QUEEN'S HOSPITAL, BIRMINGHAM. after which the discharge is profuse, with unusual disturbance of the general system, The great sympathy between the uterus and the mamma is very remarkable; and upon this sympathy the affection of the mamma does, in a great measure, depend. Mr. Carmichael has, however, seen scirrhus of both mammæ in a child, aged 12; and Sir Everard Home relates a case in which it occurred at the age of 15. On the other hand, persons of the most advanced age are not exempt from the chance of its development. Dr. Walshe relates the case of a female under his care who was nearly 70; Sir Astley Cooper has seen the disease in a female, aged 86; and Cruveilhier maintains that such facts are of almost too frequent occurrence to be looked on as exceptional. According to the opinion of Sir Astley Cooper, scirrhus of the breast occupies from two to three years in growing, and from six months to two years in destroying life; but in this case, the patient only perceived it seven months previous to its extirpation. This case is also remarkable for the absence of pain, which was never much complained of, and was seldom attended with exacerbations; the case is also peculiar on account of the number of cysts which occupied the substance of the breast. 69 instances, and the chance of it may be sufficient to warrant you in recommending the patient to submit to the operation. I have the satisfaction of knowing, that several persons on whom I have operated under these circumstances, are now alive and well, but who would certainly have been dead long since, had I not had recourse to it." I may here remark, that the treatment this patient received three months previous to her admission into the hospital was unwarrantable in the extreme; no man, who understands his profession, would ever think of thrusting his lancet into a scirrhous breast; for this imprudent act caused in this case, by the irritation it produced, the rapid increase in the tumour, and the throwing out of an extensive fungus, which, by repeated bleedings, was enfeebling the patient. CASE XXI. COMPOUND FRACTURE OF BOTH THIGHS AND LEGS. Samuel Hare, aged 40, labourer on the Gloucester railway, admitted into the Queen's Hospital, on July 29th, 1846, at half-past five o'clock, p.m. It is stated that about an hour previously, a loaded luggage train passed over the lower part of his body; he did not lose much blood at the time. When admitted he was in a complete state of prostration, with cold skin, weak slow pulse. On examination, there was found compound fractures of both legs and thighs, with a large lacerated wound on the right thigh; very slight oozing of blood from the wound. Stimulants were administered, but he gradually sank, and expired at twenty minutes past six o'clock, p.m. The results of the operation for the extirpation of cancer are very unfavourable. Mr. Mayo's experience has led him to the conclusion that, "after amputation of a scirrhous breast, under the most favourable circumstances, that is to say, when the operation is performed at the earliest period at which the structural character of the disease has declared itself in the gland, no other part being yet invaded by it, and the diseased structure On post-mortem examination the next morning, the being entirely removed, I believe that in ninety-nine following extensive injury was discovered :--A comcases out of a hundred the disease returns either in the pound comminuted fracture of the right femur, about cicatrix, or in the axillary or subclavian glands. The its middle third, with a large lacerated wound, extendoperation, therefore, cannot be performed with any ing more than six inches from above downwards, and reasonable prospect of saving the patient eventually four inches across, the muscles beneath on the inner from the disease." Dr. Macfarlane states that he has side of the thigh being extensively lacerated and torn; never seen a case, even of the most favourable descrip- comminuted compound fracture of the right tibia and tion, in which the disease did not return, although every fibula, the former bone being much shattered at the precaution was adopted to render the operation suc-junction of its middle, with its upper third; a lacerated cessful." Dr. Macfarlane refers to 118 cases, and although in the majority the parts were freely and extensively removed, at an early period, and under the most favourable circumstances, in many instances no distinct indication of constitutional deterioration being present, yet in all the disease returned both externally and internally, and proved fatal. What then, are the cases in which amputation of a scirrhous mamma may be deemed proper? Sir Benjamin Brodie gives the following reply:-"When the skin is perfectly sound-when the nipple is not retracted-when there is no diseased gland in the axilla-when there is no sign of internal mischief— when there is no adhesion of the breast to the parts below-and when the patient is not very much advanced in life, I should say, that there is a reasonable chance of an operation effecting a cure. I do not intend to say that in all expected cases there will be a permanent cure, far from it; but there will be in some • Outlines of Pathology, p. 573, wound on the outer side of the right ankle, and one also on the sole of the foot; a compound comminuted fracture of the left femur, with a lacerated wound of about half the size of that on the right; a very extensive compound comminuted fracture of both the bones of the left leg. No wounds or fracture of any other part of the body was discovered; the marks made by the carriage wheels are very evident on the right thigh. The severe nature of the accident caused in this patient such a prostration of the system, that re-action did not ensue; had he revived amputation of both thighs above the aeat of injury, would have been the only chance left for recovery. (To be continued.) NORTH STAFFORDSHIRE INFIRMARY. CASE OF EXOSTOSIS OF THE TIBIA, AND By J. SEDDOM, M.D., F.R.C.S., &c., lately