small wound over the anterior surface of the tibia, and the skin above the outer malleolus was very much contused and fluctuated from the effusion of blood beneath it. When the foot was moved an indistinct crepitus was felt. We cannot say that the Doctor's description is particularly lucid, for no one on reading it can venture to pronounce either where or what the fracture was. However the limb was placed upon "M'Intyre's splint," and the spirit lotion applied. At night he took an anodyne, castor oil next morning, and an antimonial solution was administered internally from time to time. On the 8th we find the following report.

"Slept ill; pulse 108, very full and strong; bowels once relieved; tongue slightly furred; skin upon the outer side of the leg is evidently gangrenous, and that upon the inner side considerably discoloured. An incision was made through the former, some serum was discharged, but the wound bled very little. He was bled to twenty ounces." At 11, P. M. the pulse was 132; the " gangrene" did not appear to have spread upon the outside, but the skin on the inside was more extensively discoloured. He was bled again to 3x. after which he slept a little, and on the 9th was improved. The pulse was 112, and not so strong; the skin was hot; the thirst less; the bowels once relieved. The "gangrene" had not spread at all upon the outside of the limb, and there was some healthy purulent discharge from the incision ; on the inside the gangrene had extended a little. The last blood drawn was neither buffed nor cupped. The fermenting poultice was applied to the leg and the antimonial solution continued. The feverish symptoms now subsided, and on the 11th the pulse was 100; skin cool; tongue less furred; appetite returning; "the gangrene had ceased to spread, but the sloughs had not begun to separate."

"It now became obvious that we should not be compelled to amputate by the extension of the gangrene, but when the sloughs came to be detached and both the tibia and fibula were laid bare to a considerable extent, with a copious purulent discharge, and

rather profuse sweats, I was greatly inclined to amputate the leg; and had not some of my colleagues entertained a more favourable opinion of the case than I did, it is probable the operation would have been proposed to him.

"There was great encouragement however to persevere in our attempts at a cure, from the prosperous state of the man's general health; as well as from his youth, and apparently vigorous habit. The extensive sore which nearly surrounded the lower part of the limb became covered with florid and healthy granulations; the discharge rapidly diminished, and on the 21st December he was discharged cured, a trifling exfoliation having previously taken place from the fore part of the tibia."

We have often been surprised at observing the very loose way in which surgeons employ the terms mortification and gangrene. If a leg after an accident begins to be blackish and discoloured, and especially if vesications filled with dark modena-coloured serum form upon it, the case is set down instanter as a case of gangrene. Now the fact is, that a very large proportion of this kind of cases are neither gangrene, nor likely, under proper treatment, to end in it, and therefore it is clearly a dangerous error to consider them as such. A man receives a simple or a compound fracture, perhaps of no great severity-the limb is put up in the apparatus determined on, whatever it may be-and for one or two days would seem to be doing tolerably well About this time, however, a good deal of pain is experienced in the limb, and on opening the apparatus, the leg (for we will suppose the tibia to have been broken in its shaft) is discoloured in patches of brown and yellow, from the ankle to the knee. In one or more parts, generally on the fore part of the leg, the cuticle is raised in vesications, filled with serum of port wine colour, and on breaking these the cutis itself looks mahogany-coloured, or per haps of its natural tint below. The patient all this time may be little disturbed in his general health, or instead of the prostration consequent on mortification,

may have a full bounding pulse, a hot flushed skin, a loaded tongue, in fact, the genuine symptoms of excitement.

I have had occasion to treat in this house, and are not co-incident with my experience of them in other situations.

