1. GLASGOW ROYAL INFIRMARY.

SPINAL DISEASE.

Mr. Auchincloss, Surgeon to the Glasgow Royal Infirmary, has published a case in the first number of our Glasgow cotemporary, which he considers to be valuable, as tending to confirm the opinion first suggested by Mr. Brodie, regarding the difference in the nature and treatment of ulceration confined to the intervertebral substance-and ulceration affecting the cancellous structure of the bone. The following case is offered in illustration.

Case. "7th Sept. James Graham, by trade a gardener, aged forty-five, of rather a spare habit, though healthy, met with an accident five weeks ago, the nature of which was as follows:--While standing on a bench, four feet high, with his arms extended in the act of pulling fruit from a tree, he happened to lose his balance, when, to support himself, he caught hold of one of the branches. After swinging a few seconds, the branch broke, and he alighted perpendicularly on the ground, a height of about two and a half feet. He felt little uneasiness at the time of the fall, which occurred at three o'clock, P. M. and, accordingly continued at his employment during the remainder of working hours. Since the following morning, he has complained of a sense of tightness around the lower part of the chest, with pain in the right hypochondrium, particularly aggravated by motion, though not in the least impeding full inspiration. Pulse 76, weak; bowels moderate; other functions natural. Was bled from the arm three different times by a medical gentleman, whose advice he requested at the time; and has had VOL. VIII. No. 16,

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two blisters applied to the region of the liver, but without producing any good effect.

"The impression on my mind, from a very cursory examination of his ailments on first seeing him, was that the liver, or muscles in its vicinity and about the back, had sustained some degree of straining by the fall. He was again blistered and otherwise treated as for simple injury of those parts, during the first fortnight. On one occasion, he experienced much relief from cupping near the spine on the the right side, but was in no other respect benefited by the treatment.

"The symptoms of his complaint had become now much more apparent, and, on a more careful inquiry being made, were found to be connected with slight curvature of the sixth, seventh, and eighth dorsal vertebræ. The convexity of the curve was turned outwards, and he seemed to suffer but little uneasiness in the part ing symptoms were when firmly pressed upon. The followthen noticed.Numbness of the lower extremities, with much bodily weakness and inability to sit, for even a few minutes in the erect tiveness, and some swelling of the abposture; scanty secretion of urine, cosdomen; constriction and pain around the lower part of the thorax, most acute on the right side; loss of appetite, thirst, and a weak accelerated pulse.

"On the following day, the caustic potash was applied on each side of the protuberance, but without occasioning relief at the time, or on the sloughs separating, four days after. He became daily weaker, and expired on the 21st of Oc tober, exactly eleven weeks and two days from the date of his falling from the tree. For some time previous to death, his belly

was tympanitic and swollen to a great size; and he was much troubled with feelings of numbness in the left shoulder.

"Inspection-The pleura were extensively adherent on both sides. The lungs, with the exception of the posterior part of the right, which was collapsed, exhibited their natural appearance and structure. There was an abscess, containing about five ounces of curdy-looking purulent matter, in the posterior mediastinum. This was situated in front of the sixth, seventh, and eighth dorsal vertebræ, and encroached considerably on the right side of the chest. The body of the seventh vertebra was almost wholly destroyed by ulceration; but this had proeeeded much farther on the right than the left side. The bodies of the other two vertebræ were also partially absorbed. In no part, however, had the disease ex. tended to any of the intervertebral cartilages, all of which remained in an entire state. Notwithstanding the extent of destruction, the osseous structure both of the diseased vertebræ and of those in the neighbourhood, was of its natural hardness and colour. The liver was healthy, as also the other abdominal viscera."

There are very few cases of this kind on record. Mr. Brodie has offered two, in his treatise on diseases of the joints.