one of This plan was unremittingly pursued till the middle of April, but the tumour had become decidedly larger, and the patient was now suffering considerable pain. A consultation of my colleagues was therefore called, when I submitted for their consideration a proposal to remove the tumour by excision; this was decided upon, and the operation undertaken, May 2nd. A free incision, commencing at the lower part of the poplitieal space, and within the inner hamstring, was extended about four inches downwards, on the inner edge of the gastrocnemius, and parellel with it. This was continued across the muscle, and carried a little upwards, so that the cut had somewhat of a hooked appearance. By this means, a flap was formed of the muscles of the calf, which was turned upwards; two bleeding vessels were tied at this stage of the operation. The tumour now became apparent, covered only by an expansion of muscular fibres. The house-surgeon, Mr. S. Alford, having drawn aside the vessels and nerve, by means of a hooked copper spatula, the muscular fibres were divided so as to expose the tumour clearly; bad an extensive attachment to the tibia, and overhung its inner edge, so as to fill up the interosseal space at this part. By means of a chisel and mallet applied to its inner edge, it was partially divided; the chisel was then worked into the internal structure of the tumour, with the hand alone, and by raising the handle of the instrument, the bony mass was forced from its attachment; a few projecting points of bone were removed by the bone-nipper. Some lint having been applied to the bottom of the wound, the muscular flap was laid down, and a piece of lint placed over it, and this being retained by a bandage loosely Sumat applied, the patient was carried to his bed. Tinct. Opii, min. xxv. e Mist. Camph., oz. j. statim. Hydrarg. Chlor., gr. iv., hora somni. than was anticipated. The tumour was as large as a middle-sized potato, had a nodulated appearance, and a flesh colour, having somewhat the resemblance of large granulations; but this appearance was only superficial; internally it had a cancellated bony structure. The diameter of its base was nearly three inches. May 3rd. The limb somewhat swelled; the bandage and outer dressings were removed, and lint soaked in warm water applied. 4th. Going on favourably; some fever; bowels have not been moved. Med. Efferv. Ol. Ricini, oz. ss. Appl. Catapl. Lini vulneri. 6th. Some erythema about the ankle. Appl. Catapl. Lini parti affectæ. 12th. Going on well; the muscle bulges from the wound, but has a healthy granulating appearance; general health good. Middle diet. White lead cerate spread on lint applied to the wound, and support given by a bandage. 17th. Improving. Lint wet in sulphate of zinc lotion applied to the wound, and support given with adhesive straps and bandage. From this time the patient continued to improve. He was discharged cured, June 30th. Soon after his discharge he resumed his employment as a farmer's servant. I have lately heard of him, and learn that he is perfectly well, and follows his employment without inconvenience. The difficulties of the operation which presented themselves to myself and colleagues before it was undertaken were:-First, the danger of wounding the vessels and nerve, passing from the poplitieal space; secondly, it was thought possible that the tumour might extend so far upwards as to endanger the opening of the capsule of the joint; and lastly, if the excrescence were of a firm texture there might be considerable difficulty in detaching it from the bone. However, as it was considered that amputation of the limb would soon be required if the tumour continued to increase, it was decided to undertake its removal, having first apprized the patient of the dfficulties and danger of the case. I had no apprehension that the disease was of a malignant character, as the patient had a healthy aspect, and his general health had always been good. PROVINCIAL Medical & Surgical Journal. WEDNESDAY, FEBRUARY 10, 1847. We have lately had our attention drawn to an important document from Mr. Chadwick, which, although addressed to a local authority, the Town Clerk of Liverpool, and for a special purpose, yet contains the enunciation of sound principles, of general application in reference to the subject of which it treats. This document is in the form of a letter-a The operation was effected with much less difficulty well-merited testimonial to the unwearied zeal, HEALTH OF TOWNS: MEDICAL INSPECTORS. 71 was, on the average, twenty-one years:-the loss of life of the adults who died in Liverpool, as compared with Ulverstone, was on the average, twelve years and six months to each individual. Supposing the lost labour of these adults to be worth only ten shillings per week, the lost productive labour of that year was, demonstrably, a loss of nine hundred thousand pounds. The loss from the excess of sickness which accompanies the excessive mortality,-supposing twenty cases of sickness to one death, and the expense of cure or alleviation only one pound per case, must have been one hundred thousand pounds :-the loss of expense from the excess of funerals alone, at only five pounds per funeral, must have been eighteen thousand pounds during that one year. "Now, there were at the time of the census 165,094 adults in Liverpool. The impending loss of life to each of these adults is twelve years and a half-that is to say, of death twelve years and a half-before others whose sanatory condition is better, will have to submit to the general doom. Taking this premature loss of life in the pecuniary view merely,-reckoning the value of each adult's productive labour at no more than ten shillings a week,-the impending loss is at least £325 per individual." research, and talent evinced by Dr. W. H. the "It appears," says Mr. Chadwick, "that during one year the excess in number of deaths in Liverpool was no less than 10,000 above the general average mortality of the country. In year