Under this head, we hope to give a selection and re-union of important cases reported from the public institutions of this and other countries, which will prove the most valuable department of a journal ever offered to the medical practitioner, of town or country. We shall take great care to disembarrass reports of all useless or irrelevant verbiage-nor shall we notice those cases that afford no useful practical hints, or interesting phenomena. In our criticisms, we shall be guided solely by rigid impartiality-and a desire to cor rect error and establish truth.

1. ST. GEORGE'S HOSPITAL.

STATE OF THE PUPIL IN DEEP INTOXICATION.*

A young man was brought into this hospital, some little time ago, having fallen from the Bristol coach half an hour previously, in a state of complete intoxication. When admitted, he was quite insensible-the pulse 70, and rather labouring-the pupil dilated at first, but, in the course of a very short time, it had become contracted almost to a pin's point. At the back of the head there was a circular wound of the scalp, about the size of a shilling, exposing the bone perfectly denuded beneath, but unaccompanied with fracture or depression. In the course of the day the pulse got up, and he was bled; and in the evening he brought up, by vomiting, a most disgusting mass of port, brandy, &c. after which he became much more sensible, and the pupils began to act. Next day he complained of nothing but the scalp-wound, in spite of which, and all Mr. Rose's remonstrances to boot, he walked out of the hospital, got upon the top of the coach, and set off once more for Bristol.

Upon this case the reporter remarks"We mention it principally with a view of calling the attention of our readers to the excessive contraction of the pupil, a state which Mr. Rose says he has generally seen in complete intoxication. In this patient there were many of the symptoms of compression of the brain; and

indeed there cannot be a doubt that indi. viduals are occasionally most severely, and even fatally treated for such compression, when rest, or, it may be, the stomach-pump, are all that is wanted."

STRANGULATED HERNIA.

Two cases are reported in the Medical Gazette, (No. 4,) which we shall notice, in order to show Mr. Brodie's practice.

On

The first case was that of a stout young countryman, admitted under the care of Mr. Rose. The hernia had existed since childhood, was never completely reducible, and the symptoms of strangulation had obtained for twenty-four hours prior to the performance of the operation. opening the sac, a knuckle of intestine was found, which was returned, but, besides this, there remained a quantity of omentum, which had contracted old and strong adhesions to the sac. This was Jeft unreduced; an abscess subsequently formed in it, attended with pretty urgent symptoms, but under the judicious treatment of Mr. Rose the patient did remarkably well.

The second case occurred to Mr. Brodie. The patient was a watchman-the symptoms commenced a 5, A. M. of the performed at 3, A. M. of the 16th. As in 15th December, and the operation was

the former instance, intestine and omentum were down, and the circumstances being the same, the intestine was returned, and the omentum left undisturbed in the sac. This patient also did well.

Surgeons are now so universally impressed with the advantages of the early operation in hernia, that we shall say not a word about that. The treatment of the omentum in these cases is the point to which we would wish to direct the attention of our readers. Sir Astley Cooper, in his published lectures, (and a greater boon than these lectures, we think, bas not been conferred on the rising professional generation for these many years,) If the makes the following remarks. omentum be very large-mortified-or if it be "hardened and have a scirrhous feel," it should be removed wholly, or in part, the divided vessels secured by fine ligatures, and these, one end being cut off,

should be left hanging from the wound. If omentum alone adheres to the sac, it may be freely separated and returned. So far, Sir Astley; Mr. Brodie, however, thinks otherwise, and as the reporter has detailed his method of treatment, we shall take the liberty of quoting the passage, without note or comment of our own.

"In his (Mr. Brodie's) Clinical Lecture upon Joseph Haplin's case, he observed, that whenever difficulty obtained in reducing the omentum, either from its being adherent, mortified, or from its being converted into a large fatty mass, the old practice used to be to cut it off, or apply a ligature upon it. With regard to the ligature, authors are almost unanimous in disapproving of it; in fact, as Sir A. Cooper shrewdly remarks, it is renewing with increased severity what the operation was intended to relievethe stricture on the part.

