into the cellular tissue, and it extended over the head, the neck, the trunk, and the upper extremities to the ends of the fingers. At the sternum, the finger, before reaching the bone, penetrated fully an inch. It was unfortunate that a post-mortem examination was not permitted, but the evidence afforded by Dr. Atlee is, we think, conclusive. He shows that when the neck had struck the scraper, the rings of the trachea had been separated from one another, but that they had remained in place until dislocated by the act of throwing the head backwards. When this occurred, the air contained in the lungs was forced violently into the cellular tissue of the body.

66

ART. 97.-On the Treatment of Suppurated Cervical Glands.
By M. PAGET, F. R. S.

(Medical Times and Gazette, Jan. 2, 1858.)

In the notes of practice among the out-patients of St. Bartholomew's Hospital, to which reference has been already made, are the following remarks:The great number of strumous children, that come to out-patient's rooms with slowly suppurating cervical and other lymphatic glands, supply, I believe, evidence enough that the best plan in all such cases is to leave the suppuration to increase till the skin over it is so thin, that one might think that in a day or two spontaneous ulceration would ensue. The thinnest part of the skin should then be punctured with a small knife, so as to make an opening not more than . two lines in length. Through this opening the pus should be allowed to flow out slowly the abscess-walls should on no account be pressed. If the pus will flow in mere drops, it is well; if it stop altogether, no harm will follow. No more should be done than to cover the abscess with a soft poultice or with warm water-dressing, which should be removed twice or three times a day. The abscess thus treated will slowly empty itself, as the inflamed and stretched skin slowly recovers its elasticity and contractile power; or if the little wound should heal before the emptying, it will in a day or two reopen; or, at the most, the puncture may need to be repeated. The advantage of the plan is, that the punctured skin does not ulcerate or slough, the abscess-wall does not inflame, and recovery ensues without disturbance of the general health, and with a scarcely visible scar. In the great number of cases that I have thus treated, I do not remember to have failed to obtain these advantages. Usually, the healing of the abscess is completed within three weeks-in strong contrast, both as to time and manner, with the tedious healing and ugly scarring that often ensue when these abscesses are left to open spontaneously, or are opened widely with the knife or caustic.

"The internal treatment which I have always employed in these cases when suppuration has taken place (and which, if any, will prevent its occurrence), is the giving of tonics, or iron, and good food. The medicines for children may be, according to the case, from two to five grains of the potassio-tartrate of iron, or from five to ten grains of the liquor cinchonæ, or a drachm of the codliver oil, three times a day. The first I think best in ordinary cases, in which the characters of struma are well marked, and not complicated; the second appears best when with struma there is marked debility, drooping, deadly pallor, duskiness; and I think it is a very good plan to give the bark with limewater; the third seems fittest when great emaciation exists. In all cases it appears useful to give occasional small doses of the hydrargyrum cum cretâ, with rhubarb or the sesquioxide of iron. I doubt whether iodine does good in any of these cases, unless in combination with iron."

(B) CONCERNING THE CHEST, ABDOMEN, AND PELVIS.

ART. 98.-A new Bandage for Fracture of the Clavicle. By Dr. Julian

CHISHOLM.

(Charleston Med. Journ. and Review, March, 1858; and American Journal of Medical Science, April, 1858.)

Dr. Chisholm describes a simple, and what seems to be, at the same time, a very efficient bandage for fracture of the clavicle.

The bandage is formed of a strip of cloth, from three to five feet long, and from eight to eighteen inches wide (according to the size of the patient), which is slit from both ends in such a way as to leave a bridge from one to two inches wide in the centre, connecting the two lateral half strips. A soft pad having been placed in the axilla, to act as a fulcrum upon the riding fragment, the affected arm is carried over the chest, the palm of the affected hand resting upon the side of the thorax, under the border of the opposite armpit. This position of the arm removes all deformity, and brings the fragments in apposi tion. The centre of the bridge of cloth is now placed under the elbow, the superior strip, which covers half the height of the affected arm, is made to encircle the chest; one end is carried forward, the other backward, to meet the opposite armpit, where, after enveloping the hand, and being firmly drawn upon the affected arm, they are secured with needle and thread, pins, or an ordinary knot. The inferior strap, which is placed under the affected arm as a sling, is made to traverse the chest in the same way, the ends meeting over the opposite shoulder, where they are secured by the same means. If at the several points where the strips cross each other, a stitch or a pin is placed, the result will be a firm casing, which, even in the most restless child, cannot be disarranged. The needle and thread is by far the preferable mode of completing and sustaining the adjustment, as the stitches are not apt to be interfered with by the patient or friends; pins, on the contrary, are often tampered with, particularly if there should be any restraint from the bandage. As the material is quite soft, no binding or excoriations are produced. The bandage supports the entire limb in an easy position, and clasps the arm sufficiently to prevent injurious motion, without being irksome to the patient. It requires no constant renewal, as one single application, if carefully made and properly secured, can be worn until the cure is perfected.

