly done. The patient died some weeks after the operation, not directly from the operation itself, not from secondary hæmorrhage at the site of the ligature, not from suppuration of the tumour, not from anything connected therefore with the aneurism or the ligature, but from one of those more remote conditions that are common to all operations in surgery-viz., the development of pyæmia. So far, therefore, as the condition of the artery was concerned, there was no reason to depart in this case from the ordinary treatment of aneurism. So far as the result of the operation was concerned, there was no reason to regret the operation that was performed, inasmuch as the operation itself was successful, the patient dying of an intercurrent constitutional condition that might be looked upon as an accidental complication. In the second case, the one that occurred last autumn, also an aneurism of the upper part of the thigh mistaken for an abscess, a very different. method of treatment was adopted; for after a consultation between Mr. Heath and myself, it was agreed that we should lay open the sacshould perform the old operation for aneurism. Now why was a different method of treatment adopted in this case from that which I had recourse to in the first, although the situation of the tumour in the two cases was very similar? For this reason, that the aneurism had already been punctured, and blood had escaped from it. I think you may lay it down as a rule in surgery, that when an aneurismal tumour has once been punctured, or in any way opened, whether accidentally or purposely, it is useless to ligature the artery leading to the sac; that you must lay open the sac, and ligature the artery on either side of the aperture in it. This, gentlemen, is a very easy thing to advise to be done, and it sounds a very easy thing to do; but I can assure you that there are very few operations in surgery that are more difficult than, in many cases, is this operation of laying open the aneurismal sac, sponging out its contents, and ligaturing the artery on either side of the opening communicating with the sac. Any surgeon who has had occasion, as I have had, to perform the operation which Mr. Heath performed in this case, will agree with me that it is by no means an easy one in a very great number of cases, where you have to do with a large aneurism full of coagulum, connected with an important vessel, and deeply seated. Now in this operation there is one great danger and several difficulties. I will mention this danger and these difficulties, and I will tell you, so far as I can from my own experience, the best mode of overcoming them. The grea danger in this opera the pressure to which they have been subjected in consequence of the effusion of plastic matter. So you have a large cavity with an opening at the bottom of it, the opening leading to the artery somewhere or other, but the position of that artery more or less disturbed, more or less masked and obscured by these masses of coagulum, by this plastic infiltration, by this thickening and cohesion of the tissues to one another around it. tion is that the patient may die of hæmorrhage before you can get the ligature round the artery. You lay open the sac, and, unless you are very careful, you may get a rush of arterial blood that you cannot arrest, and that may give rise to sudden syncope and death in the course of a very few seconds or minutes if you have to deal with a large artery. The first thing, therefore, in all these cases is to compress the artery above the aneurismal tumour. That, fortunately, you can The next thing is to pass the ligature around now do in all cases of aneurism in the lower ex- the artery. Now the artery does not lie exposed tremity. If the aneurism is anywhere low in the in this sac: quite the contrary. You have to thigh, you can compress the femoral artery as it scrape or to dissect or to cut through the postepasses over the pubes; while if you have to do with rior wall of this sac, which always overlies the an aneurism in the upper part of the thigh, by means artery. That constitutes the great difficulty of of Lister's abdominal tourniquet, which we em- the operation-to open up this posterior wall in a ployed in this case, you can compress the abdomi- proper direction, and to get the aneurism-needle nal aorta, and control the bleeding. Indeed, if I round the part without wounding the contiguous mistakenot, Lister's abdominal tourniquet was in- vein, or transfixing the artery, or doing damage vented in order to control the circulation through to the neighboring parts. The best way of doing the abdominal aorta in a case of this kind which that undoubtedly is the plan we adopted eventuwas operated on by Mr. Syme, of Edinburgh. ally in this case, and which has been adopted But when you have to do with aneurism of this with advantage in similar cases by other surgeons description-diffused aneurisms that have been-viz., to introduce a large steel probe or a meopened, or in which it becomes necessary to perform the old operation of laying open the aneurismal sac-in the upper part of the body, at the root of the neck, or in the axilla, you cannot compress the artery leading to the tumour, and therefore you have a condition of very great difficulty and of very great danger In these cases the proper plan undoubtedly is to adopt the very practical recommendation that has been made by Mr. Syme, and put in practice by him-namely, to make a small opening into the tumour, an opening just sufficient to enable you to insinuate your fingers, and so to work your whole hand gradually into the tumour in that way, so that the entrance of the hand may plug up the opening in the sac; to feel with your fingers for the opening into the artery, and to get your fingers against that, so as to restrain the flow of blood from it, before the rest of the sac is laid open, and not to lay open the sac until the fingers are fairly pressed upon and into the opening in the artery, and so to restrain the flow of blood from that opening whilst the rest of the sac is being freely laid open. In that way, then, you overcome the great danger in these cases, the danger of death from hemorrhage during the operation which would infallibly occur if you were to lay open the sac freely without adopting one or both of these precautions. Now for the difficulties of the operation. The hæmorrhage having been completely arrested, by compression of the artery above the tumour, or by pressure of the fingers at the opening leading into the tumour, you lay it open freely and completely, turn out the coagula, and sponge away any dark or fluid blood that may be there. You then open the interior of the aneurism. But what is that interior? It is not the interior of a smooth sac, but it is a large ragged cavity, with masses of coagulum or solid fibrin sticking to it in different directions, with the remains perhaps of an old sacculated aneurism at the bottom, with a quantity of plastic matter infiltrating the tissues around it, with the anatomical relation of the parts utterly and completely disturbed and destroyed by the pressure of the tumour and the infiltration with coagulated blood, with great thickening and solidification of parts around from tallic bougie into the opening into the artery, and We now come to the third case, that of popliteal aneurism, in which I amputated the thigh. Why did I treat it in that manner? Well, in this case, the choice lay between laying open the aneurismal tumour (the old operation) and amputation. I preferred amputation because the man was in a very exhausted state from the loss of blood which had occurred in consequence of the puncture of the tumour; and I was afraid if I endeavored to lay open the aneurismal tumour, that we should get more or less hæmorrhage during the operation, that the operation would be a prolonged one, that there would be profuse suppuration, and I thought that the patient would stand a much greater chance if the limb were amputated. Accordingly I had recourse to amputation here, and the patient made a satisfactory recovery. There was no drawback of any kind. Thus, then, you will have seen that three cases of aneurism mistaken for abscess required different methods of treatment, and I have described to you the reasons which led to the adoption of the different operations in each case. |