"Mr. Brodie is inclined to think that the excision of the omentum is not so devoid of difficulty and danger as some would seem to infer. If no vessels are tied, the hemorrhage may be very considerable; indeed, Mr. Hey has published two cases in which the patients nearly died of it. If, again, the arteries are tied, the ligatures cut off close, and the omentum returned, we are not sure that bleeding may not take place within the abdomen, from vessels which did not bleed while the omentum lay expos ed in the sac, and which therefore were not secured: and, besides, what is to become of the ligatures? Mr. Earle related to Mr. Brodie a case of this kind, in which they were discharged through an abscess which presented itself at or near the umbilicus. The patient recovered; but nevertheless, an abscess of the belly, which bursts at the umbilicus, cannot be supposed to be always free from danger. If, instead of the ligatures being cut close, one end of each of them be left hanging out at the neck of the hernial sac, the omentum must of course - remain drawn down to the abdominal ring; and in what respect is the patient better off than if a portion of it had been left in the sac itself? There is also some danger in this case of inflammation of the cut end of the omentum, and Mr. Brodie mentioned one case in which an abscess formed in the omentum, at this part, immediately within the internal ab

dominal ring, and the patient died in consequence.

"He, however, stated that he did not mean to condemn the excision of the omentum in all cases, but merely to express that it ought not to be done without a very sufficient reason; and that in cases where there is not a very large quantity of omentum in the hernia, but where it is extensively adherent to the surface of the sac, it is safer to leave it where it is found, than to cut off a portion of it, or to dissect through the adhesions. success of this practice, in the two preceding cases, is certainly in its favour. The patients are left as well off as they were before the strangulation took place; and probably better, inasmuch as it is most likely that the omentum, after the operation, must have contracted adhesions to the neck of the hernial sac, making them less liable to a descent of the intestine."

The

2. MIDDLESEX HOSPITAL. ANOMALOUS EDEMATODE SWELLING OF THE LEG.*

A watchman, æt. 32, was admitted in October, with an enlargement in the left leg and thigh, which had begun suddenly, as we understand it, three years previously, had never diminished, except when in the recumbent position, and was productive of much distress and suffering. His constitution was broken down-secretions imperfect, and he voided with much difficulty turbid and scanty urine. The left leg was about 22 inches in circumference, natural in colour, tender to the touch, elastic, but indenting on firm pressure. He took diuretics, was cupped and blistered for the first three weeks after his admission, when an acute attack of hepatitis came on, which was subdued only by the most active treatment. During the attack, the leg was free from pain, and had nearly regained its natural size, but the moment the hepatic inflammation ceased, the swelling, &c. of the leg returned. This happened a second time in November, on the 25th of which he left the hospital, in consequence of some expressions inadvertently used, and has never since returned. The reporter

* London Med. Gazette, No. V.

observes, that this case bears some resemblance to phlegmasia dolens, and in a female, after parturition, might have been so considered. The symptoms, however, of phlmegasia dolens do not remain unrelieved for so long a period as three years, though, certainly a degree of swelling of the limb may remain for life. To us, it appears that the case was one of chronic inflammation of the cellular tissue generally, and this opinion is strengthened by the fact of its alternating with the acute inflammation of the liver. We have seen one or two cases, somewhat similar, occurring in patients who were much exposed to damp and cold, and where the appearance of the limb was far from being unlike that presented in phlegmasia dolens, although the disease ran on to a different and fatal termination.

3. ST. THOMAS'S HOSPITAL.

ABSCESS BETWEEN THE BLADDER AND PUBES.

This case is related in the fifth number of the Gazette. The patient was a female æt. 42, who had been married at the age of 20, and miscarried in the sixth month. She was not pregnant again for 18 years, when she again miscarried in the fifth month. After this she did not menstruate for 18 months, when she was attacked by profuse flooding, which lasted for three days. In the following month she began to suffer from pain in the uterine and lumbar regions, and November 21st she entered the hospital under the care of Dr. Elliotson. She was sallow, debilitated, and complained of violent pain in the hypogastrium, pubes and loins, with numbness and tingling in the right thigh. Tenderness of the hypogastrium and pubes to the touch-copious discharge of puriform matter from the vagina, occasionally tinged with blood-urine generally free, sometimes retained for two days to gether-general ill health. The uterus, on examination, was healthy, but the discharge dark and fetid. These symptoms were not relieved by calomel, leeches, blisters, &c. &c.-the discharge continued copious-cough came on-she grew weaker, and on the 16th December she sank.

