On the 23d the outward swelling was not apparently diminished, but he said that he had experienced great and immediate relief from the leeches, and the bowels had been freely purged. He was directed to use a myrrh gargle, and to take 3j. of the sulphate of magnesia in iss. of the compound infusion of roses, every eight hours. From this time to the 5th of November there was but little variation in the daily reports, and not much change had occurred in the local symptoms. There was still much swelling of the external fauces on each side, and the same difficulty existed of obtaining a fair view of the tonsils. The patient was still unable to move his tongue, or to separate his jaws to the width of more than half an inch. During this period he had occasionally felt an obscure sensation of throbbing in the throat, and he sometimes complained of pain shooting from the throat into both ears. He was much distressed throughout by the accumulation of viscid and ropy mucus in the fauces, and was almost continually, whilst awake, trying to hawk up the mucus. The same offensive fœtor was present: this was in some degree corrected by a gargle containing the chloruret of lime, in the proportion of 15 grains to the pint of distilled water. The bowels continued freely open; the pulse was a little above 100, and of moderate strength and fulness; the skill cool. Leeches were repeatedly applied to the throat, always with relief to his uneasy sensations there, but never with any decided influence upon the external swelling, which remained hard and somewhat tender. A blister to the left side of the neck, and poultices, had also been applied, and the steam of warm water for some time diligently inhaled. No apparent benefit resulted from these measures. He obtained sleep and ease, after one or two very disturbed and restless nights, by the occasional exhibition, at bed-time, of half a grain of the acetate of morphia. He was able to swallow soft food." On the 5th November, fluctuation being perceptible below the symphysis of the chin, a lancet puncture was made and much fetid pus discharged. On the next day he could open his mouth better, and no ulceration of the tonsils could be detected. On the 7th, at 9, a. m. florid blood to the amount of 12 or 14 ounces was discharged from the mouth, and coagulated into a clot intermixed with some portions of a curdy whitish substance. Infusion of roses with sulphuric acid directed against the back part of the mouth with a syringe arrested the bleeding, and obscure fluctuation being felt externally in the lower part of the throat, a puncture was made and some horribly fetid pus let out. At half-past 9, p.m. the hæmorrhage recurred, and a pint or more of florid blood issued in a small stream. The patient could open his mouth so imperfectly that the fauces could not be "mopped" by a sponge dipped in alumn solution, and the latter was therefore syringed in, when the hæmorrhage ceased. At half-past 4, a. m. of the 10th, two quarts of blood lost, when the patient became faint. Dr. Southey and Mr. Mayo saw the patient when the bleeding ceased, and it was found impossible to ascertain precisely from what part it had proceeded. The opening externally made by the lancet, was surrounded by a gangrenous appearance for a quarter of an inch on every side. It was supposed that the lingual or some branch of it was opened, but on which side or where the consultants could not tell. It was determined therefore not to tie a carotid on a speculation, but to support the strength by bark and quinine. On the 9th the hæmorrhage did not return, but a quantity of dark coagulated blood was discharged from the external opening at the lower part of the throat, between which and the bleeding spot internally, it was obvious a communication must exist. The gangrenous appearance had not spread. On the 10th a small slough separated, and a puriform discharge had taken place from the external wound. On the 11th, he was reported as doing well; pulse 108; skin warm. From this time till the 21st he continued slowly to gain strength, and he was allowed a small quantity of mutton chop. Soon, however, after taking this, which excited coughing when swallowed, the hæmor rhage returned to a trifling degree, and at half-past 11, p. m. it recurred profusely, and did not cease till one or two pints of blood had been lost. At midnight Dr. Watson arrived and met Mr. Mayo in consultation. The patient was languid, chilly, weak, and pale, with a feeble pulse at 144;-a probe introduced into the wound passed towards the left side of the neck, on which the os hyoides could be felt quite denuded and rough. Mr. Joberns now joined the other gentlemen, and it was determined to tie the left carotid artery. In moving the patient for this purpose the hæmorrhage recurred afresh, and although Mr. Mayo was able, by introducing his finger into the wound, to compress the artery