"In treating of this disease, with the view of distinguishing it from a similar affection originating in the intervertebral substance, Mr. Brodie regrets that there should exist no better criterion than the

following, to direct us in our judgment. In ulceration confined to the cartilage, he remarks, the patient is benefitted almost immediately on the issues being made, or, at least, feels himself uniformly easier after each application of the caustic; but this does not take place in the other species, for in it issues of every sort constantly fail in affording even the slightest relief. Moreover, he supposes that the form of disease which begins in the substance of the bone, is generally rapid in its progress, being more immediately followed by suppuration than that which commences in the intervertebral substance; and that, in consequence, destruction of the contiguous vertebræ takes place to a much greater extent in the one species of disease than in the other. 'But farther than this,' says that excel

"It affords me much pleasure to be able thus far to bear testimony to the truth of Mr. Brodie's statements, respecting the diagnosis of these two affections. From a knowledge of the facts adduced by him, and to which I have now referred, I was enabled, in the present instance, to form an opinion as to the true nature of the disease, which was afterwards fully justified by the dissection. The case certainly affords a very striking illustration of the great rapidity of the disease, and of the utter inefficiency of caustic issues as a means of cure."

CASE OF COMPOUND FRACTURE.*

A great improvement has been effected of late in the treatment of compound fractures in this Infirmary by Dr. Young, in consequence of the continuation of the dressings, the method of treatment recommended by Baron Larrey.

John Durrough, æt. 32, labourer, was admitted into the Infirmary, July 16th, 1827, under the care of Dr. Young, having received a few hours previously a compound fracture of the left leg, and inferior maxillary bone. Inferior extremity of tibia is fractured transversely, about an inch above ancle joint-fibula is fractured obliquely immediately above malleolusancle joint is laid open on its outside an terior and posterior to extensor tendons, the ligaments on inside of joint are not injured. There is a wound of the integuments, extending from external malleolus, obliquely upwards and backwards, and continued round to inner malleolus, communicating with a wound which had been inflicted on the inside of ancle. Along the outside of joint there are many bony particles, which have been detached

from the extremities of tibia and fibula.

The ancle joint is but very slightly displaced, and the large arteries and all the tendons around the joint have escaped and are covered by the fascia. Lower jaw is fractured obliquely a little to right

* Mr. Plymsoll's Clinical Reports Glasgow Infirmary.

side of symphysis--there is great tendency to displacement, as the fractured extremities separate from each other, except when the mouth is kept open. Under chin there is a wound an inch long, which communicates with fracture. A consultation was immediately held on this case, and from the extensive and complicated nature of the injury and its proximity to the joint and the joint itself having been involved, immediate amputation of the limb was determined on. The patient, however, would not undergo the operation. Pledgets of oiled caddis were applied to wounds, and retained by adhesive plaster, and the leg was then put up in splints. 27th, Splints and dressings have been removed to day. For the first time wounds have a healthy granulating appearance, with a little healthy pus on them. No redness, pain or tention of surrounding integuments--splints and dressings continued. August 2nd, Splints and dressings have been again removedwounds continue to improve---limb can be freely moved about for the application of bandages. 23rd, Has had rigors-erysipelatous redness on fore-part of ancle, and absorbent vessels about knee-joint are inflamed-leeches were applied with great effect and pain and fever have diminished. Scarcely any constitutional derangement occurred subsequently. September 10th, Wound at outer ancle healing rapidly-that at inner ancle has cicatrized-bones have re-united-straps and bandage. October 6th, Dismissed cured.

Case of Ununited Fracture cured by Pressure.

Daniel M'Vey, æt. 44, porter, was admitted September 21st, 1827, under the care of Dr. Maclachlan. He had a few hours previously, whilst in a state of intoxication, come in contact with the leader of a stage coach which was driving on rapidly, by which he was thrown down, and the coach passed over him, inflicting an oblique fracture of the left humerus. There was a good deal of swelling around the fracture, and the broken ends of the bone rode to a considerable extent. The arm was put in splints, which were removed at the usual time, but no union had taken place. The splints were reapplied, but still without effect. Dr. Maclachlan having retired from the

hospital, the case was consigned to the charge of Dr. Anderson, who had recourse to pressure. Linen compresses were laid over the fractured ends of the bone, and splints and bandages were afterwards applied. A decided improvement was successively observed, in the course of the subsequent examinations, and by the 1st of January, 1828, the cure was complete.

2. BARTHOLOMEW'S HOSPITAL.

ERYSIPELAS TREATED BY INCISIONS.