On examination, there was found in front and behind the symphysis, extend

ing beyond the external abdominal rings, so that the round ligaments passed through it, an abscess, containing dark and fetid pus, which had a free exit through the urethra. A portion of this was destroyed -the surface of the bone was rough and blackened, but not carious, whilst the bladder and vagina were perfectly healthy.

STRANGULATED HERNIA.

A case of strangulated hernia, terminating fatally, is reported in the last Number of notice. the Lancet, which we deem it right to

The patient was a stout man, who had laboured under constipation of the bowels for some days, attended with pain and colic, for which, in fact, he was sent into the hospital, no allusion being made to hernia, which, however, was speedily discovered there. The swelling took the usual course of inguinal herniaoccupied a portion of scrotum-and the integuments were inflamed. The man had vomiting and hiccup-the countenance was not depressed-pulse feeble-much tenderness of abdomen. He had, according to his own account, a swelling in the part since his birth, but latterly it got larger. The taxis was ineffectually employed, and then Mr. Green proceeded to operate. The hernial sac_contained much serum, aad a knuckle of intestine, of a chocolate colour, was found, partially adherent to the sac. The hernia was of the congenital kind. Although the ring was freely divided, a stricture still existed, beyond the ring, girting the intestine. This being cut through, the gut was readily returned. It is the pracfice of Mr. Green not to give any purgative medicine for some hours after an operation for hernia, and this practice was followed in the present instance. The reporter, however, seems to have discovered a mighty flaw in the GAZETTE account of the case--namely, the administration of a couple of glysters immediately after the operation, instead of some sulphate of magnesia the next day at noon! Most important misstatement! This beats the Lancet hollow. That veracious intrument never committed such an error, wilfully or accidentally! But, allowing that the enemata had been ad, ministered immediately after the operation, it would not have been an infraction of the precept laid down by Cline, and

followed by Green-that of not disturbing the bowels too soon by purgative medicine. The enema merely empties the colon, and does not affect the small intestine. But this is a piece of knowledge far beyond the scope of the reporter's sensorium. The patient died in three days after the operation, and no dissection was permitted. This case is spun out with the most tiresome verbiage in the Lancet, to the extent of four columns! Surely some of the reporters must be paid by the acre rather than by the sheet of letter-press which they blacken in every volume of the LANCET!

CASE 2.-Morbid Growth in the Femur. The patient, was a wretched-looking creature, about 50, a martyr to rheumatic

FRACTURE OF THE FOURTH AND FIFTH CERVICAL VERTEBRE.*

We cannot but congratulate our contemporary on his HOSPITAL REPORTS. They seem to be given in a spirit of great candour and fairness, and the cases are generally interesting, whilst they are unalloyed by that sickening ribaldry and slang which grace this department of the Lancet. This is as it should be..

Case. G. F. æt. 45, was admitted under the care of Mr. Vincent, at 8, A. M. Dec. 18th, having fallen on the back of his head from the top of a loaded wagon, by which he was stunned for the time. On admission, the occipital bone was found denuded of its pericranium for some extent-pulse small and feeble-sensibility and motion diminished in the upper and lower extremities-pupils contractedpriapism-respiration chiefly diaphragmatic. When Mr. V. saw him at half-past twelve, there was complete paralysis of the lower half of the body, with pain in the back of the neck, where a projection could be felt, in the situation of the fifth cervical vertebra. The pulse rose, and at 12 P. M. he was bled to 3xvij. Next day the paralysis of the upper extremities had increased; he passed his stools involuntarily, and the bladder required the introduction of the catheter night and morning. He was bled and purged, but without any amendment, and or the 21st he died.

DISSECTION. The base of the spinous

* London Med. Gaz. No. V.

three years' standing, and had been once almost cured by an issue. The joint was greatly swollen, and projected in a conical form towards the inside of the leg.The apex appeared to contain fluid, but the rest of the tumour was firm and unyielding, like a fungous growth. There was excessive pain and constitutional disturbance; and, besides this, the poor wretch had diseased bladder and stricture of the urethra, so that he was no very promising subject for an operation. This was done by Mr. Vincent on a Saturday, and, on the succeeding Friday, the patient had a fit of the gout, and died.

