876

had my hearty concurrence in the course headopted, to which he was prompted chieflyby the inconvenience attending the operationin lodgiugs. I need not add, that I rejoicesincerely in its successful result.As a general method, my opinion has not

been favourable to the application of litho-trity in children, or even in youths, beforepuberty. It is also well known, that I havefrequently refused to operate in the cases ofadults, though tempted by the olfer of largefees; but my objections in these cases werenot grounded on the mere size, or hardness,of the stone, but on the contra-indicationsfurnished by the general state of the patient,which either forbade the operation peremp-torily, or rendered the chances of successtoo uncertain to allow me to commit to i

them the credit, both of the operator and theoperation.To object to the application of lithotrity,

on account of the size and hardness of thestone, without any other forbidding circum-stance, would look like affectation in me, towhom belongs the merit of having reduced,by lithotrity, in the case of Mr. John Laugh-land, of Kilmarnock, the largest concretionthat has hitherto been safely removed fromthe bladder. This was a solitary stone, of ’,lithate of ammonia ; it was excessivelyhard, weighed seven ounces, one drachm,and must have formed a mass, pretty nearlyequal in size to that of a turkey-egg. Histownsman, Dr. M’Christie, and many others, ’,were present at the sittings in this mostremarkable case.

I beg respectfully to deny that my opinion iiis such as it is stated in the report. I might ;,even go much farther, but I must now re-frain, as I shall submit certain propositionsto the Westminster Medical Society, on Satur-day, the 18th instant, which will dispose ofthis point, finally. I purpose, on that occa-sion, to exhibit an instrument which, whileit carries the sphere of this interesting ope-ration far beyond its present limits, willconsolidate the footing it has already ob-tained, put an end to those distressing acci-dents, another of which, I am informed, hasjust occurred in private practice, and acce-lerate, in an extraordinary degree, the labourof the manoeuvre, and the deliverance of thepatient. I have the honour to be, &c.,

W. B. COSTELLO.

38, Bruton-st., Berkeley-square,March 7th, 1837.

W. B. COSTELLO.

NORTH LONDON HOSPITAL.

TARTAR EMETIC IN S’t’RAKGULATED HERNIA.

CASE 1.—W. B. was admitted Nov. 8,under the care of Mr. COOPER. He is a

strong, muscular man, accustomed to well-digging. Has been subject to oblique

inguinal hernia, from the age of six year,4;he has never worn a tiuss for it; and ithas been usually very easily reduced by thetaxis, except in two instances. Whilecarting some ice this morning, the herniadescended, and after repeated trials it wasfound irreducible. He became sick, andvomited a dark brown fluid of an earthysmell. The hernia had descended at eighto’clock, A.M., and at half-past three, P.M.,he was brought to the hospital. The tumourwas large, contained fluid, was painful tothe touch, and slightly reddened. - Hisbowels had not been moved. After an un-successful attempt at reduction by the taxis,Mr. HALLAM had him placed iu a warmbath, at 106°; the pulse was 120, full, hard,and wiry. He was then bled to xxiv,with the effect of making him sick andfaint, but renewed efforts at reduction wereunavailing. He now took two grains oftartar emetic, which, after a short period,produced much relaxation and depressionof the system, but no immediate sickness.All attempts still continuing to be of noavail, he was kept in the warm bath tillsix o’clock, the temperature being kept upby repeated additions of hot water, and thehernia then gradually returned, the painabated, tenderness only remaining.- - Hewas put in bed, and vomited a greenishfluid. The bowels were relieved by an

enema of castor oil. He passed A-’coiiifoit-able night, and in the morning went awayfrom the hospital quite well. ’ ,