Dr. Chisholm says he has used this simple contrivance for several satisfaction.

years with

ART. 99.-Removal of the Entire Body of the Scapula. By Mr. Walter, of

Pittsburg, U. S.

(British Med. Journal, March 20, 1858.)

CASE.-John Kling, a farmer, residing in Franklin Township, Westmoreland County, Pennsylvania, æt. 44 years, of hepatic constitution, had enjoyed good health until some two and a half years ago, when pains of a rheumatic character were felt about the left shoulder, not, however, so severe as to interfere for a considerable time with his daily duties. About a year ago a firm tumor became perceptible on the body of the left scapula, with occasional dull and lancinating pains. The tumor steadily and gradually increased, and with its increase the pains became more severe and constant. When he applied for. admission into my hospital, it had attained a size as large as the head of a child three years old, was hard, immovable, and firmly attached to the body of the scapula; the skin covering it was slightly red, and traversed by enlarged veins. There were two fistulous openings on its surface; one caused by a seton which had been passed by a medical practitioner some time before; the other the result of an abscess which opened spontaneously. This latter led to a cavity in the diseased structure, exuding a glairy mucous fluid in small quantity. His sleep had become so broken by continual pain, and his appetite so injured, that his strength was much reduced, and his pulse small and rapid.

On a careful examination of the tumor, from its nature and firm attachments, I determined on resection of the scapula, assisted by Drs. Henderson, Lusk, and Gunster, on September 12th, 1854. A long and free incision was made from the acromion process horizontally to the posterior border of the scapula, and another from the centre of the first directly downwards below the margin of the tumor. The flaps of skin thus formed were reflected; the neck of the scapula, being found sound, was freed by touches of the knife; a chain saw was passed underneath, and the body of the bone severed from its neck; the whole mass and body of the scapula was then detached from the thorax. Profuse bleeding from the subscapular artery occurred, which was ar

rested by ligature. The wound was lightly filled with lint; the flaps of skin approximated, and retained by a few stitches, a linseed-meal poultice covering the whole; and the patient was removed to bed.

It is worthy of note, that before commencing the operation, chloroform was administered, but discontinued, from its effects on the pulse and respiration, causing a sudden corpse-like appearance of the patient. All danger was, however, averted by artificial inspiration, with the tongue drawn forward; and the operation began while the patient was yet partially insensible to pain. For several days the injurious effects of the anaesthetic continued, the patient feeling very sick, with frequent vomiting; the circulation very feeble. Recovery, however, gradually took place; the wound suppurated duly and kindly; appetite returned; all functions became healthy.

At the end of four weeks the large wound had entirely closed, in part by first intention; the residue by suppuration. A week later, the patient left the hospital, being able to make considerable use of his arm. A year afterwards, I heard from him, expressing his gratitude and delight at being freed from a painful disease, and able to follow the laborious duties of a farmer. Such was the freedom of motion and restoration of power in the arm, that he deemed it no longer necessary to observe the advice I gave him on leaving (to give it all possible rest, and to attempt no exercise but of a gentle kind).

The extirpated tumor, upon examination, was found to consist of a cartilaginous mass filled with a spicule of bone, the periosteum of the scapula being absorbed, and its surface corroded, and covered with stalactiform excrescences.

ART. 100.-Obliteration of the Superior Vena Cava. By Dr. OULMONT.
(New York Journal of Medicine, Jan., 1858.)

