TRALEE HOSPITAL.

PNEUMO-THORAX, from PerforaTION.

In the May number of our esteemed Dublin contemporary, Mr. Poole, assistant surgeon of the 32d Regiment, relates a case of the comparatively rare disease at the head of this article. The subject of it was a young soldier, of healthy appearance, admitted into the Tralee Hospital on the 27th of March, 1832. The chest was not well formed. He had had pneumonia two months previously, and was affected at the time of entry with violent cough, dyspnoea, viscid expectoration; but without any loss of resonance, or other sign of disorder in the chest, except some mucous rattle in the lower left lobe of lung. The disorder was considered bronchitic, and treated with antimonials, light diet, and counter-irritation. He improved much, and was convalescent. On the 27th April, however, the lower portion of right side gave a dull sound on percussion, and the respiratory murmur was heard indistinctly, but without any aggravation of symptoms, till the beginning of May, when the cough again became troublesome, and the aspect generally unhealthy. On the 12th May, loud bronchial breathing was heard in the mammary region of the left lung, with bronchophony, but no ronchus, the resonance continuing. On the 21st, a considerable change took place, the patient having been attacked with pneumonia of the lower part of the left lung, which yielded to bleeding and antimony, but not without leaving hepatization.

"After the signs of this latter lesion had entirely disappeared, a mucous râle persisted through the whole of the posterior portions of the lung,the anterior part giving a clear sound on percussion, until the 1st July, when the metallic tinkle was distinctly heard, and a diagnosis of pneumo-thorax made, although the respiratory murmur and a deep gurgling could be distinguished in the portions of the lung, over which percussion elicited the clearest sound. There never existed any signs of an excavation, but

the patient coughed up, on the 4th and 5th of the month, a large quantity of a sero-albuminous fluid, proving that a communication existed between the lung and the sac of the pleura. From this time he sank rapidly, and expired on the 6th of the month.

Autopsy twelve hours after death.Considerable marasmus; left side of the chest, at the inferior portion, much bulged out, highly sonorous, in fact, tympanitic; right side gave generally a dull sound on percussion; on cutting through the cartilages of the left ribs, a rush of inodorous gas took place from the pleural cavity. The lung was found condensed, and pressed up towards the spine and back part of the ribs, to which it was bound by strong adhesions. A small quantity of a yellow coloured serosity existed at the bottom of the cavity. The surface of the lung was covered with several loose layers of false membrane, of a lemon colour and tough consistence; they were readily detached from the lung; the lung was firm and corrugated, it was perforated by a considerable opening, which existed at the back part of the upper portion of the lower lobe, close to the adhesion with the costal pleura; the finger could be passed by this opening into the substance of the lung, and it was found that a small quantity of purulent matter escaped by it when the lung was pressed. The parenchyma of this lobe was thickly infiltrated with tubercular matter in a crude state; one or two points of suppuration were observed, but anteriorly there was no evacuation. the back part of the lobe, however, corresponding with the situation of the fistulous opening, existed a considerable irregular cavity, which had through this discharged its contents into the pleural sac. The upper lobe of this lung was quite sound, and did not contain a single tubercle, but all its bronchial tubes were much dilated, their lining membrane highly vascular, without any apparent hypertrophy. The sac of the right lung contained some serosity, but the lung itself, with the exception of its lower lobe, which was thickly studded with crude tubercles, was sound and crepitous."

On

MEATH HOSPITAL.

SURGICAL REPORT OF CASES TREATED DURING THE PAST YEAR. By W. H. PORTER, Esq. &c.

The Dublin Surgeons, Mr. Crampton, Mr. Carmichael, Mr. Porter, and others, have done themselves much credit by the readiness they have evinced to communicate clinical facts to the profession. Yet we think we perceive some indisposition to exertion creeping over the energies of the Irish hospitallers.

Mr. Crampton's throat is dry, and the surgeon-general has not lately poured forth his clear and sonorous chirurgical strains. We shall quarrel with these gentlemen, if they now turn laggards. It must not be.