CASE 2.-H. A. was admitted Nov. 9,under the care of Mr. COOPER. He is ayoung man of strong healthy appearance ashoemaker. While assisting in lifting d

heavy box yesterday morning, it fell, andpressed him against the wall, causing apainful feeling in the groin, with a sense ofrupture in that region. He continued aboutduring the day, but in the evening appliedto a surgeon, who considered it hernia, andendeavoured, but unsuccessfully, to reduceit by the taxis. At ten o’clock this morn;ing he came into the hospital, said he hadvomited at least three pints of a black nan-seous fluid in the night, and felt great painand tenderness over the abdomen. Thebowels have not been moved. Mr. HALLAMfound it to be oblique inguinal hernia onthe right side, with pain, upon the leastpressure, and irreducible by the taxis. Hewas placed in a warm bath, at 1’10°; andattempts at reduction failing, he took twograins of tartar emetic, which, in about tenminutes, produced great relaxation of thesystem. His pulse, which was previously130, and full, became compressible, thoughquick. The taxis was again applied, andthe hernia gradually returned. Previousto reduction, he complained of a bitter,nauseous taste in his mouth. His bowelswere relieved by an enema., shortly after the

877

reduction. He stopped in the house a dayor two, and then went out well.Mr. CoopER remarked on these cases, that

though there was no direct evidence of theextent to which the tartar emetic had actedin the reduction of the hernia, neverthe-less, he thought that there was sufficientground for trying that medicine in futurecases. Most surgeons, it was true, did notcQnsider the use of the tartar emetic ad-tieable, " as there was generally sicknesseaough." In these cases, however, therewas reason to think it had done good, at allevents it could do no harm. ’

;<iVCS TREATED BY INCISION AND LIGATURE.

A. B., aged two years, was admitted Feb-ruary 6. , The mother states, that two daysafter the child’s birth, she perceived a redline near the angle of the mouth, which shesupposed to be merefy a scratch of a pin.A small tumour soon appeared, which in-creased rapidly. At the age of ten weeks,the tumour was of about the size of a hazel-nut. A needle was passed across its base,and a ligature applied, so as to embrace thetumour. Two days after the operation, theincluded part was cut off with a knife,close to the needle. The wound healed,but before two months had elapsed, thevascular tumour again made its appearance,

in the site of the wound. The tumour hascontinued to grow, notwithstanding it hasbeen operated on in different ways, by

several surgeons, by ligature, caustic, tyingthe coronary artery, &c., in all eight times.When the tumour re-appeared it lookedred, and was of a roundish shape. Strongnitric acid was applied to it, but withoutejecting more thau the mere destruction ofthe tissue with which it came into imme- Idiate contact. It has also been broken up ’,with needles. The child was brought to

Mr. LISTON, at the above date. The bowelshaving been brought into a healthy state, bymeans of calomel and scammony, repeatedat short intervals, Mr. LISTON proceededto operate on the 8th.The child having been securely rolled up

in a sheet, and held by an assistant, a

crucial incision was made through the inte-guments, with a scalpel; the four flapswere then dissected back, with great care,so as to expose the tumour fully ; a needle,armed with a double ligature, was thenpassed through the base of the swelling,and the ligature left. Another ligature waspassed, at right angles with, and underneaththe first, and the needle was withdrawn, asin the former one. The attached part ofthe ligatures being divided, four distinctthreads were left, the extremities of whichwere tied in the manner describecl. Littleblood was lost during the operation. Cold-water dressing was applied for twenty-four hours.

Feb. 14. The tumour has separated by theprocess of ulceration. On the 17th, Mr.Liston, thinking that some of the diseaseremained upon one of the flaps, passed aligature around it. On the 28th the re-

maining portion of the tumour separated,and the disease was thus completely era-

dicated.March 6. The wound is nearly healed ;

there will remain but a very slight scar.The parents are allowed to take the childhome, and to return with it occasionally.

N1EVUS TREATED BY LIGATURE ALONE.

