bronchial secretion, but little råle can be perceived | is likewise affirmed by Chelius. It should be stated by applying the ear to the chest, and I consider the that the wound of the vessel was oblique or diagonal, secretion comes principally from the trachea and larger and that it had a length of about two lines. The bronchial tubes. There is less strength than there vessel in the situation of the injury is perfectly was a month ago, and there is too much reason to permeable, and there is no appearance whatever of the fear she may ultimately be exhausted by the cough. "plug of plastic matter" observed in the experiments Another blister has been applied to the chest, with of Saviard, Petit, and Scarpa.*) The lower extremity some relief, and various cough medicines have been of the divided nerve was shrunk and atrophied, and tried. The pulse is usually about 110. She takes there was a slight enlargement (a neuroma,) at the but little food now. extremity of the upper divided end; there was no observable indication of wound, either of the pharynx or glottis; the subclavian artery of the left side, and the innominata with its chief and lesser branches, appeared to me to be of unusually large size. The viscera of the abdomen, and the contents of the cranium, were not examined, the friends of the patient being unwilling that any further investigation than of the parts immediately implicated should be made. 11th. More prostrated and feeble; sleeps much; complains of pain at the vertex, and a coldness of the left side of the head; pulse variable in speed and volume, and at times intermittent, ranges from 100 to 160; still much muco-purulent secretion in the air-passages, which is easily expectorated; urine abundant, and of natural appearance as it has been throughout. I have repeatedly urged the use of broth injections, but she refuses to have them administered. 22nd. Mrs. Osborn died this morning a little before nine o'clock, having lingered since the last report in a state of the most extreme exhaustion, feebleness, and emaciation. For many days she has taken little else than cold water. She has suffered much latterly from he pain at the vertex, and in the ear, and along the course of the vessels on the left side of the neck. She died without a struggle. Post-mortem examination ten hours after death. Present-Dr. Heygate, Messrs. Wright, D. Fox, Borough, Greaves, and Taylor. Body extremely emaciated. Heart loaded with fat; langs did not collapse on opening the chest; the left lung a good deal congested posteriorly, and the right also congested posteriorly, but to a less extent; there was much frothy muco-purulent matter in the larger bronchial tubes, and the bronchial membrane was much injected. In the neck, at the site of the ligature, the cellular membrane was condensed and firmly adherent to the adjoining structures; the point of ligation was well marked, and the artery was filled with a dense brownish-coloured fibrinous coagulum, which commenced about half an inch from the origin of the vessel; the artery was considerably diminished in size; above the ligature, and especially at the bifurcation, the vessel was contracted and hardened, and contained the same kind of fibrinous coagulum, but in a proportionately less quantity; in this situation, too, there was a very minute abscess in the coats of the artery; the posterior face of the internal carotid, immediately above the point where it is given off from the common trunk, presented a well-marked appearance of the wound which had furnished the alarming hæmorrhage at the time of the injury, and in the same situation the par vagum was found to have been divided. (I have since found, in examining the parts after they had been some time in spirit, that the reddened line which had indicated the point of injury of the vessel, at the time of the dissection very distinctly, has disappeared from the maceration. The edges of the wound had closely united, and there is no trace of the wound on the internal coat of the artery. This condition of the parts is similar to what is stated to have occurred in the experiments of Béclard, and the possibility of which Remarks.-The chief points of interest in the foregoing case, may, I think, be briefly stated to be the following:-1st. The extreme rarity of the occurrence of a case of wound of a vessel of so much importance as the internal carotid, in which there is any opportunity of rendering surgical aid. 2nd. The difficult deglutition and imperfect closure of the glottis in the act of swallowing. 