In a report on the recent advances of the medical sciences in France, by Dr. Brown-Séquard, reference is made to a paper by Dr. Oulmont upon this rare and little-known affection. Dr. Oulmont, it appears, has observed four cases, and found fifteen other cases in various books or journals. He divides these cases into two categories, in one of which the obliteration is due to concretion or internal tumors, while in others he places the cases of external pressure upon the vein. Of his nineteen cases there are five of coagulation of blood in the vein, three of internal cancer, five of cancerous tumors of the mediastinum or lungs, two of tuberculous ganglions, four of aneurisms of the aorta. Ordinarily the first symptoms are coughing and dyspnoea, sometimes amounting to intense orthopnoea. In some cases there has been blood with the mucus of the expectoration, and even a real hæmoptysis or hæmatemesis, with palpitations of the heart. In other cases, the first symptoms have been cephalalgia, vertigo, and cerebral congestions. In some cases a very predominant symptom of the disease, and a constant one after a time, oedema of the face has been the first observed. It begins either on one or the other side of the face, quickly extending to the whole of it, and to the forehead and pericranium. The neck and the superior limbs become afterward infiltrated, and at last the oedema reaches the chest and the upper part of the abdomen, rarely extending further down, while the inferior limbs are perfectly normal. There is in the face and other infiltrated parts a bluish color, giving the appearance of cyanosis. All the superficial veins are more or less enlarged.

After a time cephalalgia and vertigo are almost immediately produced at every movement; sometimes there is a real attack of apoplexy.

Among the other symptoms we will point out insomnia, various hemorrhages (from the nose, the lungs, or the stomach), fits of suffocation, cough, &c. The pulse, strange to say, remains usually quiet, except at the end of the disease, when fever supervenes. Frequently there are palpitations, and sometimes

albumen in the urine.

All these symptoms increase gradually, and at last delirium, coma, agitation, fever, appear, and are soon followed by death. In some cases death came suddenly and quite unexpectedly. We need scarcely say that, unfortunately, there is nothing to be done in the way of treatment in this disease, except complete rest, the avoidance of emotions and of stimulating food and drinks.

ART. 101. Case in which a Foreign Body was removed from beneath the Heart. By Dr. E. S. COOPER.

(Pamphlet, San Francisco, Whitton & Co., 1857.)

The report of this remarkable case is published by the San Francisco County Medical and Chirurgical Association, as an additional paper to its "Transactions for 1857," and it is authenticated by the names of several medical men who were witnesses of the operation.

CASE.-Mr. B. T. Beal, æt. 25, of Springfield, Tuolumne County, California, with some other young men, in a frolicksome mood, resolved to burst an old gun, and accordingly loaded it with about eighteen inches of powder, to which they connected a slow match and then endeavored to seek security by flight. Unfortunately a brisk wind blew up the powder with great rapidity, and the gun exploded before they had retreated far. A slug of iron had been driven into the gun as a temporary breech pin, which bursting out in the explosion struck Mr. Beal on the left side below the armpit, fracturing the sixth rib, entering the chest, and lodging, as was afterwards found, beneath the heart upon the vertebral column, just to the right of the descending aorta, where it had evidently remained from the period of the injury, on January 26th, 1857, until it was removed April 9th, seventy-four days after. In a state of extreme prostration he was brought to the city, having had frequent discharges of several ounces of purulent matter at a time from the chest through the original wound. The left lung had lost its function, probably less on account of the violence done the lung at the time than from the subsequent accumulation of pus in the chest, though he had bloody expectoration for a few days. He came to my infirmary in Mission Street, 8th of April, and during the night following had alarming symptoms of suffocation, so much so that I entertained most serious apprehensions that he would not live till morning. So urgent had his symptoms become that after his arrival he was constantly in absolute danger of dying from suffocation, so that no time was to be lost, even for him to obtain rest from the fatigues of his journey.