when Dr. Play fair examined Liverpool, with other towns in Lancashire, the excess in the number of deaths in Liverpool above the rate of mortality in Ulverstone, in the same County, was 3611. The loss of life by all who died that year, as compared with Ulverstone, adult Such is the loss experienced by the population of Liverpool in life, health, and productiveness. Let us now see what are the arrangements which are to be made to meet it. Among the foremost of these is the establishment of an efficient system of inspection and the appointThe actual ment of a qualified inspector. extent and nature of the evil must be detected and laid bare before the proper remedies can be applied; and these again require to be indicated, the best mode of their application to be pointed out, so as to accomplish the end proposed, and their working, also, to be superintended by com "The subject matters of the attention of the officer of health," we again quote from Mr. Chadwick, "are those causes which affect the condition of the population in the wholesale, causes which frequently cannot be met by separate and isolated arrangements in single cases. For individual cases, alleviation only is in general available; and the business of alleviation or cure, now engages the chief, if not the sole, occupation in the borough of Liverpool of twenty-seven physicians, 325 surgeons and apothecaries, and 365 chemists and druggists.” To meet this requirement the wealthy Corporation of Liverpool proposes the appointment of a medical inspector, with a salary of £300 per annum! with liberty to engage in private | duties performed throughout the country for a practice!! In reference to the labours of Dr. Duncan, Mr. Chadwick observes: "At the very outset, I would say that a pension of £300 per annum would be but a sorry recompence for what he has already done for the population of Liverpool, by the preparation of the two reports on their sanatory condition." He elsewhere shews, in reference to the proposed amount of salary, that "For the more important business of prevention-for investigating and indicating the removable or preventible causes of sickness and mortality, which ravage a population of from 280,000, or more, of persons, it appears that the Corporation propose to appoint one officer only, and to pay very little more than £1 per thousand of the persons whose general health it will be his business to protect, by indicating the general arrangements requisite for that purpose!"—and that the proposed expenditure to ascertain and point out the means of averting the impending loss of £325 per adult individual before alluded to, is "at the rate of half a farthing per annum for each adult." 66 very inadequate amount of remuneration, for the smallness of which the opportunities afforded for private practice have been held out as an inducement and a compensation. We rejoice to see Mr. Chadwick taking so just a view of these transactions, and we cannot but think that the intercourse which that gentleman has enjoyed in the course of certain of his official duties with such men as Dr. Duncan, by rendering him better acquainted with the talents, energy, and devotion required for the efficient discharge of medical duties, has tended to remove some early prejudices from his mind. We shall conclude these observations with one more extract from this admirable letter:"It is possible, and probable, that Dr. Duncan might be quite willing to perform the services in question gratis, and even be at expense (as he must already have been,—and 1 have reason to know he has been) in performing them ;-but that does not alter the question or the pernicious character of the example. ་ "The principle set forth by Mr. Burke in his speech on economical reform, as applicable My estimate," observes Mr. Chadwick, "of to public offices of the general government, the service requisite for the initiation of meaare equally applicable to such local offices sures of prevention in Liverpool was of three as the one in question. 'I will,' he says, or four officers of health at the least, giving even go so far as to affirm, that if men were their whole time to the service, at an expense willing to serve in such situations without salary, of £2,200 per annum, which, if efficiently they ought not to be permitted to do it. Ordidirected, would be a very economical expendi-nary service must be secured by the ordinary ture, as powerfully tending to reduce the annual charge of £18,000 for the excess of funerals alone. But the intended compensation for the inadequate pecuniary provision, for the services of one officer, that he may take private practice, is entirely destructive of all efficiency, even if a full number of officers were appointed, and the remuneration assigned were adequate." And again, in reference to the subject of combining private practice with the discharge of public duties: "Regular private practice not only acts constantly as an inducement to the neglect of regular public duties, but often as a severe penalty for the proper performance of them. In tracing the causes of epidemics, the officer of health must at least occasionally find it in the mismanaged or neglected state of properties owned by his patients, or by persons holding local public office, persons of powerful influence, who sooner or later may exert it to his prejudice." It will not fail to be observed, that the foregoing remarks, though applied to the individual case before us, are capable of being extended to other localities, and to other official medical motives to integrity. I do not hesitate to say that that state which lays its foundation in the rare and heroic virtues will be sure to have its superstructure in the basest profligacy and corruption. An honourable and fair profit is the best security against avarice and rapacity, as in all things else a lawful and regulated enjoyment is the best security against debauchery and excess.' REVIEW. hare undoubtedly tended to direct the public taste into this channel; but