3rd. The excited and variable state of the circulation; and lastly the engorged condition of the pulmonary vessels, and the consequent suffocative cough and abundant bronchial secretion. With regard to the first point I may state that I have been unable to meet with more than one recorded instance in which the internal carotid was proved to have been injured and in which the common carotid was tied. The case is related in Mr. Cooper's admirable Dictionary, and was under the care of Andersch; the common carotid was tied after a wound of the internal carotid, and the patient died on the eighth day. In the present case life was prolonged beyond the eleventh week and looking to the state of the parts as revealed by the post mortem examination, we may fairly be permitted to regard it in a surgical point of view as successful. Secondly, the difficulty of swallowing and imperfect closure of the glottis, which in the first instance were, perhaps very naturally, attributed to some injury of the pharynx and upper part of the respiratory tube, are beautifully explained by the fact of the par vagum having been divided. As one effect of this injury must be a paralysis of the recurrent laryngeal nerve, (a motor nerve,) and as it supplies, as I need hardly remind you, the inferior constrictor of the pharynx, and the crico and thyroarytenoidei muscles, we are at no loss to understand the double embarrassment of the patient in the act of swallowing. Indeed so great was the distress occasioned, that at times it was almost impossible to prevail upon her to take even the small quantity of nutriment necessary to sustain life. • Vide "Chelius' Surgery by South," Vol. 1, p. 298. FOREIGN MATTERS EXPELLED PER RECTUM. 485 The third and fourth points of interest,-namely, had the effect of materially facilitating the steps of the irregular and hurried state of the circulation, and the operation. The neck was thereby considerably the difficult respiration, may properly be considered lengthened, and the alternate rising and falling of the together. The irritation in the air-passages, and the sternum and clavicle, and the emptying and refilling abundant secretion and cough, arose probably from of the cervical veins, in great measure prevented. It congestion of the pulmonary vessels, which I imagine has also, according to Mr. Sibson, the very desirable to be caused by the sudden closure of one important effect of preventing the descent and deepening of the outlet from the left side of the heart. It would carotid during the inspirations. naturally follow, if the free egress of the blood from the left ventricles were prevented, that the pulmonary veins must become engorged, and indeed the whole HISTORY OF A CASE IN WHICH A MASS Cornwall Infirmary. (Read at the Annual Meeting of the South Western Branch of the Provincial Medical and Surgical Association, held at Truro, July 16, 1847.) A. C., a young woman, aged 16, voided with excessive foreign matters, the first about the size of an ordinary pain, on the 12th of March last, two large lumps of pullet's egg, the second larger and longer, much compressed, and very hard, having a thin albuminous coating, which served to conceal the character of the contents of the lumps until forcibly separated. After having been carefully washed and dried, the materials of which the masses were formed were found to be numerous small parcels of dyed wool, of various colours; of hair, of different colours; of thread; of fitted together, and weighing one ounce and five worsted; and of cotton and linen rags, all compactly drachms, avoirdupois. thoracic circulation must be obstructed-a condition | which would give rise to great irritation of the pulmonary organs, and the abundant mucous secretion present in this case. A precisely similar state of things By EDWARD JOHN SPRY, Esq., Surgeon to the Royal occurred in my patient, Mary Scattergood, upon whom I operated for aneurism of the arteria innominata, both after the ligature of the common carotid, and subsequently after tying the subclavian artery. I find too from an excellent paper by Professor Miller, of Edinburgh, in the London and Edinburgh Monthly Journal of Medical Science, 1842, that in the majority of the fatal cases of operation on the large arteries of the neck, he considers death is attributable to inflammation of the lungs; and my friend, Professor Fergusson, of King's College, seems to incline to the same opinion. Of course, under common circumstances, our sheet anchor in combating such symptoms would be repeated blood-lettings, and the administration of opium; but in the case of Mrs. Osborn, there were such frequent and alarming attacks of syncope, and the utter prostration and exhaustion from the loss of blood at the time of the injury were such, that we were repeatedly driven to the employment of stimulants in large quantity, when other symptoms seemed urgently to demand an antiphlogistic mode of treatment. In short, the advanced age of the patient, and the absolutely drained condition of the vascular system, in spite of the local engorgement, forbade the use of any other remedies than opiates, expectorants, and counterirritants, due attention being at all