In another specimen upon the table, you will see a fracture of the neck of the bone, where osseous union has taken place. On looking at its posterior surface, it is clear that the fracture extended within the capsular ligament; on looking at its fore-part, this is doubtful. The head of the bone is depressed, and the limb consequently shortened. These fractures, extending beyond the limit of the synovial membrane, as I have explained, commonly unite by bone. Here, howerever, is another preparation, in which the head of the femur is broken, and, though the fracture extends through the neck to the outside of the capsule, the uniting substance is ligamentous. But, as only three weeks had transpired from the time of the accident, when the patient, an aged female, died, it seems to me probable, that if she had lived longer, the union would have been of an osseous nature. Gentlemen, I now request your attention to two facts of practical importance, brought before us by the foregoing views: The first is, that we cannot always be positive about the fracture being entirely within the capsular ligament. The second is, that the majority of cases, when they are of this kind, admit of union by ligament, and a few by bone; while all others reaching beyond the limit of the synovial membrane towards the trochanter, having more or less of a longitudinal direction, generally unite by bone, as well as common fractures." Mr. Cooper considers it manifest that our duty, as surgeons, should always be to aim at bringing about union, by whatever substance it may be accomplished. He enjoins, whatever apparatus be employed, the quiet maintenance of the limb in a certain posture. without any attempt at pressure directly over the hip. Mr. C. does not appear to give a decided preference to any particular apparatus. IV. HOSPITAL AND CLINICAL REPORTS. I. SINGULAR TUMOUR FROM THE UTERUSMR. LAWRENCE AND DR. CONQUEST AT FAULT. [St. Bartholomew's Hospital.] OUR new contemporary, the London Medical and Surgical Journal, for as a weekly contemporary it is new, although, as a less frequent coadjutor, it is more antique, our new contemporary, then, has published a remarkable case which occurred to Mr. Lawrence and Dr. Conquest, and appears ed doctors. Ars longa, vita brevis, expeto have sorely puzzled these not inexperiencrientia fallax, said Hippocrates, and modern surgery must share in this instance a little of the opprobrium of ancient physic. But to the point. The case is headed "Caution to young Practitioners,” and comes in the shape of a clinical confession, or homily from Mr. Lawrence. We must give it entire, for it is brief and to the purpose. "GENTLEMEN, In the course of your practice you will often have occasion to exercise great caution and vigilance in ascertaining the nature of the complaints with which the patients who consult you represent themselves to be affected. You will have to guard against attempts at deception; and you will do well not to trust at all times to the explanations, which you may hear. I am about to describe to you an insructive example, which particularly illustrates this precept. A young woman was recently received into this hospital, and her disease was said to be gonorrhoea. She was a patient in Faith's Ward. After a few days the discharge from the vagina was observed to be of a colour very different from that usually seen in the gonorrhoeal fluid: it was dark coloured, and almost intolerably fetid. A suspicion began to be entertained, that the disorder was of a more serious character than was at first supposed; an examination of the uterus therefore became necessary. Upon carrying the finger to the os uteri, I felt it somewhat hardened; and from it protruded a substance extremely soft and elastic, which bore no marks of polypus, or indeed of any other uterine excrescence with which I am acquainted. It was elongated-not very large, and appeared to be attached to the internal surface of the uterus by a very thin peduncle. I found no appearance of disease in the uterus, and I concluded that this growth could have been easily removed. In the meantime the chloride lotion was used, and the discharge was deprived of its foul odour at least. This young woman had been a companion to some gentleman, but her complaint, as she herself acknowledged, was a complete bar to that fruition which she was led to expect. I determined upon extirpating the tumour; but before doing so, I thought it prudent to request of Dr. Conquest, whose peculiar experience might have enabled him to form a better judgment than I could of the young woman's disease, to visit and examine her. He accordingly paid her a visit. He proceeded to an examination; but he could not declare the nature of the tumour-although he said that he was sure he could remove it without much trouble. He was urged, however, to do so; and after examining a second time, he pulled away the substance which proved to be nothing more or less, gentlemen, than a piece of sponge! (A laugh.) It had been there for a considerable time-it was productive