few days. At this date the limb was found to be free from swelling, and the deformity evidently less. Union also appeared to be firmer. The apparatus was re-applied, and in order to keep up as much pressure as the patient was able to bear, a tourniquet was applied immediately over the point of fracture. On the 31st of October the apparatus was removed for the purpose of accurate examination, and it was found that the limb was lengthened half an inch since the commencement of the treatment; that the deformity was less, apparently from absorption of a portion of the callus which had been deposited on the outer part of the limb, and that no motion could be discovered at the point of fracture, or any grating sensation perceived when the weight of the body was borne upon it.

Dr. Norris observes that, in the first case, the non-union was probably the result of the want of proper support and pressure-in the second case, of the same circumstances, in addition to the existence of a fracture of the leg. For, where more than one fracture exists in the same person, firm union may take place in one some time before it occurs in the other. Pressure and rest are best adapted to cases of no long duration, and to young persons. Dr. Norris prefers the tourniquet to other means.

II. RUPTURE of the LIGAMENT OF THE PATELLA.

James Hughes, ætat. 30, was admitted on the evening of July 13th, for an injury of the knee received a short time previously by a fall from a height of eight feet into a well. He states that his limb was strongly flexed at the time of the fall, and that he struck the ground with his knee. Though suffering great pain he was able to seize a rope which was lowered to him, and allow himself to be drawn up to the surface, but on attempting to rise upon his feet he found that he was unable to support himself on his left limb. He was immediately removed to the hospital, where upon examination by the resident surgeon, a hollow was observed over the knee which on first sight was supposed to result from fracture of the patella, and separation of the fragments, but which on close examination was seen to proceed from a rupture of the ligament of the patella and a consequent displacement of that bone upwards. On the next day, although there was swelling, Dr. Norris found a deep depression existing immediately above the tubercle of the tibia, and the patella drawn up to the extent of an inch and a half. This bone admitted of a much greater degree of lateral motion than that of the sound side, could be distinctly traced, and was found to be uninjured. The treatment consisted in extending the limb upon a splint, and applying a roller from the foot upwards, which was passed around the knee in such a manner as to draw down the patella towards the head of the tibia. limb was then placed on an inclined plane, and cold applications applied over the knee. Nothing of great moment happened, and, on the 27th, the patient spontaneously left the house. The patella occupied its natural position, and a considerable hardness could be felt in the space between its lower edge and the tubercle of the tibia.

The

III. WOUND OF THE PALM OF THE HAND-SECONDARY HÆMORRHAGELIGATURE OF THE RADIAL ARTERY-RETURN OF HEMORRHAGE-CURE BY PRESSURE.

H. L. farmer, admitted July 22. He states that four weeks since, he received a cut with the end of a scythe in the fleshy part of the palm about an inch below the end of the radius. The injury was followed by considerable hæmorrhage, which was arrested by means of pressure on the part. The wound from the

time of the accident gave no trouble, though it did not cicatrize, until eight days since, when considerable hæmorrhage took place from it. This was repeated at different times during the day, and the following morning he came to the city and applied to a surgeon, who in order to arrest it, secured the radial artery just above the wrist. After this he returned home and continued to do well until the night before his admission into the hospital, when the wound again bled profusely, and was only arrested by making very considerable pressure upon the wrist as well as over the wound. After admission, the pressure which had been hurriedly and irregularly applied, and which caused great pain, was removed, and the wound which was not above half an inch in length was sponged off, but no bleeding took place. The ligature upon the radial artery, had not yet separated; the incision made in order to secure it had not united, and its edges were much swollen and inflamed, as was also the back of the hand. Moderate pressure, by means of graduated compresses and a bandage, was made over the wound and lower part of the ulnar artery, and the hand and fore-arm were secured to a splint and elevated, and cold applied. Tinct. opii, gtts. xl. given, and absolute rest in bed enjoined.

On the 1st of August, the ligature separated from the radial artery; and, on the 7th, the wound was cicatrized, and the patient discharged.

Dr. Norris remarks that, in wounds of the arteries of the wrist or palm, if the wound be large and the ends of the vessel accessible, everybody admits that both ends should be tied. But, where those ends cannot well be got at, the practice is to secure the vessel above. "Where the case is recent, this method is mostly successful, but when any length of time has elapsed since the injury, particularly in wounds of the palm, where the anastomoses between the vessels are free, it very frequently fails, the hæmorrhage after a time returning by the inferior end of the vessel. The employment of graduated compression upon the vessels of the fore-arm as well as over the wound, was in the above case fully successful in preventing any return of the hæmorrhage, and is applicable to most similar instances, but in all cases in which this is trusted to, it should be recollected that to ensure success, the pressure must be well and evenly applied, and a state of perfect rest secured to the limbs by means of a splint elevating the limb, too, is a most important matter where this method is pursued."