Such a case as this may appear to a person who has not seen many of the same description, as one that is fraught with imminent peril, in fact, as a case of traumatic gangrene. But indeed it is not of so dangerous a character, and under attentive and soothing local treatment, with free depletive measures, if the case has been one of the sthenic character, the skin which has perished will come away, the leg will recover itself, and all will do well. We cannot help thinking that the case recorded by Dr. BalJingall as one of traumatic gangrene, approached much nearer to that which we have described, than to what he has considered and termed it. We see, for our own parts, no evidence of gangrene in that particular instance; the limb was not cold; it did not die; the sloughing was superficial; the pulse was not weak, rapid, or intermitting, but full and strong; the recovery from the gangrenous state was speedy, and that under bleeding and depletory measures; in short, it was not a case of mortification requiring amputation, but an instance of inflammation set up in the skin, and perhaps the cellular membrane at the seat of injury, ending in superficial sloughing, but implicating generally neither the limb nor the constitution. In the following remarks of Dr. Ballingall, we, for the most part, perfectly agree, and we are sure that those who have seen most of these bad accidents, will deprecate with him the exclusive and narrow views which some take of their character and treatment.

"Of compound fractures I have hiterto said but little in these lectures, nor do I now propose to enlarge, for although in the two cases just mentioned you have witnessed a successful termination under the treatment adopted, yet they are, upon the whole, a class of accidents the results of which have been to me the least satisfactory of all that

"Had these results been the consequence of one uniform mode of treatment, I should naturally have concluded that that treatment was erroneous. But when I look back to the mode of dressing the woundssometimes by a piece of lint soaked in blood, and allowed to form an encrustation over them sometimes by covering them with a paste of gum, or a pledgit of simple dressing, and sometimes by bringing their lips into accurate apposition with adhesive straps:-When I look again to the different positions in which the limb has been placed -either closely enveloped in splints-lying less constrained in a fracture box, or simply resting on a pillow-sometimes in the bent-sometimes in the extended position :-And when I look also to the various means taken to subdue the violent inflammation and high symptomatic fever accompanying these injuries; by general, or by local bleeding, according, to circumstances; very frequently by the use of cold evaporating lotions to the seat of the injury, and sometimes by the use of anodyne fomentations or cataplasms; I cannot admit that the unfavourable results which I have so often had occasion to deplore have been attributable to any bigoted prejudices or exclusive partialities in the mode of treatment

"In my remarks upon this subject, I took occasion to observe that we are greatly in want of a work on these accidents, from some surgeon of varied and extensive experience. I say varied experience, because it appears to me that we are often led by the irresistible force of habit to give our attention too exclusively to one mode of treatment. I remember to have heard an hospital surgeon assert that he never expected to lose another case of compound fracture, by following up the practice, which seemed to him to be a new one, of closely enveloping such fractures in splints and bandages, without undoing them for weeks together. But it is not from those who take such a limited or exclusive view of this matter that we are to expect such a work as I could wish to see, but from those who are capable of discriminating between those cases (perhaps numerous ones) in which the above practive is advantageous, and those in which

it is not only injurious, but absolutely insufferable.

"Before quitting this subject I would beg leave to mention that there are two points in the treatment of compound fractures upon which my own observation has led me to form a very decided opinion, and to offer you a remark which may possibly prove useful hereafter. I have, I think, too frequently seen a reluctance to use the saw in removing the protruding extremities of the bone, when these were either difficult to reduce, or of a sharp and spicular form; and I have, I think, sometimes seen the closure of the external wound attempted by means too forcible and too long continued."

We do indeed require a monograph upon the subject of compound fractures, and not the catch-penny production of a puffing adventurer, but one that shall be the result of extensive and varied observation. It is only the surgeon of a great hospital who could give us such a work as is wanted. We must now take our leave of the able lecturer for the present, but much remains behind that is highly deserving of attentive considexation. To this we shall return as opportunities present themselves, and again we beg leave to part from Dr. Ballingall with feelings of sincere respect.

XXXVIII.

ST. GEORGE'S HOSPITAL.

I. OPEN FORAMEN OVALE.

Case 1. A very fine little girl, four or five years old, was run over by the state carriage of the Princess Sophia of Gloucester, on the 30th of April, the day of the Drawing Room at St. James's. Both wheels passed over the body of the child, who it seemed, from the bye-standers' report, was prostrate, with the face to the ground. She was picked up immediately, and brought to the hospital in a state of extreme collapse, with the skin cold, the face pale, and the lips white. A

graze of the integuments was found in the loins, but no fracture could be felt. When put to bed she vomited; stimuli were given but she never rallied; and at the expiration of between two and three hours she expired.

