The cases are reported at length, perhaps a little too much so, and we must refer our readers to the originals. We shall content ourselves with noticing a point or two.

Mode of passing the Ligature for Popliteal Aneurism.

In a case in which Mr. Cooper tied the femoral artery, instead of the usual mode, when the artery is exposed, of drawing the saphenous nerve outwards, and then passing the aneurismal needle, armed with the ligature, between the artery and vein, Mr. Cooper adopted the following plan:-immediately on opening the sheath, he passed an aneurismal needle, unarmed, below the whole of its contents, from without to within, and to such a distance, that its curved extremity appeared close to, and on a level with, the upper and inner edge of the artery. There were two branches of nerves in this case, running along the upper surface of the artery: having gently detached these, by means of the blunt edge of a small probe, Mr. Cooper "tilted" them over the exposed end of the aneurismal needle; on which, therefore, remained lying only the artery and vein. Between these, Mr. Cooper now insinuated the end of the probe; and through the space thus made, passed the needle, having removed it cautiously from its former situation. In this situation, the needle was armed by an assistant, and the ligature then secured in the usual way. This method appeared to place the separation of the artery from the nerves and the vein more under the command of the operator, while it caused the least possible disturbance to its cellular attachments.

"I may remark," says Mr. Cooper, "that the position in which the thigh is placed before the operation, is of great importance, in reference to the subsequent passage of the ligature. By the full rotation of the thigh outwards, and by the bending of the leg, all the muscles are relaxed; and by a pillow being placed under the leg, the patient is freed from the apprehension of moving the limb, and thus interfering with the operation. In regard to the direction of the incision necessary to expose the artery, there is no doubt that, as a general rule, the inner edge of the sartorious muscle is the best guide; but frequently in cases, where, from œdema extending over the thigh, this edge cannot be distinguished, a line inay be taken from the centre of Poupart's ligament to the inner side of the patella, and the point at which it is intersected by another line, taken from the anterior superior spinous process of the ilium to the tubercle of the inner condyle of the femur, marks the spot at which the ligature should be applied. The artery, in the case in question, was, as before narrated, seen pulsating on its exposure; but I may state-though to many the remark will be superfluous-that this is far from being uniformly the case. I have seen even the carotid lie so perfectly quiescent after exposure, that a surgeon has thought, from the total absence of pulsation, that it could not be an artery. The whitish-coloured

vessel which is exposed in these operations is only discovered to pulsate by being pressed between the finger and thumb. From the details in Case No. 2, I think that the advantage of passing the needle before it is armed with the ligature, is sufficiently shown. It is necessary to take great care that the point of the needle

be not too sharp; or there will be considerable danger of wounding the vein, whilst the needle is being passed between it and the artery. As to the tightness with which the ligature should be drawn, the surgeon should exercise his discretion, and is best taught by experience. It is frequently stated, that the inner and middle coats of the artery should be felt by the operator to give way under the ligature; but, in a very great majority of cases, I have not been able to detect any thing of the sort. In old persons, where the coats are more likely to be indurated or ossified, a less degree of force will of course be proper. In Cases Nos. 2 and 3, the patients were sensible of an injury at the moment at which the aneurism may be supposed to have originated; and the same remark applies to the following case, No. 4. This is an unusual circumstance."

CASE OF LIGATURE OF THE COMMON CAROTID ARTERY.

The Rev. Mr.

-, aged 34, a native of Barbadoes, having lately arrived from that island, made application to Mr. Cooper, on June 30th, for the cure of an aneurismal tumor on the right side of his face.

The tumor was about the size of a small walnut, deeply imbedded within the substance of the parotid gland, and placed close to the neck of the lower jaw, apparently in the exact situation of the division of the external carotid into the temporal and internal maxillary arteries. Its pulsation was very perceptible to the finger; but not so readily to the sight, from its being covered by the parotid gland. On applying the ear, the peculiar whiz characteristic of aneurisin was distinctly perceptible. By pressure on the common carotid artery, not only this, as well as the pulsation, ceased, but the tumor itself entirely disappeared: the pressure being removed, it most rapidly resumed its former position and appearance. On depression of the lower jaw, the prominence of the tumor was no longer discernible. This state of things had led to no inconvenience whatever to the patient; for he apparently performed every function as naturally as if entirely free from disease.

The tumor had first been noticed accidentally about a twelvemonth previously. Mr. Cooper, as well as Sir B. Brodie and Mr. Liston, recommended an immediate operation. It was performed at half-past two, P.M, on the 7th of July.