of great uneasiness-and it was deliberately placed in the position which it held, in order to answer certain purposes, which do not require to be more particularly specified. But this will be a lesson to you, exhorting you to be upon your guard, and to take care that you do not implicitly rely upon representations which you cannot yourselves confirm." Appended to the foregoing are some clinical remarks by Mr. L. on a case of gonorrheal ophthalmia in a female. The case itself is not of much moment, nor the observations of much importance. Mr. Lawrence is made to remark, that he has never before seen acute gonorrhœal ophthalmia in a female. In his work on Gonorrheal Ophthal mia and Syphilitic Iritis, he gives the particulars of a case of this description, communicated to him by Mr. Macilwain, and as there can be no good reason why males should suffer exclusively from the disease, and, further, as these cases alone prove that females do suffer occasionally, we conceive that the paucity of such instances in Mr. Lawrence's practice, must be in some measure the result of accident. Still, it cannot be denied that men are attacked in a much larger proportion than women. In our review, or rather analysis of the work of Mr. Lawrence, to which we have already alluded, we remarked the almost singular reluctance evinced by Mr. Lawrence to the employment of astringents or stimulants in the more acute affections of the eye. It appears from the clinical lecture before us, that this reluctance is a little diminished. It is hard to forego cherished opinions, and abandon practices consecrated by time and theory. Yet those who will not only think, but experiment for themselves, and those who will watch without prejudice the bold experiments of others, will probably venture farther than Mr. Lawrence has yet done. We had very lately an opportunity of witnessing a case of gonorrheal ophthalmia, treated by Mr. Guthrie at the Ophthalmic Infirmary, which he has erected, with infinite credit to himself and advantage to the poor, in the neighbourhood of Charing Cross. The inflammation of the conjunctiva was treated by means of the ointment of the nitrate of silver, assisted by moderate local depletion. The eye was perfectly saved. II. CHIMNEY SWEEPER'S CANCER. Mr. Earle has made some observations on this disease, which are not undeserving of attention. The subject of the case was a patient named Bennet, æt. 28, who had an affection of the inguinal glands, apparently produced by soot, and analogous to chimney sweeper's cancer. There was a deep chasm in the groin, surrounded by ulcerated edges, which seemed disposed to throw out a fungous growth, and exhaled the ammoniacal odour, which Mr. E. considers as characteristic of the disease as an acid odour is of rheumatism, and a gangrenous one of phagedæna. On investigation, the patient admitted that, about 15 years previously, he had been employed in carting soot, and, at times, had warty excrescences on the scrotum and groin; at last the inguinal gland became affected. Mr. Earle has paid some attention to the subject, and presents the following as the results of his enquiries. "The chimney sweeper's cancer has been classed amongst the number of malignant diseases, and is thought to be at first caused by a peculiarly stimulating property contained in soot. It was well known that a great deal of ammonia was contained in soot, but what it was that caused the disease in question, had not been as yet ascertained. However, it was well known to be peculiar to those countries where coals were used as fuel. This disease was described by Pott, who had published the only accurate account on the subject. He (Mr. Earle) having formerly attended a number of stations occupied by the sweeps, had been enabled to collect a mass of cases of this disease, the results of which were confirmed by subsequent experience. As that inquiry had led him to form some exceptions to the rules laid down by Pott, it was the more important to state them for the information of the pupils. The disease in question was invariably produced by soot, applied to the rugæ of the skin and scrotum; it commences with warty excrescences, which may remain stationary for years, and depending upon various circumstances. The patient in the present case was attacked gradually till six years ago. After some time the disease reaches the skin, throwing out a peculiar growth with a scirrhous hardness, and a peculiar odour very different from that which proceeds from those warts that are sometimes found on males and females from other causes. This growth increases by degrees, and ultimately involves the parts contagious. According to Mr. Pott, the disease always commenced on the lower part of the scrotum; but this was not invariably the case, as the following remarkable instance would prove: A few years since, a gardener, shortly after strewing some soot over a garden, to destroy slugs, observed an extensive growth of warts make its appearance upon his wrists. Amputation was found requisite to insure the