times had to the state of the primæ viæ, and the persevering and almost hourly administration of nutriment. I have not thought it necessary to make any observations on the operation of ligature of the carotid, but I may be pardoned, perhaps, for shortly pointing the attention of the meeting to a suggestion of my esteemed friend, Mr. Sibson, of the Nottingham Infirmary, in reference to it. In a case of aneurism of the right common carotid, in which the vessel was successfully tied by Mr. White, of Nottingham, Mr. Sibson advised that the patient should expire forcibly before the commencement of the operation, and that the chest should be firmly bandaged, the patient, during the operation, being directed to breathe as much as possible by the aid of the diaphragm and abdominal muscles alone. This expedient was accordingly adopted, and At the time of passing these lumps she was 30 reduced, by a severe illness of many months, as to be quite unable to sit up, and her mother was under the necessity of holding her in the sitting posture, whenever she attempted to relieve the bowels, so that she had the very best evidence of their expulsion from the rectum. She took them immediately to a pump in the yard, and having procured two sharpened sticks, she endeavoured to separate the materials of which they were composed, but it required considerable effort on her part, and the long continued pressure of a large stream of water, to accomplish the task. The patient had been so reduced by her previous illness, of which I will give an outline presently, as to give up all hope of recovery; and when I visited her on the day following this event, I asked her in the presence of her parents, and in the full consciousness of her critical condition, if she recollected having swallowed any part of the matters evacuated. She most solemnly assured me that she did not, and her parents added that they firmly believed her statement. The mother then said, in reply to a question which I put to her, as to the possibility of her obtaining access to such things, that when her daughter was learning to walk, she could get at the seat of a settle in the kitchen, by the edge of which she held, and that the children often amused themselves by turning over the contents of this box, in which old rags of all sorts were deposited; that she believed her daughter must have then indulged in the odd fancy of swallowing the various matters now presented to your notice. My attendance on this young woman commenced in September, 1846; she was then in an anæmic state, complaining of general debility. The usual treatment was adopted, and her health improved. The catamenia appeared slightly about two years before, and then ceased. her from her friends, who described her state to be fluctuating, still suffering acutely at times, and requiring now and then a dose of morphis, and so she continued until the 12th of March, when the singular evacuation was effected, with a description of which the case was commenced. From that time she steadily improved, and on the 3rd of July she was able to come to Truro. She appeared healthy, and fresh-coloured. She had grown considerably. The bowels acted regularly, although now and then she suffered severe pain, and her digestion was languid. The catamenia have been regular for the last three periods. DISLOCATION OF THE HIP-JOINT, REDUCED , UNDER THE INFLUENCE OF ETHER. On the 30th of October, I was again requested to see her, and found her complaining of severe pain in the bowels, and her mother directed my attention to a considerable swelling, just below the margin of the right ribs, and occupying the whole of the right hypochondrium. This tumour had a well-defined edge extending toward the epigastrium, and firm pressure on it occasioned pain. Leeches and fomentations were diligently employed, succeded by alteratives and frictions of iodine, but with little result. By E. F. DEHANE, Esq., Surgeon to the Dispensary, Rigors came on; severe darting pains were felt, requiring her to take frequent doses of the solution of the acetate of morphia, in addition to the fomentations and general treatment. The symptoms indicated the formation of abscess, and I prepared the parents for that event. Bilious vomitings soon after this came on, and on one occasion she brought up a large quantity of green bile and pus, streaked with blood. This was repeated at intervals, and her strength rapidly gave way; the pain she felt at times was excruciating, and she was reduced to a mere skeleton. In this condition she was when Dr. Barham visited her on the 13th of November, and it appeared to us that there was very little opportunity left but to carry out the principle of the Euthanasia, scarcely considering that there was a chance of her recovery. As she resided seven miles from Truro, I saw her very seldom after this period, and on one of my