A criticism on a case of Mr. Carmichael's has been taken in ill part. We know not the exact phrenological explanation of a fact which we have noticed, but the fact itself is a good one notwithstanding-that, in our critical experience, we have never seen the man who thought that he was over-praised, nor him who did not think a criticism on himself ill-natured.

If there ever was a medical journal in which approbation has been liberally, handsomely, gratuitously given, it is this. None are more disposed than its conductors to take the will for the deed -none give the generous cheer more loudly nor more long. Yet the instant they attempt to criticise, be it ever so considerately, they are overwhelmed by complaints of unkindness and cruelty. The writer and his friends should, however, reflect, that the reviewer's must be the ungentle craft,and that his ink grows colourless, if it is not mixed with gall. Unless his pen, like—

Ithuriel's spear, Still shows the cloven foot-the lengthen'd ear, it is decried by the public for an useless stump, and its characters wear neither form nor impress. For ourselves, we can only say that it always gives us pain to utter even a just criticism, and we appeal to our readers for the general candour, manliness, and generosity of our remarks.

To return to Mr. Porter and the Meath Hospital. We cannot forbear

from introducing his prefatory observations, displaying, as they do, the good sense of the writer, and offering some excellent hints to reporters and to authors.

"The general practice of all hospitals," says Mr. Porter, " must be nearly the same, and as the leading characters and treatment of the ordinary forms of disease are pretty accurately understood, very detailed reports are neither necessary nor instructive, unless when adduced for the purpose of establishing some important pathological fact, or introducing some improvement in practice. But in every establishment of this kind, particular cases will occasionally occur, not only novel in their nature, and therefore curious, but by reason of their infrequency, difficult and uncertain in their management. By the publication of such cases in an authentic form the hospital surgeon may confer the greatest benefit on his profession, for he enables the practitioner, of extensive opportunities, who has met with similar cases, to compare the observation and experience of others with his own, and thereby approach the truth; whilst to the younger practitioner, he furnishes a guide and assistance in the difficulties of his profession, which, though far from perfect, may nevertheless be valuable. In this spirit and with this view, I have selected the following cases, each possessing its own peculiar interest,and on which I forbear to offer comment or observation, wishing to render the details as short as shall be consistent with clearness; and knowing that the case, which to the practitioner at the bedside will appear rare, or difficult, uncertain, or important, may to the reader in his closet, deprived of the numerous aids derived from personal inspection, seem to possess little more than ordinary interest, and unworthy of being obtruded on the profession."

It appears to us, that the object of hospital reports is not merely to publish extraordinary cases, or to chronicle remarkable improvements, though both are highly desirable and necessary. It must be remembered, that a large portion of the medical public is placed

beyond the reach of those opportunities for maintaining a high standard of professional knowledge, which so amply abound in large cities. The surgeon, in thinly-peopled districts, or in our colonies, has no access to hospitals-no medical society-neither leisure nor opportunity, nor perhaps inclination, for laborious reading. His chief source of information is a medical journal, and on this he must depend for keeping him near the level of his brethren in the towns. He does not require to be told of extraordinary cases, which may never fall under his personal observation; but he looks for details of the current practice, for records of those facts which occur in masses, and constitute the sum of useful practical experience.

We think that hospital reports, if systematically given, would afford more valuable information to the profession, and diffuse more widely a knowledge of the true principles of reasoning, than any other kind of publication. The reader would acquire that taste for facts, and that disrelish of all not simply deducible from them, which tend, more than any other mental exercise, to give a bold and independent bearing to the intellect, to encourage acuteness of the observation, and to confirm the soundness of the judgment. The hospital reporter should endeavour to present a faithful picture of the varied character of hospital experience. He should not select the striking cases only, for they are the minority in nature; but, on different occasions, he should attempt to present the different orders of facts which are really met with in the hospital wards. If, influenced by the modesty of Mr. Porter, all reporters were to refrain from noticing the common cases, the public would be feeding on unnatural and stimulating viands, which must corrode their taste, instead of affording it wholesome nutriment. It is as if every host should offer only brandy to his thirsty guest, because he might procure pure water elsewhere.