from higher considerations, the importance of a knowledge of the anatomy of the inferior animals, and a familiarity with their habits, has been of late more fully recognised; and there is reason to believe that ere long, natural history will be received as a part of general, as comparative anatomy is now of medical, education. To our illustrious countryman, John Hunter, to the immortal Cuvier, and to Owen, upon whom the mantle of Cuvier has been gracefully described as having descended, are we indebted for the most valuable discoveries in this department of science. Independently of his other important works, the "Lectures on Comparative Anatomy," by Professor Owen, have been generally recognised as conveying the most valuable and profound information on that subject which has yet been communicated; and we hailed the appearance of the second volume with unmitigated pleasure, which has been increased rather than dimin. ished by its perusal. After a careful consideration of its contents, we pronounce it to be a work which must add greatly to the already high reputation of its author. It will be recollected that in 1843, Mr. Owen published a volume of lectures "On the Anatomy of the Invertebrata." Various causes delayed the appearance of the present volume beyond the period originally intended for its publication; but we have no reason to regret that circumstance, as the Professor informs us, that "The desire to verify some of the propositions there enunciated, by repeating the observations on which they were founded, has led to many new dissections and examinations of numerous specimens; and that the utility of the present volume has been farther regarded, by ingrafting into the text some remarkable discoveries with which the science of comparative anatomy has been enriched, since 1844; and by adding details, which the time allotted to the Hunterian course compelled me to omit in the theatre." Our space will not admit of our entering into the merits of the work seriatim; we must confine ourselves therefore to a cursory survey of its contents. The Introductory Lecture deserves a careful perusal; and many of its passsges are full of beauty. Take for instance the following: 73 is associated with a recognisable object,—with some part which may be vibrating, contracting, or pulsating in his own frame. Again, "We know that it has pleased God to grant us faculties, by the right use of which we may obtain a true knowledge of His works; and it seems part of His providence to permit certain parcels of knowledge to be thus introduced from time to time, to the dissipation of the erroneous notions which previously prevailed. By the exercise of these faculties, the true shape of our spheroid was determined, and after some opposition, accepted; next its true relations to the sun, as repects its motion. It has been reserved for the present generation to acquire more just ideas of the age of the world; and anatomy has been, and must be, the chief and most essential means of establish ing this important element in the earth's history. But anatomy aids not only the geologist, but the geographer. By comparing the local distribution of restored extinct species from coeval geological strata over all the earth, with the geographical distribution of existing animals, we obtain an insight into the past conditions of continents and islands; we determine that our own island, for example, once formed part of the continent, and obtain data for tracing out much greater mutations and alternations of land and sea.” The following five lectures are devoted to a consideration of osteological homologies, and the osteology of "The great aim," says Mr. Owen, "of the fishes. philosophical osteologist, is to determine by natural characters, the natural groups of bones, of which a vertebrate skeleton typically consists; and next, the relations of individual simple bones to each other, in these primary groups, and to define the general, serial, and special homologies of each bone throughout the vertebrate series." The opinions brought forward by the author on this subject, bear evidence of acute observation, profound thought, and sound judgment; and will, we think, be found to stand the test of time. Interspersed with the necessary detail-which is as interesting as a description of bones can be-are observations indicative of much sagacity, and a just appreciation of the adapta. tion of means to ends. "The predaceous sharks are the most active and vigorous of fishes; like the birds of prey, they soar, as it were, in the upper regions of their atmosphere, and, without any aid from a modified respiratory "And first permit me to dwell a little on the inesti- apparatus, devoid of an air-bladder, they habitually maintain themselves near the surface of the sea, mable privilege which we enjoy in entering on our professional studies, by the portal of anatomy. How by the actions of their large and muscular fins. The vast and diversified a field of knowledge opens out gristly skeleton is in prospective harmony with this before us as we gaze from that portal? Consider what mode and sphere of life; and we shall subsequently it is that forms the subject of our essential introduc. find as well marked modifications of the digestive and tory study; nothing less than the organic mechanism other systems of the shark, by which the body is of the last and hightest created product which has been rendered as light, and the space which encroaches on introduced into this planet. Contrast this, which both the muscular system as small, as might be compatible with those actions; besides, lightness, toughness, and sage and poet have called the 'noblest study of man. kind,' with the dry and unattractive preliminary elasticity are the qualities of the skeleton most essential exercises of the lawyer or the divine. Every new term to the shark. To yield to the contraction of the lateral which the anatomical student has to commit to memory inflectors, and aid in the recoil, are the functions which |