visits her mother said that she thought the swelling had shifted more to her left side, which on examination I found to be so far correct, that in consequence of her great emaciation, a tumour could be readily felt in the descending colon and left iliac fossa; but the original swelling in the hypochondrium was not much reduced, it was softer. I directed the same plan to be continued, fomentations, friction of the bowels with anodyne embrocations, the occasional use of morphia, with every nourishing preparation that her appetite would permit her to take, to support her strength. One remarkable circumstance attending this illness was the regular and easy evacuation of the ordinary contents of the bowels, which were for the most part of a natural colour and consistence. January 9th, 1847. I found her much easier, and the whole abdomen softer; the sickness had subsided, but as there was still considerable swelling in the right side, I was induced to give her, with some tonics, small doses of the solution of the bi-chloride of mercury, which she continued about a month with apparent benefit. Her appetite had improved, and she had gained a little flesh. From this time she took little medicine, but wore a belladonna plaster over the epigastrium to relieve the occasional pains she felt there. I heard of Wolverhampton. Thomas Connelly, a strong muscular man, employed as a furnace-man in the neighbouring iron works, was brought to the wards of the Dispensary on the 15th instant, under the following circumstances:-He was getting over a stile, when his foot slipped through the bars, his body falling in an opposite direction, by which his leg had to sustain the whole weight of the body, which acted as a lever against the leg and thigh; the consequence was, that the head of the femur was dislocated into the foramen ovale. The accident occurred four days before admission. On examination it was found that the limb was elongated to the extent of three inches, the heel elevated from the ground, the toes slightly everted, the knee advanced, and the thighs separated from each other; any attempt to handle the parts produced exquisite pain. Now I thought this, in conjunction with my colleague Mr. J. Cartwright, and Mr. Pope, the House-Surgeon, a proper case for the exhibition of æther, which he inhaled for about five minutes, when he became to all appearance intoxicated, but by no means insensible. He was placed on his back upon a mattress, the pelvis fixed with a towel, and the pullies attached to the upper part of the thigh, and the extension, of course, made upwards and outwards, so as to remove the head of the bone from the foramen ovale back to the acetabulum, at the same time inclining the foot inwards across the other leg. Having continued the action of the pullies for about four minutes, the head of the bone returned into its place with a sudden jerk. The patient did not appear to suffer much pain, although great force was gradually exerted for its reduction, and he had the appearance of a person partially tipsy, and continued to talk and laugh throughout the operation. The case is going on well. Wolverhampton, July 25, 1847. WEST NORFOLK AND LYNN HOSPITAL. Ferdinend Hess, a sailor, aged 18 years, had fallen from the yard-arm of a Prussian bark, lying in the river, upon the deck, and from thence into the hold of the vessel, October 24th, 1846, noon. He was picked up perfectly insensible, and immediately conveyed to the hospital and visited by Mr. Cotton.-Symptoms: pulse weak; surface pale and cold; breathing slow; pupils somewhat contracted; lies in a senseless comatose condition, but screams loudly, uttering obscene English, (his only acquaintance with the language,) when the injured parts are examined. The face and head are much bruised and injured; the left eyelid ecchymosed and closed; there is a large puffy swelling with depressed centre, above and behind the left ear, about the occipitotemporal angle of the parietal bone, and free bleeding | from the auditory passage; the left thigh is fractured at its centre; the left shoulder much contused and flattened; the arm elongated and lying loosely by the side; there is marked crepitation and considerable mobility on rotating and raising the limb. Head shaved and cold applied. Liston's straight splint adapted to the thigh; arm placed on a pillow, and fixed by straps to the side. 8 p.m. Has been occasionally shouting and screaming during the afternoon. He is now continually raving and calling out; pulse sharp and frequent. Venesection, carried only to seven ounces, owing to its lowering impression upon the pulse. A scruple of calomel with sugar, placed on the fauces; a drastic enema of jalap, salts, and gruel thrown up the rectum; after which he became more quiet. Allowed only cold water to drink. * October 25th. 5 a.m. Head bot; pulse rapid and faller; blood still oozes from the ear; talks incoherently; has passed urine freely in the bed. Enema repeated with the addition of turpentine. Calomel and croton oil placed on the tongue. 