between his finger and thumb, the patient sank, became convulsed, and presently expired. The mode of death was by asphyxia and not by syncope. "This conclusion, which the symptoms attending the act of dissolution had not left doubtful, was confirmed upon the examination of the body on the 23d, thirty-seven hours after death. The carotid artery had been previously injected, and its branches were filled with wax these branches were severally traced. It was found that an abscess had existed, which opened internally behind and below the left tonsil, and nearly opposite to the epiglottis; through this outlet the bleeding into the mouth had taken place; the wall of the abscess where it opened internally was very thin. This abscess ran along the left side of the larynx, leaving the os hyoides rough and bare, and terminated externally by the opening already described, and which was made by the lancet. The facial and lingual branches of the carotid arose (as they are known frequently to do) by a common trunk. The lingual branch was traced to the situation of the abscess, where it terminated by an open mouth, about which the matter of the injection was found extravasated; on tracing the same artery beyond the abscess, it was seen to be quite empty. There could be no doubt that this was the artery from which the hæmorrhage had proceeded, and that it had been divided by ulcerations at the place where the abscess was situated. On slitting up the trachea, bronchi, and their branches, they were found to contain coagulated blood; there was a firm clot in the larynx; and another, composed partly of tenacious mucus, in which the coagulum of blood was mixed and entangled, remained at the summit of the fauces. The lungs were large and distended, and blood could be traced through many of the bronchial ramifications into the very air vesicles; this was more the case in some parts of the lungs than in others. A section of those parts where it was most evident presented just such appearances, but smaller and more numerous, as are seen in what Laennec has called 'pulmonary apoplexy.' On the external surface of the lungs, as is frequent in that disease, some well defined spots, of an uniformly dark colour, were visible; upon cutting into these they were found to have been produced by a sanguineous engorgement of the extreme vesicular branches of the air tubes, the boundary depending apparently on the extent of the lobules in the several cases. some parts of the lungs this appearance did not exist-in those parts where it occurred, it was partial; blood had been forced to the extremities of some air tubes, and not of others. The blood in the blood-vessels was fluid, and escaped before the condition of the cavities of the heart, in regard to their contents, was ascertained. No vestige of ulceration could be perceived on either of the tonsils." In We have one remark to make on this interesting and really melancholy case, and that is an expression of something like surprise, at no medicine of astringent or styptic properties having been administered internally. Dr. Watson is well aware of the powers of the acetate of lead in checking hæmatemesis and hæmoptysis, and that too when the hæmorrhage is of a formidable character. Yet the acetate would appear to have been withheld altogether, nay it is not even mentioned, in the present instance. There is another remedy of a different character, which is undoubtedly possessed of considerable powers as an internal astringent, we mean the quack medicine which bears the name of the styptic of the Chevalier Ruspini. What it is we do not know, and as practical men we do not care, but we are certain that it is a valuable agent in arresting hæmorrhage. We have witnessed its powers on several occasions, and we have heard that in a severe case of hæmoptysis which lately occurred at St. George's Hospital, it proved effectual in stopping the discharge, after alura, acids, and the acetate of lead had failed. We are rather surprised that no medicine whatever of this class was exhibited by Dr. Watson in the present case, but we dare say he could offer a satisfactory explanation of the omission, II. SLOUGHING OF THE THROAT-HEMORRHAGE—SUCCESSFUL LIGATURE OF THE CAROTID,* Case. This is detailed by Mr. Luke, of Broad Street Buildings, Surgeon to the London Hospital. The result was more fortunate than in the preceding case. T. B. ætatis 45, a tall, rather muscular man, of sanguineous temperament, captain of a coasting vessel, trading between Cornwall and London, while in the former place, was stung by a wasp on the wrist, which became much inflamed, attended by a pustular eruption around the part. Livid red blotches, about three days after the sting, appear ed on the trunk and extremities, with fever, neither of which created any alarm. With these upon him he went on board his vessel, bound to London. On his passage he had the misfortune