18th. Free from symptoms. Ol. ricini, 3ss. statim.

19th. Sleeps well, and says his appetite is good.

20th. The wound is uniting. To take the common house purgative medicine every morning it may be required.

31st. Complains of a swelling near the umbilicus, on the same side as the hernia, which, on examination, is painful, and appears to be inflammation of the cellular texture, below the external oblique muscle, To have 20 leeches applied and repeated, with warm evaporating poultices. B. Puiv. jalap. c. 3j. statim.

Nov. 1st. Is better, but the swelling continues-leeches repeated.

20th. The swelling, which was never accompanied by external inflammation at last pointed close to the umbilicus, and an opening being made, a tea-spoonful of matter was discharged, and the wound healed in a day or two.

Dec. 1st. The hardness which remained after the little opening closed, suddenly descended, with some external inflam. mation, to the line of incision made in the operation, and an abscess soon pointed, which was opened, and a table-spoonful of matter was discharged.

Dec. 7th. Discharged cured, being furnished with a truss.

Mr. White operated in another case of a similar description, and on the same side, a few days afterwards, in the person of an old man of 74. The hernia, a very large scrotal one, had been strangulated three days when he was brought to the hospital. The man was very weak and exhausted, the danger imminent. Mr. White performed the operation the moment he arrived. On opening the sac, the intestine was found of a black colour, and nearly in a state of mortification, and in considerable quantity, and a great deal of very fetid fluid escaped. The same difficulty was experienced in returning the intestine as in the former case. Mr. White enlarged the opening; still the intestine could not be returned, until, in a manner similar to that in the case of Bentley, the intestine was raised and supported, when Mr. White returned it without difficulty. The man was put to bed, but died about an hour afterwards.

In a clinical lecture, delivered on the subject of these two cases, Mr. Guthrie particularly impressed on the students the importance of the fact, that when a large quantity of intestine and omentum were protruded, it was hardly possible to return them with only a moderately-sized incision of the stricture, unless the parts were supported, so as to take off their weight, and the action of the abdominal muscles was quieted Of which these two cases gave ample proof. He had had, he said, a similar case some years back, which terminated most favourably. He was sent for during lecture to the patient, who lived in Tottenham Court Road, and, finding the symptoms urgent, he operated immediately; the quantity of small intestine protruded was so great, as to resemble a link of sausages hanging up in a shop. The stricture being divided, he attempted to return a part of the gut: finding it would not go up, he drew a portion down from within the abdomen; but still the difficulty remained. After several ineffectual trials, even to restore the pieces he had drawn down, he at last thought of supporting the whole above the level of the wound, when the intestine was readily returned, piece by piece, in succes

sion. Mr. Guthrie desired the students would observe, that if so much difficulty existed when the stricture was divided, they must expect it to be infinitely greater before any operation was performed; and therefore it was, that very large scrotal herniæ usually required an operation for the relief of the patient, more particularly if they had been previously reducible. It was from this knowledge, gained by experience, he had been led to operate in the case of Bentley, after only an examination of the state of the part, and without trying any other means of relief.

This case was, he said, infinitely more valuable on another account. It showed the necessity of an attentive and welldirected medical treatment after the ope ration. Without it, the operation would have been useless. It not only consisted in the abstraction of blood, but in the refraining from administering purgatives, until the inflammatory action was subdued, and then only in such quantities as would act in a very gentle manner. There was no error in medical surgery so great as that, which many surgeons fell into, and which was even recommended from high authority, viz. of having recourse to severe purgation after an operation for

hernia. Repeated glysters and gentle purgatives, combined even with opium, were greatly to be preferred, and it was only when all fear of inflammation seemed to have passed away, that others more active might be had recourse to, and then even, he said, they might be very injurious, and instanced a case, in which too severe a purgative having been accidentally given, brought on from the wound a fecal discharge, which happily, however, subsided, and the patient recovered. In the case operated upon by Mr. White, the mischief had gone too far, both locally and generally, to be arrested by the operation, but it was very satisfactory to observe, how much the black colour of the intestine had changed to a brown, and even, in some parts, to a red colour, after the stricture had been taken off.

AMPUTATION.

There have been three amputations, one of the thigh and two of the leg.

James King, aged 35, admitted Sept. 3d, with a diseased ankle-joint, under which he had laboured for four years past. The amputation was performed by Mr. Harding, on the 29th November, by the double-flap operation, the principle one being formed from the under part; two sutures were inserted on each side of the tibia to prevent the application of sticking plaster over it; little blood was lost during the operation, which was done with great precision and dexterity. On the 30th, the pulse being full and quick, with pain in the side, twelve ounces of blood were directed to be taken from the arm, which was cupped and buffy. Haustus catharticus.

pulse 98; feels pain, which he refers to the great toe.