patient's recovery. This disease will sometimes attack the common integument of the cheek, and he himself has seen many instances of this kind in chimney sweepers. The disease, when it attacked the scrotum generally, advanced to the adjoining parts, spreading to the perineum and boundaries of the anus, not unfrequently affecting the testicle; ulceration and sloughing sometimes take place, and spread to the body of the testicle. It would appear from various observations, that its progress in glandular parts was different from that which takes place in the common integument. In the present case, a large chasm formed in the groin, and was making its way into the cavity of the abdomen, the edges throwing out that peculiar secretion which is so characteristic of this affection. The disease always spreads to the contiguous parts, clearly proving that it did not commonly proceed in the course of the absorbents. He (Mr. Earle) was acquainted with a case in which a bubo made its appearance: the bubo suppurated, and assumed a character similar to the primary affection. The individuals attacked by this disease were generally of a pallid hue, with wan and leaden countenances; their general health was greatly affected; but the circumstance which particularly deserved their attention was that peculiar secretion and ammoniacal smell which, if once recognized, could never be mistaken. Indeed, the odour in such cases formed as certain a diagnosis, as the smell in various other diseases, such as rheumatism, phagedena, &c. It would be of great use to recollect these distinguishing signs, as they lend much assistance to the surgeon. The infrequency of this disease would be explained, by its seldom attacking persons under thirty years of age; very few cases occurred between twenty and thirty. Children were not liable to this affection; and it was some consolation to humane individuals to be aware of the fact, as it was generally supposed that the children bound to this trade were doomed to a life of suffering in every respect. The man now in the hospital had never been apprenticed to the trade, and was not attacked with the disease for a considerable number of years. From a long course of observation, he (Mr. Earle) considered that there were strong grounds for supposing that a constitutional predisposition was required for the developement of this disease, an idea which was materially corroborated by the fact of children not being liable to its ravages. Most of the cases which he had observed were in persons between the ages of thirty and forty; and it was often twenty years before those individuals were affected, as was fully proved in the case of the patient now in the hospital. It was also a singular fact, that the disease shewed itself in particular famihes; as he had known two or three generations which had fallen victims to its effects, and all about the same period of liie. Indeed, there could be no doubt that a certain state of constitution gave rise to the disease. With respect to the mode of treatment, he had no hesitation in saying, that, as far as he knew, no topical or internal remedy could be of use; the scalpel was the only resource, and it might be relied upon with confidence, provided that care was taken to remove the entire of the diseased mass. When the glands in the groin were affected, he pursued the same practice; even when the testicle was attacked with disease, it would be right to give the patient a chance by removing the affected testis, provided the spermatic cord were sound. A case, illustrative of the success of this practice, occurred last July twelve months, in a patient who came to the hospital in a hopeless state. The inguinal glands were enlarged; there was a local affection occupying the whole of the scrotum; the testicles were involved in the disease, so that it was necessary to remove both; the entire scrotum was removed, with both testes, and it was even judged prudent to dissect away a considerable por tion of the corpus spongiosum of the urethra. Notwithstanding this extensive excision, the patient is now alive, and perfectly well; and the disease in the groin is subdued. The man ran a great risk, as considerable inflammation of the integuments supervened; there were large sheets of sloughing of the integuments, and at one time he had a slight attack of trismus; the wound sloughed in the perinæum, and allowed an exit to the urine in that part, but it subsequently closed, and the man now makes water in the ordinary way. This case afforded a proof of the entire locality of the disease. In another instance, the disease was so completely local, that it was only necessary to remove part of the tunica albuginea. As the result of his experience, he should in all cases recommend the extirpation of the diseased part, and to some extent beyond its influence. But he would at the same time require the patient to abandon his business, as a return to it would be almost certain to bring on a return of the disease. From the rapidity with which this disease proceeded, when