An incision, about two inches in length, was made, commencing on a level with the middle of the thyroid cartilage, along the inner side of the sterno-cleidomastoideus muscle, but nearer to the median line than usual. A small superficial artery was divided and secured there was not much venous hæmorrhage. A quantity of cellular tissue being divided, the omo-hyoideus and sterno-hyoideus muscles were exposed; and the artery was felt pulsating at the bottom of the wound, which appeared very deep. The omo-hyoideus being then drawn downwards and inwards by means of an aneurism-needle, and the neck a little relaxed so as to bring the parts better into view, the sheath was cautiously opened, as much to the inner side as possible. The artery was thus exposed. There was no obstruction from any swelling up, or over-lapping of the jugular vein which did not, in fact, present itself to view. An aneurism-needle, unarmed, was then passed beneath the artery; upon which, at the time, a small nerve was lying: and when this had been carefully detached, for a small distance, by means of a blunt silver probe, the needle was armed with the ligature. One end of this was now passed between the upper surface of the artery and the small nerve already spoken of; and this being held securely, the other end was drawn out, together with the aneurism-needle, from beneath the under surface of the vessel. effect produced on the tumor by pressure on the artery was observed; and being found to be satisfactory, the knot was made. The aneurismal sac immediately became flaccid, and yielded entirely to pressure. The wound was closed by two ligatures and adhesive plaster, and the patient placed in bed, with his head raised and neck relaxed.

The

During the operation, he displayed unusual fortitude and submission; neither disturbing the parts about the throat by uttering exclamations, nor offering resistance by struggling. Towards the latter part of the operation, prior to the ligature being put round the artery, he once or twice coughed, with a peculiar barking sound; but this was evidently involuntary.

The right side of the face was cold for that day. Every thing went on well. The ligature did not separate until the 10th of August, when the report goes, that the facial and temporal arteries on the right side of the face appear to be obliterated. There is no perceptible difference in the vessels on the opposite side. The patient mentioned a curious circumstance. He asked if he had been observed to make during the operation, a curious noise, like the bleating of a goat; and said, that it was quite involuntary, and was attended with a curious sensation, as of some one squeezing the lower part of his throat, and also a sudden sense of weight at the stomach and a disturbance in the bowels; so that he was, for a minute or two, afraid he should not be able to retain his fæces. These sensations, together with a general sense. of faintness, occurred at the same instant; and, he said, seemed to depend on Mr. Cooper's pushing aside something with his finger in the wound. No doubt this was the nervus vagus. Mr. Cooper makes a remark on the method of operating, which we think is of importance.

"The patient being placed in the recumbent position, I commenced my incision more to the inner side, or towards the sterno-thyroid muscle, than is usually recommended; with a view, upon opening the sheath, of more immediately exposing the carotid artery; being convinced, from examination, that the usual direction given to cut down along the edge of the sterno-cleido-mastoideus muscle leads rather to the jugular vein than to the common carotid artery. This conviction seems verified by the fact, that most authors, in their description of this operation, speak of its difficulties principally arising from the distention and rising of the jugular vein, a circumstance which not only did not occur in this instance, but the jugular vein was not even brought into view, nor did it in any way interfere with the application of the ligature. The only difficulty I met with, was from the depth at which the vessel was placed from the surface, and of which the appearance on the dead subject offers no criterion. Having made the opening into the sac so much on the inner side for reasons already given, this depth of the vessel offered impediment to the ligature being passed, as usual, from without inwards, but readily permitted its passage from within outwards; a mode which is equally safe, if the forefinger of the operator is placed so as to protect the vein from any injury from the point of the needle. I armed the aneurismal-needle, as I always am in the habit of doing; as the needle passes so much more freely without than with the ligature. The patient seemed not to express pain from the tightening of the ligature at the moment; nor did he afterwards exhibit any indications of suffering from the sudden change of circulation to the brain."

Two cases of EXCISION OF THE ELBOW JOINT are reported. Mr. Cooper observes upon the subject :—

"The operation is indicated when it is evident that nature can only effect a cure by anchylosis, and when at the same time it is plain that the constitution is unequal to endure the prolonged and exhausting irritation attendant upon the exfoliation of bone and protacted discharges. Of course, the more the disease has been confined to the structures of the articulation itself, and the less the bone has suffered, the greater will be the probability of a successful result.I may here remark, that in operating upon the elbow-joint, the inner incision should be carried close to the olecranon process, so as to run no risk of injuring the ulnar nerve, which should be then drawn inwards by a metal retractor. It will not be injured by this step; being protected by the adipose tissue, in which it lies imbedded, and by which, indeed, it is completely hidden. The outer in

cision should be made sufficiently distant from the olecranon to leave the extent of space required for the removal of the diseased parts; which is much facilitated by flexing the elbow-joint after the transverse incision has been made. It has been recommended to divide the triceps muscles from the olecranon preliminarily, in order that, after the latter has been removed, it may be re-united with the ulna; but I do not think that such a union can occur, except by means of adventitious matter, which in all cases is desposited, and which is always sufficiently firm and continuous to maintain the function of the muscle, and protect the posterior part of the new joint.

With respect to the results and general bearings of the operation, I think the principal benefit derived from it is, that it lays open and perfectly exposes the affected tissues, and thus facilitates their separation; in order to effect which, Nature would otherwise have to form sinuses and ulcerations. The advantage gained by it is better estimated by the extent of surface exposed, than by the quantity of bone removed; no more of which should be brought away than is evidently affected by disease, which we shall generally find, is confined to the articulating surfaces."