6th. Says he did not sleep from the pain in the toe, but is much easier this morning. Bowels regular; tongue clean; pulse 100. The pain on the outside of the tibia.

7th. After the stump had been dressed this morning it began to bleed, and about 8uz. were lost before compression could be made on the artery. He had no pain before it came on, but there was a good deal of twitching and jerking of the stump. Pulse 120, and feeble.

The stump was examined, when the outer part between the tibia and fibula appeared in a sloughy state, and from this part it bled generally; an equal compres sion being made upon it, and the part bandaged, the hæmorrhage was suppressed. A mild purgative given; some wine; his dinner a mutton-chop.

8th. Is tolerably free from pain; no return of the hæmorrhage; passed a good night; pulse 136.

In the afternoon the hemorrhage returned. Mr. White finding no particular vessels bleeding, and that a ligature cut through the part, removed half an inch of the surface to reach a sound part, when the hæmorrhage was effectually stopped. The man gradually sunk, and died in the evening.

On examination, the whole of the stump appeared perfectly healthy, with the exception of the single sloughing spot alluded to. The anterior tibial artery and veins were sound. The man was in a weak state prior to the operation, from long continued disease.

Moses Barnes, aged 49, was brought to the hospital, December 1st, the right leg having been torn off in consequence of the foot having caught in the iron chain trace of a cart-horse who was plunging violently at the time. The tibia projected several inches beyond the muscles, which were torn very irregularly. The man suffered great pain at the time, which continued. Mr. White, on his arrival, which was on being sent for, removed the remaining portions of the leg, by the flap operation, about three inches below the tuberosity.

2d. The patient passed a restless and sleepless night, complaining of pain and twitching of the limb. He is this morning easier, but is evidently much hausted. Pulse 132, weak, and not regular. Tongue dry in the middle, the eyes

clear.

ex

slightest effect: Mr. White remained himself with him until 2 o'clock.

The patient was a short, thick, strong, and rather corpulent man. Mr. Guthrie, who happened to be in the hospital before Mr. White arrived, desired the students to attend particularly to the case, and to the appearance of the man, the impression on his mind being, that he was a bad subject for the accident, and that the termination would not be fortunate.

Christopher Stout, aged 36. Thigh amputated for disease of the knee-joint, (ulceration of the cartilages,) Dec. 6th, 1828. The operation was performed by Mr. White, with facility and despatch, and the patient is nearly well.

Mr. Guthrie took the opportunity after the amputation of showing to the students the stump of a man, John Bartholomew, whose leg he had amputated 12 years ago. The tibia bad been sawn through at the

tuberosity, and the head of the fibula had been removed. A sufficient portion of tibia had been left to rest upon. The consequence was. that this man could walk four miles an hour on his wooden leg with ease, and was in the habit of carrying one hundred weight on his head from Covent Garden into Westminster, near the hospital, twice every day. Mr. Guthrie said, that by leaving the knee-joint, and the attach ment of the inner hamstring, the straight progressive motion of the limb was preserved, and which was always lost when the knee was removed. The patient waddled, and had great difficulty in preserving his equilibrium The only danger in the removal of the fibula was, that the head of it in perhaps one case in 20, entered into the composition of the knee-joint, which circumstance might in general be ascertained by a careful examination of the fibula previous to the operation.

XIII.

CASE OF PNEUMO THORAX IN A MEDICAL GENTLEMAN; WITH AN ACCOUNT OF AN OPERATION PERFORMED FOR ITS RELIEF; THE EFFECTS OF THE OPERATION; THE APPEARANCES ON DISSECTION; AND REMARKS ON PNEUMO-THORAX GENERALLY.

One of the most remarkable cases of this disease on record, has recently occurred; and being in the person of a medical practitioner, excited intense interest among a very large circle of physicians and surgeons, who were visiters or attendants on one of their brethren. The case was exceedingly important in many points of view, and was watched and examined, both before and after death, by a greater number of medical men than were ever before seen round the bed of a private patient. The diagnosis and event were looked to by a large assemblage of practitioners, as decisive of the merits or fallacy of auscultation and percussion-and the reputation of one man, at least, was at stake. We shall now proceed to the particulars

Mr. CORNISH. SURGEON, residing in Milner-place, near the Cobourg Theatre, and aged about 25 or 26 years, became affect

ed with dyspnoea and symptoms of thoracic inflammation, about the latter end of November or beginning of December last, which he neglected for many days, and continued to pursue his avocations in the three branches of the profession. About the 15th or 16th of the same month he was accidentally seen by Mr. Cooke, an intelligent practitioner of Bridge-street, Lambeth, who strenuously recommended sanguineous depletion, confinement to the house, and the other items of the antiphlogistic treatment. It was with difficulty he could be persuaded to take to his room; but he was too ill to go on longer with his practice.