Two cases, treated in this way, have lately been reported in the MEDICAL and PHYSICAL JOURNAL, from Bartholomew's Hospital, one of which is said to have been lost by subsequent hæmorrhage, in consequence of the neglect of the nurse. The first case was that of a man, aged 70 years, who came under the care of Mr. Lawrence, for phlegmonous erysipelas of the right leg and thigh, extending to the groin. Three incisions were made-one in the thigh, two inches long-another, three inches long in the calf of the legand a third, smaller than either, just below the last. Much purulent matter escaped, and large sloughs were discharged from the wounds, without much hemorrhage, and with decided relief. In the night, however, the man appeared to be dying; but was recruited by ammonia, brandy, and other stimulants. He recovered.

In this case, it appears that Mr. Lawrence had recourse to incisions "by instalments," which he so much ridiculed in the practice of others.

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Case 2. An old man came into Bartholomew's in the beginning of January, with erysipelatous inflammation of the leg and foot, succeeding a blow. The usual treatment not appearing to produce benefit, Mr. L. made an incision, about two inches long, across the back of the foot," and as there was but little bleeding at the time, it was encouraged by fomentations and a poultice. It appears that hæmorrhage soon afterwards came on, and the nurse took no notice of it till nearly a quart of blood was lost! The house-surgeon was then summoned, and had great difficulty in stopping the bleeding. From this time, the patient, though rallying a little occasionally, gradually

fell back, and died nine or ten days afterwards.

We would not say positively, that this man died in consequence of the hæmorrhage, seeing that the patient was oldthat the disease in such subjects is generally hazardous—and that the man lived nine or ten days after the hemorrhage. The neglect, of course, falls on the nursebut we cannot help wondering that the incision should have been made " across the back of the foot," as surgeons generally prefer to make wounds in the direction of vessels, nerves, and tendons, rather than across them. Perhaps the report is inaccurate, or there was some specific reason for the mode of incision, which is not stated. The case shows that, after incisions in erysipelatous parts, the most rigid instructions should be given to the house-surgeon, and the case never left to the sole charge of a nurse.

AXILLARY ANEURISM.

In No. 286 of the Lancet, there is but one report from all the London hospitals, but like the single fault of poor Hickey, the attorney in Goldsmith, "that one is a thumper." It occupies no less than seven dull columns of close print, and the unfortunate readers may well exclaim with the frogs in Æsop, "ah! Mr. Reporter, this may be sport for you, but it is death to us!" As we are not paid by the yard, we shall make somewhat shorter work of it than the Lancet, and indeed we notice the thing more for the sake of what fell from Mr. Lawrence, than for any great interest in the case itself.

J. L. æt. 39, a very muscular man, received a blow on the shoulder, which was followed by pain, and numbness in the arm. In the course of three or four months the limb began to swell, and about a month or so prior to his admission, he noticed a swelling and beating about the right shoulder, attended with excessive pain. He was first treated for rheumatism, and subsequently bled and leeched.

He entered Bartholomew's on the 7th Sept. under the care of Mr. Lawrence, with an imperfectly circumscribed elastic swelling, "possessing all the characters of an aneurism," its upper edge being felt

about two inches above the internal end of the clavicle, and its lower boundary, where the three upper ribs are closely involved, being nearly indefinite." There was no discolouration of the skin, but the veins were distended; pulsation very powerful in the upper part of the tumour, not perceptible in the lower; limb swollen; little or no pulse at the wrist of that side; much pain on the inner side of the arm, and numbness of the fingers; voice, respiration, &c. natural; pulse of the radial artery 70, firm, and full. He was ordered to be kept quiet, purged, and digitalis was administered. He was bled, also at intervals, and went on, sometimes better and sometimes worse, until the latter end of November, when the pulsation in the tumour became less distinct, and soon altogether ceased-the tumour became stationary and firmer-pulse at the radial artery, which had increased, was less distinct-and the pain and swelling of the limb were so far diminished that he could move it more freely, and grasp more firmly. Previous to this, the stethoscope had been applied, but no disease of the heart, or its large vessels within the thorax could be detected. The amendment went on progressing" until the month of January, 1828, when he began to be affected with slight cough and irritation about the trachea, and on the 15th, the tumour suddenly and rapidly increased; the arm swelled, and the cough was very troublesome. In spite of bleeding and the application of cold, the disease increased; the tumour acquired an immense size; a slough formed over the scapula; he was forced to swallow drachm doses of laudanum to procure sleep, and on the 9th of February. death put an end to the poor fellow's tortures.