10, a.m. Much flatus from the bowels, but not otherwise moved; vomited about two hours ago fætid stercoraceous-like matter, when the raving ceased and a comatose condition supervened. 2 p.m. More conscious; mutters on being roused or disturbed; pulse 120, small and weak; skin warm. As the bowels have not been relieved threw up again a drastic injection. 11 p.m. The enema has acted freely, and the boy is more rational. Pulse less weak; occasionally wanders and attempts to remove the straps which secure his arm. 487 October 26th. 10 a.m. Is still in a semi-comatose state; bowels moved three times in the night; had slept at intervals, awoke moaning; tongue furred; skin hot; pulse 110, full; the ear discharges a sanguineo-purulent fluid. Give only cold water for diet. Continue the spirit wash to the scalp, and should symptoms of increased irritation or sigus of compression occur, irritate again the rectum. 10 p.m. Bowels freely opened; has been less drowsy, and the muttering has altogether ceased; skin less hot; pulse more compressible. October 27th. Calm and collected; pulse 90; skin cool; frequent fluid evacuations from the bowels, in which was found an immense Ascaris lumbricoides ; effusion of scalp disappearing; endeavours to express in his own tongue his desire for food. Let him have a little gruel. 28th. Better; pulse quiet, 86. 29th. The house-surgeon called in the night, found bim recovering from a severe convulsive fit; has slept a little since; points to his ear, in which he seems to be suffering much pain; pulse quickened; tongue white and furred, and skin hot; is occasionally dozing and incoherent. Apply eight leeches behind the ear, and hot fomentations assiduously afterwards. Pulv. Calom. cum Jalap. statim. Vespere.-Dozed heavily during the morning, and did not notice the application of the leeches; pulse 78, on being roused 90; pupils mobile. In case of a recurrence of convulsion, or the pulse becoming slow and labouring, do not hesitate to bleed. A tea-spoonful of fœtid semi-purulent matter escaped whilst examining the auditory passage. October 30th. No return of convulsion; had slept but little, but remained quiet; some bleeding from the nose, and spitting of bloody mucus from the mouth; pulse 80; skin cool; complains of his shoulder. Permitted to have milk. 31st. Rather restless and delirious during the early part of the night. November 1st. Rested better; pulse 70, weak; no symptoms of suffering or of cerebral, irritation. Let him have bread with his milk. 11, p.m. Much pain in the ear. Apply eight leeches, and afterwards hot fomentations. 2nd. Pain removed; rested well after the application of leeches, &c.; free discharge from the ear; bowels unmoved two days. Solution of sulphate of magnesia with senna. 4th. The draught acted freely; going on well. 6th. Cleanse and foment the ear occasionally, which continues to discharge very offensive sanio-purulent fluid. Allow only milk and bread for diet. 17th. Health good; discharge from the ear has ceased; thigh re-bandaged. Allow, in addition to the milk, some broth and pudding. December 9th. No headache nor uneasiness; angry and abusive about his diet, and very refractory; refuses to lie still in bed. Let him have middle diet. The swelling of the scalp has entirely disappeared; the depressed portion of bone, about the size of a shilling, surrounded with callous irregular edges, is easily detectable by the fingers. 30th. Allowed to get up; the thigh secured by applied; the fractures of the extremities adjusted; a plaster and side splints. vigilant look-out observed; and a resort to cautious bleeding and other derivative and subdepletory measures, only on the supervention of exalted action and febrile inflammatory disturbance. Returning power and con January 10th, 1847. Whilst carelessly walking and larking about the wards, fell and again fractured the thigh. Liston's straight splint re-applied. March 25th. Allowed to get up, but to remain quiet.sciousness quickly followed the vomiting; and purgaApril 3rd. Union complete; walks with the assistance of a stick. 11th. Complains of headache and pain in the left ear, which has discharged during the last few days a fœtid purulent fluid. The illuminated speculum shewed three or four myrtleberry-like granulations around the ruptured tympanum and surrounding ulceration. Haust. aper. domest. statim. Apply six leeches behind the ear, and afterwards hot fomentations. Low diet. 13th. Ear discharges freely. Solution of inspissated ox-gall to be dropped in night and morning. 