Dissection. On opening the abdomen, about a pint of bloody fluid was found in it, but no rupture of any large vessel could be detected. The principal extravasation appeared to be in the right renal, lumbar, and iliac regions. The synchondrosis pelvis on the right side was separated, and near the acetabulum, but apparently not into it, the os pubis was broken. The latter fracture extended into the foramen ovale. The transverse processes of the 4th and 5th lumbar vertebræ were broken across at their roots.

On opening the heart the foramen ovale at its most inferior part was found to be pervious, and presented a circular aperture, the bore of which was full as large as, if not larger than a goose's quill. The ductus arteriosus was closed at its aortic end, but at its origin from the pulmonary artery, it presented a small blind foramen.

Here we see the foramen ovale pervious, and the opening a large one too, without producing apparently any inconvenience, or indeed any symptom to mark its presence. We think there can be little doubt that in early life at all events, and probably also in mature age, the open foramen ovale is not of that consequence physiologists would lead us to believe. When we say the open foramen ovale, we mean that malformation only, and not combined with other disease or disorder of the heart. When the pervious state of the foramen is accompanied with enlargement and flabbiness of the organ of the circulation it becomes a much more serious matter as the following case will amply prove.

Case 2. A woman beyond the middle age, who had been in the house more than once for obstinate ulcers of the leg, was received again on the 1st of April for a return, or rather the continuance of her old complaint. This person's appearance was rather remarkable. There was a high flush upon the cheeks, and a kind of scurfiness or coarseness of the

skin, giving a disagreeable cast to the countenance. The surface of the body generally was of a very peculiar hue, neither bright red, nor yet purple, but something between them, and nearer a salmon colour than any thing else to which we can compare it. It struck one, on looking at her, as that of a person whose blood, to use a vulgar phrase, is in a very bad state. We thought when we saw her that the foramen ovale might be open, but on questioning her, she stated that the colouration of the skin had only been present for five or six years. We made at this time no further enquiries, nor did we ascertain whether any or what symptoms, exitsted to indicate disease or malformation of the heart.

peritoneal coat, one or more, tubercular patches, a little larger than peas.

A good deal of fat was found in the anterior mediastinum and investing the pericardium. On cutting into the latter, the heart was seen to be large in dimensions, but extremely flabby. Much fat was deposited upon it externally, especially in the line of the auriculo-ventricular sulcus. The parietes of the organ were so thin and rotten, that the finger was pushed through them with the greatest ease. The foramen ovale was open, and the aperture was nearly as large as a six-pence. It would have been larger but for a crescentic fold of membrane which bounded it above. The Eustachian valve was very distinct.

On the evening of the first of May, she was seized with what seemed to be erysipelas of the leg, and so violent was the attack, and so rapid its termination, that by midnight of the 2d she was dead. Since her re-admission, we had not seen her, and the following were the appearances presented on dissection, which took place upon the 4th.

The left lower extremity was in a state of gangrene. The whole back and outside of the thigh presented one immense vesication filled with dark, port wine coloured serum. About the leg there were many vesications, and the limb was generally of a dusky mottled appearance. The superficial veins throughout the body were quite as distinct as if they had been injected, the circumstance evidently depending on the stasis of dark blood within them. A colour still remained upon the cheeks, a very unusual occurrence indeed. The body externally was not very fat, but on opening the abdomen, the omentum mesocolon, and mesentery presented one sheet of continuous solid adeps, in which nothing like the vessels of the parts could be distinguished. The deposition of fat was equally great in various other parts of the abdominal cavity. The spleen was half fluid-the liver soft and lacerable with the slightest force-the kidneys in a similar condition. The os tincæ was plugged up with gelatinous matter; the uterus presented in its substance, immediately beneath its

Both the lining membrane of the heart and all the large vessels that were opened, the blood, which was universally fluid. were stained of a deep mahogany colour by

The cavity of the chest was small, and the lungs surprisingly so. Instead of presenting the healthy light gray colour, they were of a deep æruginous tint, compact and dense. They crepitated, however, and shewed nothing like a trace of inflammation. We should say that in point of size, the lungs were one third smaller than they should be in proportion to the body.