In accordance with this plan, Mr. Porter relates four cases, severally possessed of some peculiarities. They are

these:-1, Aneurism occasioned by the sequestrum, in case of necrosis' of the tibia-2, Functional derangement of the brain, the result of injury, cured by the operation of the trepan-3, Curious and interesting case of bronchotomy-4, Disease of the lymphatics of the left arm, demanding amputation at the shoulder-joint.

These cases we shall notice in regular succession.

CASE 1.-Aneurism in a Case of Necrosis-Death from Mortification and Hamorrhage.

A man, æt. 29, of drunken habits, admitted January 2d, 1833.

His face was blanched and anxious. On uncovering the limb, a small livid fistulous opening was seen on the outside of the lower third of the right thigh, slowly discharging a thin, serous blood, on pressing which the finger seemed to sink into a deep cavity; pulsation was quite distinct, and bruit de soufflet audible for some distance round it, as if from aneurism: the femur, at its lower third, could be felt enlarged, and the popliteal space filled up, but the pulsation of the artery below it was distinctly perceptible. There was intense pain in the knee, and throughout the tumor-extreme exhaustion-pulse 150, small and thrilling.

The disease seemed to have begun fourteen or fifteen years previously, with violent pain in the knee and lower part of the thigh, which rapidly swelled to a great size. The tumefaction diminished under the use of blisters. About a year afterwards, a small swelling appeared four or five inches above the knee, which was opened, and gave exit to some purulent matter; a sinus remained there ever afterwards. In August, 1832, an alarming hæmorrhage occurred from the fistulous opening, and this returned on the night preceding his admission into the hospital. The patient supposed that he had lost several quarts of blood, and he fainted from exhaustion seven or eight times.

From all these circumstances it was conceived that the case was one of popiteal anuerism complicated with

diseased bone, the sac having probably burst into the cavity of an abscess in connexion with the bone.

A compress of lint was placed over the opening, and a bandage rolled from the foot over and above it. Lemon juice was given ad libitum.

Some bleeding occurred during the night, and next day he was seized with severe vomiting; pulse 150, full and hard. On the 4th there was intense pain in the thigh. The face was bleached, with a yellowish tinge, and extreme anxiety -thirst urgent-pulse 142. Amputation was obstinately refused by the patient. The vomiting continued -the debility increased-and on the 6th there was great swelling of the thigh, with gangrene on its posterior surface, nearly as high as the buttock. A constant though feeble hæmorrhage trickled from the limb. At 9, p. m. he died.

Dissection. "On opening the popliteal space it was found filled with thick grumous clots, extending up as high as the lower third of the femur, in contact anteriorly with the bone, and with something that appeared to be part of the sac, but whether of an aneurismal sac, or the cyst of a former abscess, could not be determined. An opening existed in the popliteal artery, a little below the spot where it enters the space. The thigh-bone was found diseased in its lower half, being considerably enlarged, its surface rough, and a large portion of the posterior or popliteal aspect destroyed, so as to permit the introduction of the fingers into a large cavity within; the edges of the bone on each side of this opening were thick and very full of rough sharp points; in the upper part of the excavation the sharp point of a sequestrium was discovered, moveable, and accurately corresponding to the aperture of the artery, which it evidently seemed to have occasioned. The knee-joint filled with a yellowish serum, unlike ordinary synovia; its cap sular ligament thickened. The cellular tissue of the entire thigh filled with a reddish serum."

There is slender evidence and but slight probability of the above having been an instance of true aneurism, that

is, of the artery having been dilated into a sac, prior to a laceration or wound of the latter. It is more consistent with the circumstances to suppose that the wound was of the artery itself, and that the blood became diffused into the cavity of the abscess or surrounding cellular structure.

CASE 2. Fracture of the Os Femoris, followed by Symptoms of Idiotcy and Paralysis—Recovery after the Operation of Trephining.

Ed. Hughes, æt. 35, a healthy countryman, admitted June 26th, 1833.