On the 19th or 20th of December, Dr. Johnson was requested to see Mr. Cornish, and found him in the following condition. The patient was of the scrofulous constitution. He was lying on a sofa, on his right side, breathing with considerable difficulty, and frequent coughing. The expectoration was scanty and extremely tenacious, but without any pu rulency. The pulse was 130, sharp and wiry-skin not very hot nor dry-tongue moist, thirst moderate, right cheek flushed, urine high-coloured and scanty. He complained of great difficulty of breathing, had pain in the centre of the chest, and could only lie on the right side. On

uncovering the thorax, the muscles of respiration were seen in violent action, but the breathing was principally carried on by the diaphragm. There was no perceptible difference in the size of the two sides of the chest; but a very remarkable difference in the sound emitted on percussion. The left side sounded louder than natural-the right sounded considerably duller than natural. On applying the ear to the left side, which sounded so well, little or no respiration could be heard. On listening to the right side, which sounded so dull, the respiration was very loud, accompanied with much wheezing. The heart was felt beating rather to the right of the middle of the sternum, and no trace of it could be felt in the left side.

that the quantity of serous, purulent, or sero-purulent effusion, was very small in quantity, when compared with the aeriform extravasation. What was now to be done? There were still symptoms of thoracic inflammation present; and to quell these, and promote a free expectoration, every mean that could be devised was put in force. The next five or six days were consumed in the furtherance of these indications, but with no effect in mitigating the difficulty of breathing, which, indeed, gradually increased, the pulse seldom coming under 130 in the minute, with great and distressing jactitation In the course of the above period, several medical gentlemen saw the patient, and Dr. Walshman was added in daily consultation with Dr. Johnson and Mr. Cooke.

These phenomena appeared to Dr. Johnson to be very unfavourable, but as inflammatory action was still unequivocal in the case, Dr. J. advised Mr. Cooke, who kindly and zealously attended his afflicted neighbour till the last, to take away more blood, both generally and locally. Digitalis, colchicum, and antimony were also given, in powerful doses, with the view of making an impression on the circulation.

21st December. The urgency of the dyspnoea was a little, and but a little relieved, by the depletion. The blood was remarkably buffed and cupped. On examining the chest this day, Dr. Johnson and Mr. Cooke found that the left side was even more sonorous than before-and the respiration there still more indistinct. The pulsation of the heart was rather farther to the right --the right side very dull on percussion, and the respiration very noisy and confused. But a most important feature of the case now attracted attention-namely, the METALLIC TINKLING, (tintement metallique,) which was distinctly audible in the left side of the thorax, not only when the patient coughed or spoke, but even during every inspiration and expiration. Dr. Johnson had now no doubt of the existence of PNEUMO-THORAX, as every person who put the ear to the chest, heard the tinkling as plainly as himself. Upon accurate examination, the left side was found to be very sonorous back almost to the spine, which led to the conclusion

On Monday night, the 29th December, the patient nearly expired from suffocation, and next morning, (Tuesday, the 30th,) Dr. Johnson explained to the patient the nature of the case-namely, that there was an aperture in the left lung, through which the air was extravasated into the left pleural cavity, which cavity also contained some fluid, the precise nature of which could not be ascertained. It was stated to Mr. Cornish that the increasing collection of air was pressing severely on the right lung—that it had already pushed the heart into the right side of the chest-and that there was no prospect of relief, but from an operation. Dr. Blicke, of Walthamstow, examined the patient on Tuesday morning, with Dr. Johnson, and was so convinced of the existence of pneumo-thorax, as the cause of the dreadful dyspnoea, that he volunteered to perform the operation. Things, however, were not sufficiently ripe for such a step, and Dr. Johnson requested the patient to name a surgeon of eminence to join in the consultation. He named Mr. Lawrence, and Dr. Johnson waited on Mr. L. to request his opinion on the case. Mr. Lawrence, Dr. Walshman, Mr. Cooke, Mr. J. H. Johnson, and some other medical men, met at 3 o'clock on that day. Mr. Lawrence accurately examined the patient. He was lying on his right side, as usual, breathing most laboriously, his countenance sunk, the pulse between 130 and 140, weak and somewhat irregular. The skin was cool and somewhat moist-he had had no sleep for many nights. On laying bare the chest, the action of all the respiratory muscles was