to take cold, and was affected with sore throat, requiring confinement to his cabin. In a week he arrived in London, much worse, at which time he was visited by Mr. Gayton. The soreness, however increased, and the difficulty of swallowing was very considerable. He experienced much pain, particularly in the left side, where he was convinced a 'gathering had formed.' His opinion was confirmed on Sunday, Sept. 27th, by the bursting of an abscess, with partial relief. Together with the matter he passed about six ounces of blood by the mouth. He was still sensible of another gathering lower in the throat than the first on the same side; and exhausted as he was by disease, he began to entertain apprehensions for his safety. On Sept 29th he was brought on shore, and took up his residence with a friend in the neighbourhood of Mr. Luke's house. On the eve of this day, the second abscess burst, and shreds of slough came away with the matter: by this he was much relieved, and slept the greater part of the night. "Sept. 30th, three weeks from the commencement of his illness, I was called to him about four o'clock in the morning, in consequence of his having lost a large quantity of blood. He had been awoke by something flowing from his throat, which proved to be blood. When I arrived he had already lost about half a wash-hand basin full of blood; and shortly after he vomited more than two pints of coagula, making altogether between four and five pints lost in about half an hour. I found him in the greatest state of exhaustion; his pulse was scarcely perceptible and very rapid. There was extreme paleness of the lips; the eye sunk in the orbit; a clammy sweat upon the skin; inclination to vomit; and he could not speak louder than in whispers. On attempting to examine the throat, I could see nothing behind the soft palate, to which were adhering shreds of coagula. In a short time he began to revive, and his pulse became more perceptible. Ordered one grain of the acetate of lead, with a quarter of a grain of opium, every two hours; goulard lotion, with equal proportion of spirit, to be applied to the throat; the head to be elevated on a pillow, to be kept perfectly quiet, and abstain from swallowing as much as possible." The faintness passed away, and at 12 o'clock he was much revived. He had an anodyne at night, and, next day, was much improved in appearance; the blotches were clearly those of the pur * Med. Gaz. No. 106. Dec. 12, 1829. pura hæmorrhagica. Ordered to con being drawn to one side exposed the Or tinue as before, with the addition of beef tea. On the third, at 4, p.m. Mr. Luke was again summoned on account of a return of the bleeding, which, however, had ceased before his arrival, the patient having lost, in a quarter of an hour, between three and four pints of blood. He did not appear much exhausted, but complained in a whisper of the left side of the os hyoides, as the seat of pain, and the spot from which he had felt the jet issue. To continue the lead with the addition of half a grain of powdered digitalis, every two hours. "Oct. 4th. At 4 a.m. bleeding again returned. From the account I received I expected to find my patient dying or dead. I found him in the greatest possible state of exhaustion; faint to nausea; the pulse with difficulty to be felt, and very rapid; the breathing laborious, and extreme paleness of the countenance. He was sensible, but apparently indifferent to surrounding objects. He had lost at this bleeding. No hæmorrhage took place till the more than three pints of blood. It seemed almost certain that he must die. After a short time, however, he began to revive; the pulse became more distinct, and breathing more free, but the powers of life were so far reduced that another bleeding would inevitably prove fatal. I therefore determined to tie the carotid artery on the left side, that being the trunk which the circumstances of the case indicated to be the source of the bleeding vessel. To obtain the advantage of day-light, the captain was seated on a chair near a window. Before, however, he was arranged for the operation, his face became convulsed, the pupils of his eyes dilated; his head fell upon his shoulders; and his pulse and respiration ceased. In this state he was hurried back to bed, with the impression upon my mind that he was past hope. A few minutes shewed that he had only fainted, and he soon revived. His head was then laid over a pillow at the foot of the bed, and as the room was dark, I was obliged to proceed by candle-light. An incision of about three inches through the skin, exposed the platysma hyoides, which was divided along the inner border of the sterno-mastoideus muscle. This 7th, when the wound was dressed, and found to adhere for half its extent. He had been feverish during the preceding night, and in the evening he spat up about an ounce and a half of saliva, tinged with blood. Salts