Operation. The patient being placed on the right side, an incision through the soft parts three inches long was made; commencing opposite to the seventh true rib, and following the track of the original wound, was carried over the fifth and sixth ribs, which were drawn close to each other by contractions, consequent upon the injury. The sixth true rib was found fractured and slightly carious. A transverse incision three inches long, was now made, beginning at the centre of the first, when the soft parts were reflected, so as to expose the ribs. Torsion was applied to one intercostal and two or three small arteries which bled rather freely. The wound was now fully absterged, after which an effort was made to find the breech-pin by using the probe. This failing, the incisions were lengthened, and the ribs further exposed. A portion of the sixth rib, which was carious, was now removed, and was followed by the discharge of about ten ounces of fluid resembling venous blood, contained in a cyst which was broken by the removal of the portion of the rib. A most extensive but careful examination with the probe was now made, in order to detect, if possible, the foreign body, yet to no purpose; but air having already been admitted into the chest, I unhesitatingly removed portions of the fifth and seventh ribs, together with such an additional piece of the sixth as was necessary to make ample room to afford every facility for the further prosecution of the search. Some very firm adventitious attachments were now broken up with the fingers, which gave exit to an immense amount of purulent matter-two quarts at least-which had been entirely disconnected with the fluid first discharged from the chest. The pleura had several large holes through it, and was thickened to four or six times its natural state in some parts. The pulsations of the heart in the pericardium could be distinctly seen through these holes. Brandy was now administered freely to the patient, who appeared to be rapidly sinking. The left lung was found completely collapsed after the discharge of purulent matter. By giving brandy freely the patient soon began to revive, when the search for the foreign body was resumed. At this time the

fingers could be placed upon different portions of the heart and feel its pulsations distinctly, but could obtain no clue to the existence of a foreign body. The patient now appeared almost completely exhausted. Brandy was given freely. Chloroform was not administered at first, owing to the expected collapse of the left lung on the admission of air into the chest; but a considerable reaction taking place, a limited quantity was now used, and the manipulations continued. A sound was introduced, and the thoracic cavity explored for at least three-quarters of an hour before anything like a metallic touch could be recognized, and then it was so indistinct as to leave the matter doubtful.

The space immediately above the diaphragm was considered the point at which the metal was most likely to be found; since the immense amount of suppuration which had taken place, it was thought might have dislodged, and gravitation carried it down to the bottom of the chest. The metal not being found here there was no longer any probable opinion to be formed as to its whereabouts, and to describe the difficulties of the search that followed would be difficult if not impossible. No one can have any just conception of the degree of patience required to do what was done, save the one who did it. This is not spoken boastingly, but it is simply the truth. It is sufficient to say that a general exploration of that side of the chest was made, and then it was taken by sections, occasionally passing through holes in the pleura, which latter appeared to have scarcely no normal relations to the surrounding structures, touching by lines the entire surface of the parts, and at last the sound appeared to encounter something of a metallic nature beneath the heart, but the pulsations of that organ were so strong against the instrument as to render it difficult to settle the matter definitely. At last, however, it became evident that the location of the iron was found, and I endeavored to move it out of its position with the point of the sound, in order to get it into a place more eligible for extraction by the forceps. I failed in this, and in manoeuvring the instrument finally lost the track by which the sound had first passed back of the heart to the metal; and it was during my efforts to recover this, and which was accomplished with the more difficulty owing to some membranes falling in the way, that I discovered the sound had in the first instance reached the metal by passing between the descending aorta and the apex of the heart. The metal being again found, the sound was steadily and strongly held in contact with it until a pair of long lithotomy forceps was thereby conducted to the spot and the breech-pin seized and extracted, which, however, was the work of several minutes, owing to the great difficulty in grasping it even after the forceps was made to touch it. The forceps, however, being heavier, the motion of the heart was not so embarrassing to its manipulations as it had been to that of the sound; but owing to its size, it could not follow the sound and be expanded sufficiently to seize the metal without lifting the apex of the heart considerably out of its natural position. After the metal was extracted, the patient was turned on the wounded side, and a tent placed in the track of the original sinus, after which the wound was dressed and the sufferer permitted to rest in bed with his body still inclined towards the injured side.

April 10th.-Greatly prostrate; slight pain in the left breast; no motion of that lung; gave morphine.

11th. Same as yesterday.

12th. Slight cough; gave enema and light nourishment.

13th.-Evacuations from bowels; slight discharge from the wound, being the first since the operation.

14th.-Improving; considerable appetite.

19th. Considerable cough.

20th.-Severe cough to-day and pain in the right side, as also in that of the wound, though not so great as in the other.

Skin dry; no expectoration; urine scanty and highly colored. These symptoms were very alarming, the more so from the fact of their implicating the hitherto sound lung.

The pneumonic symptoms continued without abatement for several days, and finally subsided, but left the patient greatly prostrate. On the 26th, purulent expectoration began and continued to increase for about a week,