once established, no time should be lost, and the operation should be extensively performed. He was sorry to add, that the present case was beyond the power of the knife, for the ravages of the disease in the groin were of so malignant a description, and they spread so rapidly to the cavity of the abdomen, that he could only look forward to a fatal termination. He had heard of various remedies employed for this disease, and particularly iodine, lately tried in a case at St. George's Hospital, but he understood it produced no good effect. In his opinion, time would only be lost by using such remedies, as the only certain plan was the immediate extirpation with the scalpel." We may take the liberty of offering a comment or two on the foregoing valuable observations. There can be no question that the disease is not confined to the scrotum, as one of its names, (6 cancer scroti," would lead the inexperienced practitioner to believe. The cases mentioned by Mr. E. are decisive on this point; and we may add that we have twice seen it in the groin, unaccompanied with any scrotal implication. Mr. Earle pronounces that children are not liable to it. This is not the fact. A boy was lately a patient in St. George's Hospital, with every appearance of this complaint in his left groin. He was a chimneysweeper, and the warty ulcerated growth had most of the characters of this form of cancer. There was also considerable enlargement of the deep iliac glands. The boy took iodine, under the direction of Mr. Brodie, the ulcerations healed, the warty growths disappeared, and the enlargement of the glands was diminished. Whether the boy continues well we do not know. We suppose this is the case to which Mr. Earle alludes, at the conclusion of his lecture; how erroneously, our readers may perceive! This is a slight sample of the looseness with which medical matters are too frequently disposed of. We must then conclude that "the fact of children not being liable to the disease," is probably not a fact, and, inferences drawn from it are possibly as fallacious as their foundation. III. CASE OF STRANGULATED HERNIA-INTESTINE WOUNDED IN THE OPERATION. H. Taylor, æt. 45, was admitted at 5, a.m. of the 22d January, with an inguinal hernia so tense as to preclude all hope of reduction by the taxis. "The usual means, of course, were employed for that purpose; the warm-bath, venesection, ice, and tobacco glysters." The operation, on the failure of these usual means, was proposed, but rejected, until half-past 12 o'clock, when pain having commenced about the lower part of the abdomen, the patient consented to its performance. "After the sac had been cut into, the convolution of small intestine which presented, might measure from five to seven inches. Its appearance was generally of a favourable nature, except that it was somewhat preternaturally reddened. In consequence of the employment of a very small and shallow director, which proved quite insufficient for the necessary degree of protection to the surrounding parts, the division of the stricture was attended by a wound of the intestine. A yellowish watery fluid flowed out, resembling the morbid secretion from the serous membrane of the abdomen, and might be easily accounted for by referring to the state of irritation produced by the hernia; but the secretion, as afterwards appeared, came from the mucous membrane of the intestines. A ligature was tied round the wound, and the intestine was returned to the abdomen. After its disappearance, the operator seemed surprised at finding behind the situation of the protruded intestine, a large mass of omentum, which was attached by very firm adhesions to the posterior surface of the sac. The ordinary state of entero-epiplocele is-the omentum anterior to the bowel; and Mr. Lawrence had no recollection of having met with such a case as this before. A considerable portion of the omentum was removed; and the vessels being very large, gave out a copious discharge of blood, and a considerable number were tied. The patient was then put to bed, and allowed to remain quiet for two or three hours, after which he took compound colocynth pill and sulphate of magnesia, at repeated intervals; but without effect. The pain in the abdomen increased in the course of the evening; leeches were applied in abundance, and purgatives repeated, but no motion, except the watery secretion already mentioned, followed. Next morning he complained of great weakness; the pulse was low, and the surface of the body rather cold. Cordials and stimulants were employed without effect, and the patient died about one o'clock in the afternoon of the 23d, just 24 hours after the operation." Sectio Cadaveris. Peritoneum generally healthy, but reddened over the convolutions of the intestine on the side of the hernia. Omentum seen stretching downwards to the abdominal ring, where it was firmly secured by old adhesions; the intestines were compressed and indented by it in this course. The colon at the point of its attachment to the omentum was constricted, |