and senna immediately-infusion of roses, with gtt. xv. of Tr. Digital, every six hours syrup of poppies for the uneasiness of the throat. He passed a restless night, but was better next day; on examination, a slight fulness only could be seen on the left side; he swallowed with ease. Oct. 11th. Again fever and irritation of the throat; has spat up 2 ounces of blood; bowels confined. To repeat opening draught as occasion requires. He left off the digitalis on the 13th, in consequence of head-ache; the pupil of the left eye dilated, but vision as good as with the right. The bowels required to be kept regular, as fever otherwise ensued and a gum-boil, filled with congealed blood, formed over the incisor teeth. The ligatures were twisted, to expedite their separation. On the 26th October, the twenty-second day from their application, the ligatures were removed. After this day he went down stairs daily, and is now enabled to call on his friends and transact bu siness. He has no unusual sensation, but is weak and soon fatigued. Pulsation has returned in the arteries above the os hyoides, but not in the trunk between this bone and the site of the ligatures. The wound was not quite healed when he left town for the country. III. HÆMORRHAGE FROM AN ULCER IN THE FAUCES-SUCCESSFUL LIGATURE OF THE COMMON CAROTID ARTERY.* Case. J. Webb, æt. 23, was admitted into the Middlesex Hospital on the evening of the 18th of October. Those who brought him stated, that he had suddenly lost a considerable quantity of blood from an ulcer in the fauces; but the hæmorrhage was now stopped, and no apprehension was entertained of its immediate return. At 9 a. m. next morning, the bleeding broke out afresh, but was stopped by the house-surgeon's making pressure on the carotid artery of the affected side. On Mr. Mayo's arrival at the Hospital, he found the patient pale, bloodless, and faint to the last degree. "On examining the fauces, I saw a ragged clot of blood adhering to the right side of the pharynx, while the left tonsil and adjacent surface appeared clear and healthy. I proceeded, therefore, without loss of time, to tie the right common carotid in the middle of the neck. Scarcely a drop of blood flowed from the incision made for this purpose; the pulse in the artery, when it was exposed, was exceedingly feeble; the internal jugular vein lay shrunk and collapsed. After the operation the patient several times fell into an alarming state of faintness; but having taken some brandy, some Spiritus Ammoniæ Aromaticus in water, and some strong and spiced broth, he gradually rallied. A few minutes after the artery was tied, I inquired of this patient whether he saw equally well with both eyes. He closed his eyes alternately, to ascertain the fact; and remarked, that his * Med. and Phys. Journal, Dec. 1829. vision with the right eye was dim and obscure, while he saw distinctly with the left. At this time I could perceive no pulse in the right temporal artery. During the afternoon, distinctness of vision with the right eye returned; at the same time the pulsation of the right facial artery could be felt, though it was much less forcible than that of the left. The patient stated that he felt considerable throbbing in the left side of the head. He dozed much during the day, and slept well the following night. The next morning an attempt was made to learn the history of his indisposition. The account which he then gave, however, and has since repeated, is very imperfect. He states that, for the last four months, he has had a sore throat; that, three months ago, spots broke out upon his chest and legs; that he took pills for these complaints during the space of three weeks, and that his mouth was affected about a fortnight; that, under this treatment, the spots upon his chest went away; that, for the last six weeks, he has taken no medicine, but has used a gargle; and that his throat he has latterly conceived to be getting better. The spots on the legs and thighs have left superficial ulcers, (which, when they were shown for the first time some days after his admission, were healing.) He states that he had a gonorrhea a year ago; sores on the private parts never." On the 20th, the following was the appearance of the throat-the right margin of the uvula and edge of the right side of the soft palate were in a state of ulceration; the right tonsil was entirely destroyed with the posterior arch of the palate; the right side and posterior surface of the pharynx were ulcerated and covered with viscid puriform secretion; and at one part a portion of ashy slough adhered to the surface. Bark and acid with a chloride of lime gargle were prescribed, but no material change taking place, the cinnabar fumigation was directed on the 31st. On the following day the whole of the ulcerated surface was covered with florid granulations. On the 3d Nov. the 15th day after the operation, |