IV. DIFFICULTY OF DIAGNOSIS OF INJURIES ABOUT THE HIP-JOINT.

Dr. Norris relates several cases in which mistakes in diagnosis were committed. In one, disease of the hip-joint was mistaken for luxation-in a second, luxation for fracture-in a third, fracture was at first overlooked-in a fourth and fifth, the same error was committed. The cases themselves we need not detail—it will be enough to extract a few cautionary observations of Dr. Norris. a. "The true nature of the injury in these cases is often more evident some hours or days after the receipt of the accident, than immediately after its occurrence, and I am inclined to think that the necessity of close secondary examinations, in all instances in which there is room for a doubt as to the nature of the injury, are not sufficiently insisted on. Had careful examinations of the first two of the above cases been made the day following the receipt of the injuries, it is hardly possible that their true natures would have been mistaken, and the symptoms of fracture in the third case were only detected after a lapse of some days, though this injury was at first suspected and the patient attentively examined. It is, however, more particularly where fractures may be suspected that these repeated examinations are demanded."

b. "The exact length of the limb on entrance, with the natural position of the foot and absence of any deformity, or crepitus, led to the supposition, in both of the above cases, despite the great pain suffered, that simple contusions only

of the part existed, and this idea was confirmed at the commencement of the attacks of mania a potu, upon seeing the men up and moving about the room; but after recovery from their attacks, the eversion of the foot led to an immediate examination, when the shortening was found to exist, which, in connexion with the symptom just mentioned, could only be caused by fracture of the neck of the bone. In both cases the fragments must have been interlocked in such a way as to have prevented any shortening or motion, and so remained till the delirium occurred, when the violent efforts made to use the limb, unlocked the parts, and permitted the lower fragment to be drawn upwards.

Previously to witnessing these cases we had believed it impossible for a patient with fracture of the neck of the femur to walk upon the limb: but upon examining the records of our science on this point, I find that similar instances are noted."

And he quotes Sabatier, Dessault, Dr. M'Tyer, Mr. Syme, and M. Malle.

V. CANCER OF THE BREAST IN A MALE.

A. C. æt. 61, admitted July 18. He states that fifteen years since, while in the act of loading a cart with wood, he was struck in the breast by a heavy log. Soon after this, a small lump, not much larger than a pea, was observed by him at the part, which was hard and apparently loose beneath the skin, and not painful. For some years this never increased; but during the last eight or ten years, when the part was at all pressed upon, or rubbed by his suspender, it would inflame -at times so much so as to induce him to apply a soft poultice to it, which always speedily removed it. During this period, too, it increased very slowly in size. At present the tumor is about the size of a small apple-is extremely hard, and in no way adherent to the parts beneath-is not painful when handled, and has a small and very superficial ulceration on its outer part. He states that the tumor attained the size which it now has during the last summer, and that the slight abrasion of its surface occurred three weeks since. The skin covering the tumor is in no way discoloured, and but a single lymphatic gland, immediately above it, can be discovered to be enlarged. General health good. On the 20th, the tumor was removed. On cutting into it, it was found to consist of a whitish shining mass, almost of the consistence of cartilage, which gave a crying sound when divided by the scalpel, and showed numerous white striated bands running from its centre into the surrounding cellular structure. The wound was healed on the 18th of September.

VI. COMPOUND FRACTURE OF THE CRANIUM.

Dr. Norris relates two cases of this sort of injury-one that interests and always must interest surgeons, from the questions which its treatment involves.

Case 1.-J. F. æt. 16, admitted July 16, a. m. He had got entangled in a steam-engine, which had gradually forced his head up against a projecting bolt. This bolt, which was square at is projecting extremity, and measured three quarters of an inch on either side, entered the fore part of the head to the depth of an inch and a half. From this situation the workmen attempted to extricate him, but finding this impossible, separated the bolt, together with a heavy piece of iron to which it was attached, from the machinery, leaving it firmly fixed in the skull. Attempts were then again made, by the foreman of the shop, to remove the bolt, but without success, and a medical gentleman in the neighbourhood was sent for. The opening in the forehead was of such small extent that

it was found necessary to enlarge the wound in the soft parts slightly at its corners, and afterwards to turn the bolt until its angles corresponded to the corners of the wound before it could be withdrawn. Two or three small portions of bone, which had been driven in upon the brain, were removed after the withdrawal of the bolt. At the visit soon after his entrance into the hospital, the seat of injury was found to be at the anterior part of the frontal bone an inch above the orbitar ridge, and a little to the left of the middle line. At this point a portion of brain, judged to be nearly equal in size to a large walnut, was protruding and much lacerated. The patient was sensible and complained of no pain; pupils natural; pulse slow and feeble; is unable to raise the right arm from the bed, though he is able to close his fingers feebly, and has perfect sensation in it; no paralysis of any other part of the body. A pledget of lint was applied to the wound, and ice-water to the forehead. The treatment was antiphlogistic, and we need not particularly specify it nor the symptoms in detail.