19th. Feels quite well; there remains a slight purulent weeping and deafness of the left ear; walks with but little impediment, and excepting some slight difficulty in raising the arm, and passing the hand behind the head, the injured shoulder has completely regained its strength. Ordered in consultation to be discharged cured, as soon as a Prussian vessel enables him to return to his home. Remarks. Recovery even after more serious complications is not uncommon; the case, however, is not altogether devoid of interest, inasmuch as it helps to establish the now prevailing practice of not needlessly interfering in the majority of head-injuries. Although the symptoms did not denote concussion of the worst degree, and the youth of the patient was favourable, the seat of scull fracture, bleeding from the ear, &c., predicated considerable mischief, and, coupled with the damage to the thigh and shoulder, afforded but an unsatisfactory prognosis. The shouting and raving occurring so early after the accident, was looked upon as resulting from irritation of the brain's surface; and the absence of any persistent manifestations of excitomotory, or ganglionic implication, gave hopes that the substance of the brain had sustained no material lesion. Guided by the severity and succession of effects, rather than the nature or extent of the injury, an accurate knowledge of which can rarely be arrived at, the treatment was simple:-the head shaven and cold Of the propriety of waiting for symptoms, and the toleration of head-injuries in young persons, among several instances under my care, I particularly remember two :One a child, 5 years old, upon whose head a sea-stone had fallen, tearing extensively the scalp, fracturing through the middle of the whole length of the right parietal bone, and depressing the lower half, which, with the sanction of the late Dr. Wayte, was simply replaced with the elevator. The other a girl, about 8 years old, was struck on the left temple by a windmill sail, and considerably stunned. When brought to the hospital she complained somewhat of head. ache, and appeared drowsy, and an immense oval indentation of the skull existed at the seat of injury. A cast was taken previonsly to her leaving the hospital, when the indentation remained as at first, so deep, that the bowl of a large dessert-spoon could easily be received into it. No ill symptoms supervened in either case. Low diet, shaving the head and applying cold, quietude, and attention to the secretions, embraced the whole treatment. tion, and the repeated application of leeches, local warmth, and renewed secretions from the bowels, combined with hygienic discipline, (minus the globule imposition,) served to remove the frequently recurring attacks of internal otitis, and possibly to prevent the usual obstinate and troublesome sequences resulting from injuries to the head. A more tiresome, noisy, and refractory fellow the house-surgeon and nurses never witnessed; his violence of temper, disregard of orders, and abusive language, were considerably overlooked, at my request, as I had some misgiving of their being dependent upon perverted function and irritability of brain-fibre, the not uncommon effects of concussion, as well as owing to his inability for a long time to express intelligibly his wants and wishes. He became a favourite before he left the hospital, and acquired a tolerable acquaintance with the English tongue, and was lavish in his expressions of gratitude to those from whom he had received attention. The annoying subsequent fracture of the thigh united soundly without the least shortening or deformity of the limb, and may, with the primary fractures of the extremities, have arrested the attention of the system, and contributed to the boy's recovery. ST. PANCRAS DISPENSARY. CASES ILLUSTRATIVE OF THE CONDITION OF THE SYSTEM WHICH IS ACCOMPANIED BY OXALIC URINE. By EDWARD BALLARD, M.D., Lond., Physician to the St. Pancras Royal General Dispensary, and Medical Tutor in University College, London. (Continued from page 463.) CASE VIII.-DEBILITY. E. A- -, aged 10 years, having never enjoyed absolutely good health, and presenting some of the marks of a scrofulous temperament, was brought to the Dispensary on May 25th, 1846. It appears that five weeks ago she was sent to school, and from that time her health appeared to be declining; she became languid, and lost her appetite, and flesh. Five days ago she was seized with vomiting, accompanied by pain across the navel. Her lips and cheeks are now pale, and she presents several deformities,-namely, lateral curvature of the spine, prominence of the abdomen, a pigeon breast, slight enlargement of the wrists, and the left knee is bent inwards. The mother states that she has lately been subject to profuse night perspirations. She is weak, but the pulse is natural in frequency. She is always now complaining of thirst. The bowels are regular, and she has no vomiting. She was directed to take a nutritious diet, and to be as much as possible in |