The breasts were very large, and the glandular part was almost entirely converted into fat.

Several points in the foregoing case would be worth consideration, did our space or inclination permit us to venture on a sea of conjectures. It is remarkable, however, that although the foramen must always have been open, the symptom dependent upon it, we mean the colouration of the skin, should only have existed for five or six years. Are we to suppose that till then the heart itself was sound, and performed its functions tolerably well, despite of the malformation in question; but that then, and not before, the enlargement of the cavities and thinning of the walls of the circulating organ, made a scale in the balance of the circulation kick the beam? Our readers may form what

conjectures they please upon the subject, but for our own parts, we are disposed to favour the supposition. The state of the lungs also merits remark. Was their miniature size a congenital defect, or was it the result of the state of the heart, and the consequent imperfection of their own functions ? Muscles waste when little used, and why may not the lungs ?

II. TREATMENT OF NÆVI.

CASE 1. Subcutaneous Nævus, of the Lower Eye-lid-Excision performed.

A child about ten months old, was brought into the operating Theatre on the 23d of March, with a subcutaneous nævus, the size of a nut, on the lower lid of the right eye, not mounting quite so high as the tarsal cartilage. Mr. Brodie excised it, removing it, together with the skin over it, by two semi-elliptical incisions. One or two vessels bled smartly and required to be tied, when the wound was dressed with lint and sticking plaster, and the child sent home. The wound healed without any thing untoward or unusual, and the cure was effected without ectropion of the lid.

CASE 2. Subcutaneous Novus of the Upper Lid--Modification of the Ligature.

The child was four months old, and the nævus, about the size of a large Spanish nut, was situate on the upper palpebra of the left eye, and passed down to the margin of the tarsal cartilage, which was overlapped by the little tumour, but did not appear to be implicated with its origin. Mr. Keate introduced a curved needle, armed with a double ligature under the base of the tumour, carefully avoiding the fibrous layer that forms the lid. The needle was passed quite through transversely, from side to side, and then a second was passed with the same precaution from before backwards, exactly at right angles with the former which it crossed. The needles were then cut away and the ligatures remained. These were severally tied at the corners, so that there were four knots. and the last tightened the

rest, in a manner that we need not stop to explain. It was many days before the nævus sloughed away, and the ligatures required tightening several times before the separation was effected. We saw the child lately, and no ectropion of the lid had taken place.

CASE 3. Cutaneous Navus of the BackExcision.

On the 23d of March, immediately after the case first detailed had been disposed of, a child younger still, and healthy in appearance, was operated on by Mr. Keate. The nævus was irregular in shape, of considerable dimensions, placed over the dorsum of the right scapula, and evidently not seated beneath the skin, but in the substance of the cutis itself. It rose up abruptly at its margin from the surface of the neighbouring skin, and was covered by a thin layer of cuticle. Mr. Keate excised the tumour by including it between two semi-elliptical incisions, and then dissecting it away. An artery of some little size distinctly entered at one corner of the nævus, and a vein apparently issued from it at the other. The artery was taken up, and the wound dressed with sticking-plaster and compress.

The wound did not heal by the first intention; a smart attack of erysipelas succeeded, spread over a considerable part of the back, the whole of the arm and other parts of the trunk, and, finally, it was two or three weeks before the child and the wound were well. We saw it, however, on the 21st of April, when it looked hearty, and was perfectly recovered.

III. INJURIES OF THE HEAD.

CASE 1. Scalp Wound. Some Symptoms like Delirium Tremens.

Thomas Bevan, ætatis 27, was admitted in the evening of the 26th of April, under the care of Mr. Keate. This man was a servant at a distiller's and had been so for fourteen months. During that time, having had a carte blanche to the spirits, he was tolerably often drunk, and during that time, also, but never before, he had been subject to what seemed to be epileptic fits. Ŏn the