CONCUSSION OF THE BRAIN is thus alluded to by Mr. Cooper. “When one or both pupils remain contracted, I am induced, from my experience, to consider this as an unfavourable symptom, characterizing lesion of the brain. In those cases in which I have observed contraction of one pupil, and have had an opportunity of making a post-mortem examination, I have invariably found injury of the brain on the side opposite to that of the contracted pupil. The same violence which produces concussion may cause fracture of the base of the scull and although the constitutional treatment employed may subdue the symptoms of concussion, during the progress of reparation, effusion may take place, and evidences of compression supervene. Such a complicated injury, however, is generally denoted by bleeding from the ear, at the time of the accident; and I have known a discharge of serum from the external meatus continue for many days after the accident; and yet these cases ultimately did well. Even when this discharge is profuse, it is to be regarded as a favourable symptom, and therefore should not be checked by astringents. The case above alluded to was treated successfully, by general and local bleeding and calomel."

Case of Steatomatous Tumor removed from the Gluteal Region.

John Baldwin, aged 24, a healthy-looking man, by occupation a labourer, was admitted on May 25th, 1841, under Mr. Cooper, for a large tumor in the gluteal region.

History of Case. He states, that about nine or ten years ago he first discovered a tumor, which he says was then of the size of a pint basin previous to this it had not attracted his attention. However, as it gave him no pain, he made no complaint, till between two and three years ago, when he consulted a country surgeon, and was taken under his care. After having been in a provincial hospital about three weeks, an attempt was made to remove it, by two elliptical incisions: but the surgeon, during the operation, imagining that it had connexion with the pelvic viscera, desisted from the operation, and closed the wound. In about ten weeks afterwards he went home, and there pursued his usual occupation for two years; but perceiving that since the operation the tumor had greatly increased in size, he became anxious on the subject, and presented himself for admission into Guy's Hospital.

Present Appearances.-The tumor now is very large, and perfectly uniform: an impulse is communicated to it by coughing; but the patient states that no

change is produced in it by passing the fæces, or by any alteration in his position; and it does not increase from exercise. No fluctuation can be discovered. Great difference of opinion was entertained, as to the diagnosis of this case by some it was considered as an encysted tumor; by others, as a hernia, escaped through the ischiatic notch. Mr. Cooper wrote to the surgeons concerned in the former operation. The information obtained was not considered as conclusive against a second operation. Mr. Cooper, then, with the concurrence of Messrs. Key and Morgan (the man being extremely anxious to have the tumor removed), determined upon an exploratory operation. On Tuesday, July 28th, the man was placed in the prone position upon the operating table and an incision was made into the tumor, about three inches in length. The several layers, covering the tumor, which lay beneath the glutei muscles, were successively divided; and the nature of the tumor then became apparent. It was, in fact, a large steatoma, and had been covered entirely by the gluteus muscle, which was expanded over it. It was dissected entirely out, and was found connected with the pelvic fascia.

The man endured the operation, which lasted about half an hour, with the greatest fortitude. There was very little hæmorrhage at the time. The wound was closed by two sutures, and the man was put to bed. About four or five hours after, there was some little bleeding, proceeding from several small vessels of these, four were tied, which appeared effectually to restrain it; a sponge was placed in the wound, and it was closed. In the evening of the same day, the sponge was removed, which was followed by slight hæmorrhage; and two more vessels were secured. The patient had vomited once; but had very slight pain, upon pressure over the abdomen. The wound was closed again by sutures, and warm water-dressing applied. An opiate of the morph. hydro-chlor. was ordered. The case did perfectly well.

VII. ACCOUNT OF A PATELLA BROKEN TRANSVERSELY, AND RE-UNITED BY BONE. WITH REMARKS ON THE NATURE AND TREATMENT OF SIMILAR INJURIES.By T. WILKINSON KING.

It would seem that this was an instance of bony union of a transversely fractured patella. The points of Mr. King's remarks are these.

"If the reparative ossification is to be expected mainly on the convexity of the bone, and if this action is regulated by the degree of inflammation, I have to ask, if it be well to subdue the little undue vascularity which quickly follows the injury? And, in order to enforce the reflection, I would almost say, it is desirable to consider the means of exciting and maintaining inflammation on the surface of the patella, rather than strive to obviate the injection, which is too limited, and so superficial as to be peculiarly under the control of topical remedies.

In the absence of experience, I am not inclined to think that abstaining from the application of cold, or even attempts to excite capillary action, will be often found to succeed in uniting the fragments of a patella by bone: but I do consider that the habitual use of cold, in the main, is a needless, mistaken, and pernicious practice; and that some aid is decidedly to be looked for from an opposite method."

"The limb is doubtless to be kept extended and even, as much as may be inclined to form a right angle with the body but when our minds turn to the means by which the upper fragment is to be drawn down and confined, it should, I think, be difficult to avoid the conclusion, that every thing in the shape of a close-fitting circular strap must be, comparatively, inconvenient, inefficient, and obstructive; producing needless pressure, requiring excessive violence, and causing mischievous congestion and unhealthful actions.