On examining the tumour, much chalky substance was found in the subcutaneous cellular tissue, and on the head of the femur, the internal condyle of which was filled with a gelatinous, fungoid substance. It was something like soft soap, had broken down the bony walls of the condyle, and made its way into the joint and its neighbourhood.

It is not improbable, from the chalky deposition in the joint and around it, that this anomalous disease had its origin in the gouty or rheumatic inflammation.

HERNIA-ADHERENT EPIPLOCELE.

The Lancet, for reasons best known to itself, though, perhaps, obvious enough to some others, has hunted back to the month of November, 1826, for a case exemplifying certain points of practice, lately reported from St. George's Hospital, in a cotemporary journal. The object seems to be, to show that Mr. Lawrence is not exactly of Mr. Brodie's way of thinking,

in regard to the treatment of adherent omentum. Non nobis inter vos, &c.

The patient was 60 years of age, and had been ruptured for the last thirty. He had worn a truss, though the reduction was only partial. After some unusual exertion, on the 2d of November, a further protrusion occurred-the parts became painful-a surgeon tried ineffectually to replace the rupture-and he was sent into Bartholomew's. He evidently had strangulated hernia, and all the usual means were pursued, (and minutely detailed, for the ten-thousandth time,) without success. Mr. Lawrence operated at the expiration of eight hours from the new descent. Every stroke of the scalpel is, of course, described-but we shall inform our readers, at once, that six inches of incarcerated small intestine were found, of a dark chocolate colour. The strictture having been divided, an indentation (most wonderful to relate) was found in the strictured gut--and when this was drawn down, a small opening was found in the intestine, just above the indentation. "Mr. Lawrence supposed that the bowel had been wounded by the curved bistoury." He tied a silk thread round the aperture-cut away the ends-dissected away a portion of old, adherent omentum-tied the vessels and the whole was then dressed lightly. The reporter of this case (which occupies four deadly columns of the Lancet) does not say whether the intestine was returned into the abdomen after ligature of the perforation. The patient recovered without any bad symptoms. Under the head of "REMARKS," the reporter, who seems to have an eye to the "main chance," in the length of his cases, as well as his cuts, repeats the whole business over again, with one or two quotations from Hey, Desault, Beyer, (a new name in the surgical horizon,) Lawrence, and Travers. The whole case is unquestionably taken from the porte-feuille of a man of letters, for a special purpose, which we need not explain.

If ever a critical reviewer and condenser was needed in medical literature, it is at the present moment, for hospital reports. The writers are paid by the sheet-and it is their interest to dilate-the critical condenser is paid in a diametrically opposite manner-and the consequences are obvious.

22d. Had an exacerbation of fever last night, but it is mitigated this morningecchymosed part of the scrotum lividcellular membrane, which has been scarified, dark and sloughy-yellow hue on the lower part of the abdomen.

Quin. sulph. gr. jss. Camph. gr. ij. Amm. carb. gr. x. 6tis horis-Cat. cerevisia.

Hiccough and tenderness of the hypogastrium came on, and this was so severe on the 24th that, to prevent infiltration, it was determined to cut into the urethra, pass a catheter through the opening, and confine it in the bladder. On doing this, it was found that two inches of the urethra, anterior to the triangular ligament, had sloughed. Bowels relaxed-pulse 130 and weak.

Tinct. opii, mx. ex Julep. ammon.-Arrow-root and brandy-Quinine to be omitted.

A slough formed at the back of the scrotum, which separated and exposed the tunica vaginalis of the right testicle. On the 6th Dec. an incision was made over Poupart's ligament, and a quantity of fetid pus discharged, but, on the 15th, the boy died. No dissection was permitted.

Mr. Key, in his remarks on this case, observed that, in common cases of ruptured urethra, leaving a catheter in the bladder generally suffices, the inflammation arising from the extravasation generally setting bounds to the escape of the urine beyond the cells of the scrotum. In this case, the infiltration was exceedingly diffused, and free incisions into the

* London Med. Gazette, No. V.