On the 3rd, the protruding portion of bone had in a great measure disappeared. The mind was little, if at all affected, nor was there fever to any amount. On the 5th, the wound had begun to suppurate. On the 9th, he could raise the right fore- arm from the bed. In a day or two, he began to complain of pain over the eyes, which he did, at intervals, subsequently. On the 19th, the paralysis had entirely left the arm and he was able to raise it completely from the bed. From this date up to the 18th of August, the patient continuing to do well, the wound presenting a healthy appearance, and cicatrization progressing slowly. On the evening of the day mentioned he was seized with a chill followed by fever, pain in the head and diarrhoea. But on that day (the 19th,) there was pain in the head and pyrexia. He was bled. On the 21st the discharge was in a much less quantity, and from this time up to the 30th, the day of his death, continued to be very trifling. A day or two previous to his death his memory was slightly affected, and he was observed to sleep sounder and more than he had previously done; no paralysis. Early on the morning of the 29th he was much as he had been on the previous day, but at mid-day was found to be in a state of profound stupor with the pupil of the right eye strongly contracted, while that of the left side was dilated. In this state he continued till early in the morning of the 30th, when he died.

Autopsy nine hours after death. The wound in the head was one and a half inches above the orbitar ridge. A small piece of bone was driven in and pressing upon the brain. The dura mater around the wound was thickened and strongly adherent to the brain. The anterior lobe of the left hemisphere of the brain was of a bluish-yellow colour, softened and presenting evident fluctuation. The vessels of the pia mater were much injected; an abscess was found immediately beneath the dura mater at the point at which it was adherent to the brain, occupying the whole anterior lobe and filled with thick yellow pusthought to amount to 3v. or 3vi. The walls of the abscess were lined by a thick false membrane of a grayish colour. The cerebral matter around it was of a light yellowish colour and softened. A portion of the internal table of the bone, about an inch and a quarter in length, was found driven in beneath the sound bone at the upper part of the wound, and at the side of it, a small fragment was found firmly attached to it. The opposite hemisphere of the brain presented the natural appearances; the ventricles were much distended with serum; the edges of the fractured bone were rounded off and perfectly smooth. No further examination was admitted by his friends.

Dr. Norris observes, that the above case is remarkable from the large size which the abscess had attained, as well as from the length of time the patient survived after the accident, free from all unpleasant symptoms. The knowledge that the loose portions of bone had been removed immediately after the accident

and the entire freedom from all symptoms of compression of the brain, were sufficient to prevent a resort to any operative procedure.

But we would observe, that from the circumstance of bone being driven in and pressing on the brain, this case is, pro tanto, evidence against the plan of Jetting compound fracture of the cranium, with depression, remain without operation. The principle of the latter is, that, so much mischief being done to the brain, a little more will probably do little harm, and, if it removes all sources of irritation, will probably do good.

Case 2.-W. M. aged 34, ostler, was admitted December 3, 1832, for compound fracture of the cranium with depression of the bone. His injury had been produced two hours before admission by a blow over the right side of the head with an axe. The wound in the scalp was four inches in length, and a fracture with some depression of the bone existed. The physician who saw him previous to admission, stated that a small portion of brain had escaped from the wound. He had lost a large quantity of blood, and had no symptom of compression of the brain, or uneasiness of any kind about his head. The lips of the wound were brought together with adhesive plaster, and cold was applied to his head.

Under a very rigid antiphlogistic treatment he did well till the 13th, when he was observed to sleep more than usual, and when aroused said that his head felt heavy and painful. No inflammation existed round the wound, which had partially united. Thin pus was discharged from it, and it had for some days previously been dressed with a poultice. Cups were applied to his temples and back of the neck, and he was purged with salts and put upon the use of nitrous powders. He stated that some relief had been afforded him by the cupping, though on the 14th he complained of his head being still heavy, and slept a great deal and heavily. His pulse had become slower (60); skin dry and warm. The 15th, he was more stupid, and complained of pain across his forehead. Head shaved and blistered-saline solution. By the 20th the blister was healed, and the pain in the head was gone.

On the 22nd, it was discovered that he had not complete power over his left arm. Yet he continued to improve from this date till the 8th of January, 1833, when he complained of pain in his forehead, for which he was cupped and purged with relief. By this time he had completely regained the use of the left side.

On the 9th he had a return of the pain, and he again lost the use of the left arm. The pain was again removed by cupping and purging, and two days after he had partially regained the use of the member.

On the 16th a piece of the outer table of the bone, an inch in length, was found to be loose within the opening, and was removed.

On the 23d he was suffered to walk about the ward, and had his diet slightly increased; the wound had healed with the exception of a fistulous orifice leading to the seat of fracture. His mind was perfect; he suffered no pain, but had only an imperfect use of the arm of the left side.

He continued, as at the last report, until the 26th of March, when he was seized suddenly with a convulsion; for this, cupping and cold to the head were again resorted to with relief. The fistulous opening still remained, from which there was daily a discharge of pus.

In consequence of this attack, it was judged proper to cut down to the bone and ascertain whether or not any fragment pressed upon the brain; this was accordingly done, but no projecting portion was discovered. No material change took place from this time till the 2nd of April, when he complained of headache, which was in a short time followed by vomiting, insensibility and death on the same day.