This is detailed,

SECTIO CADAVERIS. like the case, with great prolixity; suffice it to say that the aneurism was of enor mous size, reaching from the sternum to the inferior angle of the scapula, and containing three pints of recently coagulated blood, with a little fibrine adhering to its sides. These were made up at the upper portion, of the proper arterial coats with little adherent coagulum, and below, of the surrounding textures, muscles, bone, &c. lined with a coagulum, not exceeding half an inch in depth at the thickest. The upper rib was rough and partially absorbed, the second denuded,

and the aneurismal sac extended between the two into the chest, distending the intercostal muscles, thickening the pleura, and, at its convexity, adhering to the lung. The sac originated from the axillary artery, an inch below the origin of the subclavial branches, an interval of five inches remaining between the upper and lower orifices of the artery. The latter was about one inch above the giving off of the sub-scapular. The axillary plexus of nerves was involved in the disease, and some of the nervous chords flattened like tapes, but there was no disease of the heart or great vessels.

Mr. Lawrence considered that the extension of the tumour above the clavicle, precluded the ligature of the subclavian beyond the scalenus anticus muscle. The only chance, according to Mr. L. would have been the operation on the innominata, but "there is little encouragement to perform this operation, and the chance of saving life, is probably no greater than what is derived from the hope of a spontaneous cure." "The artery might have been tied beyond the tumour. The ligature, in that case, must have been placed beyond the origin of the infra-scapular, and circumflex arteries. Mr. Lawrence observed, that we have hitherto no direct facts in favour of such a proceeding; and that, in his opinion, the probabilities were strongly against the attempt."

In this sentiment of Mr. Lawrence we

entirely agree. We have stated, again and again, that almost the only artery to which Mr. Wardrop's operation (as it is most absurdly termed) is applicable, is the carotid, because that vessel gives off no branches betwixt the ligature and the aneurismal sac. We are glad to find that Mr. Lawrence makes a proper estimate of the operation, and is not one of those good easy folks, who imagine that its promulgation is to constitute a kind of Hegira in surgery, and are eternally chaunting their allah-illa-allah's to the glory, not of the PROPHET, but of Mr. Wardrop!

P. S.-In this report, Mr. Lawrence is made to say that, no patient has hitherto recovered after ligature of the innominata. What will Dr. Valentine Mott say to this? If his statement be correct, there was a recovery from the operation, as far as the operation itself was con

cerned. The man died many weeks after the ligature had been applied-and after walking about the grounds of the hos pital.

3. NOTTINGHAM GENERAL HOSPI

TAL.

FEMORAL AND POPLITEAL ANEURISMEXTERNAL ILIAC TIED.*

Case 1. W. S. æt 42, after having taken a long walk, when in a bad state of health, discovered a pulsating tumour in the thigh, and soon afterwards another in the bam of the same side. Both gradually increased until about the middle of July, nearly eleven months after their first appearance, when that in the thigh became very painful, and enlarged rapidly, whilst the tumour in the ham slowly diminished, and from this time no pulsation could be felt in either. On admission into the hospital, August 24, 1824, the upper aneurism was found to extend from two inches beneath Poupart's ligament to nearly half way down the thigh; it was hard, marked with dark purple spots, and no pulsation could be discovered in it, but on applying the stethoscope, a sound like water forced through a narrow tube could be heard synchronous with the pulse at the wrist. The pulse in the artery above was weak, and none could be distinguished in the popliteal aneurism. He was kept quiet in bed, and cold applied, under which treatment both tumours materially diminished in size, and in great measure subsided. On the 17th September, however, after making some exertion, all the former symptoms returned with increased violence, and it was determined in consultation to tie the external iliac, which was done on the 22d, by Mr. W. Wright. The steps of the operation we need not stop to describe, but we may mention that on exposing the artery, two large veins were seen running obliquely over it, one of which was ruptured in passing the needle beneath the vessel. On the 25th, The wound was dressed, and found to have united above and below, but to remain open in the centre. The tumours diminished in size, and became softer, but in

* Mr. Booth Eddison's Report, Med. Repository for March, 1828.