On the 8th of the previous May, he was knocked down by a blow of a large stone nearly in the centre of the forehead, which produced a depressing fracture of the frontal bone. He was not rendered senseless by the blow, nor for sometime afterwards was there any perceptible consequence, as during the six subsequent weeks he was able to work, and had his intellects perfect and natural. His friends then observed him to become drowsy, listless, and incoherent; when undisturbed he was quite idiotic, but when roused he appeared to possess some memory. His manner of answering a question was very remarkable; he hesitated, seemed to recollect with difficulty, and answered as if in doubt. He tottered in his gait, and had a remarkable tremor in his left arm and hand: the tongue, when protruded, was drawn to the left, and there was also strabismus of the left eye, symptoms which appear to have been present at the time of his entrance into the hospital.

Mr. Porter, under these circumstances, cut down upon the bone, and found an irregular fracture of nearly an inch in length, one side of which was depressed to the depth of little more than three lines. The trephine was then applied, in order to permit of the elevation of the depressed bone, but the internal table was found to have been so extensively broken, that three crowns of the instrument were removed before all the fragments could be exposed and taken away; one large portion had penetrated the dura mater, and entered the substance of the brain, the removal

of which was followed by considerable hemorrhage, appearing to come from some vessel of the brain itself, and which could only be controlled by the application of several compresses, and such a degree of pressure as evidently affected the functions of the organ.

During the remainder of the day the patient continued listless and half asleep. The pulse was slow, small, and weak. On the next day he was nearly insensible to external objects; the evacuations were passed involuntarily; the pulse was weak and labouring. On the removal of the compresses and dressings he became more lively, and his pulse more full. On the following day (June 30th) he appeared much more sensible. The pulse was 86, and strong. On the 1st July, the patient became sensible, for the first time, of his natural wants. The pulse

was 110.

He progressively improved until the 16th, when he had several severe rigors and trembled violently. He was drowsy and stupid-the eyes were peculiarly wild-the pulse rapid and fluttering. He again became unconscious of his natural wants, and fell into nearly an idiotic condition. The tremors were remarkable, especially those of the left arm and leg. The bottom of the wound was covered with white granulations, resembling fungus, and the discharge was very profuse and rather fetid. The treatment for the previous symptoms had been strictly antiphlogistic. He was now ordered calomel and opium so as to affect the mouth.

In proportion as the mercurial action was developed, the symptoms passed away, and on the 28th, the patient was pronounced convalescent. After his recovery, he is said to have remembered most of the circumstances that occurred during his illness, which is rather extraordinary, considering that he is described to have been unconscious of his natural wants, to have lain in a kind of slumber, and to have been nearly idiotic.

In the November following, the patient was so well as to walk to Dublin, a distance of twenty-three miles.

This case seems to display the good

effects of mercury in the secondary inflammation of the brain and of its membranes, which ensues after injuries of the organ, and operations on the cranium. We have drawn attention to this fact upon several occasions, and we cannot take a better opportunity of enforcing it, than by reference to the particulars of the case before us. It is more than probable that, but for the mercurial influence, the patient would have suffered from formation of pus, the consequence of inflammation within the cranium.

CASE 3. Bronchotomy for the removal of a Foreign Body, supposed to be in the Larynx.

James M'Mahon, æt. 14, admitted Aug. 27.

In the previous June, whilst eating some beef-hash, a piece of bone or gristle seemed to have stopped in his throat and he was instantly seized with all the symptoms of suffocation, violent cough, &c. He remained in this state for some days, with great pain and difficulty of swallowing, and of turning the head to the left side. He was taken to a hospital, where a probang was passed down the esophagus with slight temporary benefit. The symptoms soon returned with violence. The following are the symptoms observed on his admission into the Meath Hospital.

"Deglutition so difficult and painful as to make him refrain from drinking, although very thirsty; he cannot turn his head to the left side without great suffering; voice nearly lost; breathing loud and sibilous; the wheezing greatly increased during the spasmodic paroxysms, which are very frequent. The face is pale and livid, the lips purplish. He opens his mouth badly, but as far as the condition of the fauces can be ascertained, there are no traces of inflammation. On passing the finger into the fauces, the epiglottis can be felt of its natural size, and healthy. Pulse rapid; skin hot and dry."

Supposing that some foreign_body was impacted in the larynx, Mr. Porter proposed the operation of tracheotomy, to which the mother refused her consent for two days, when it was granted.