C. F., aged six months, was brought toMr. LISTON, on the l4th of Febrnary. Themother states, that at birth she perceived’ared line, about an inch in length, resemblinga slight scratch from a pin. The mark wassituated just above the left clavicle, andcontinued to increase, slowly at first, but oflate its progress has been more rapid. At

present the tumour is about one inch in .

length, and a quarter of an inch broad. Theskin covering it is of a bright red colour.It appears to be superficial, as it can bemoved freely with the skin. No distinct

pulsation. The tumour is increased muchwhen the child cries. The health is verygood. Mr. LISTON determined on placing aligature around its base immediately. Ac-

cordingly the tumour was lifted up with theleft hand, and an armed needle was passedbeneath its base, and an unarmed one, atright angles with the first. The armedneedle was then withdrawn, leaving thedouble ligature, the ends of which weretied beneath the ends of the unarmed needle,so as to include the whole of the diseasedtissue, and the needle was withdrawn.Water-dressings were applied. The partincluded in the ligature is of about the sizeof a walnut. ,

Feb 15. The tumour separated yester-day ; the surface looks healthy, and veryextensive. On March 3rd, the wound wasnearly healed, and the disease was com-pletely eradicated.In making some remarks on the two fore-

going cases, after the operations, Mr. LISTONsaid, that they afforded good examples ofthe modification of the plan of proceedingwhich is sometimes necessary in these affec-tions. The first was a case of subcutaneouserectile tumour, in the second the skin wasinvolved, and was necessarily removed.

DISEASE OF THE ELBOW JOINT.-OPERATION.

A. S. aged 24, was admitted Nov. 11,1836, under the care of Mr. LISTON. She isa sempstress ; till within these two yearsgenerally enjoyed a good state of health ;within that period, however, she has sufferedfrom attacks of rheumatism, the last ofwhich took place twelve months ago ; shewas feverish during the attack, and had

878

pain in the left side of the chest ; she hadpains in all her joints, increased at night,but there was no heat, redness, or swellingof any of them. Under the use of medicine,and the application of leeches to the side,she recovered. Six or seven months sincethe right elbow became hot, red, and swol-len, attended with much pain and throbbing ;the swelling gradually increased in size,and three months ago burst on the outerside, and about a table-spoonful of thick,yellow matter was discharged. Leeches,and blisters which were kept open, werefrom time to time applied to the elbow.Matter has been constantly discharged fromthe opening; and she has lost the use ofher arm ever since it began to swell; and,since the last attack of rheumatism, hassuffered constantly from stiffness and painat the right side of the neck.

She has now some pain in the left elbow,above and below which joint the arm isconsiderably wasted; the forearm is rathermore than half extended, and rather supined.She cannot flex the arm, except with theassistance of the other hand, and then onlyslightly, at a right angle with the upper arm.She cannot supinate the arm ; but, with theassistance of the other hand, can slightlypronate it. The elbow joint is considerablyswelled, but much more at the outer andback part, where the surface is redder andharder. A thin, watery, yellow-colouredmatter is discharged from an opening,situated externally to the olecranon. Sincethe disease in her elbow, she has not beenable to move the fingers freely, and thewrist is painful when moved. The handsand fingers are very tremulous, and the

power of grasping nearly gone; she canonly just make the tips of the finger touchthe palm of the hand; her general health isnot very good. On passing a probe throughthe opening into the joint, Mr. LISTON saida grating sensation was given. A gumsplint was applied, from a short distancebelow the shoulder to the wrist, a rollerhaving been first applied to the forearm.The forearm was fixed at a right angle withthe upper arm, by means of a bandage ex-ternally, and a sling. The opening on theouter part of the elbow was left uncovered,and water dressing was applied to it.Nov. 28. Her wrist and fingers are

stronger; the discharge has disappeared ;the opening almost closed.Dec. 7. There was a little discharge of

thick pus four days since, and the unband-aged part of the surface was rather hot andswollen ; the discharge has now disappeared,and she is gaining strength.

Jan. 7. Her general health has muchimproved since last report; anchylosis hasnot taken place ; the operation was thereforedetermined on.Previous to operating, Mr. LISTON said

the excision of the joint was a proceeding

advisable, under certain circumstances,when the extremities of bones were dis-

eased, with the view of saving a valuableportion of a limb. This case, as far as hecould judge, was a very favourable one forthe operation. The patient’s health hadbeen much improved since her stay in thehospital. He did not think he should bejustified in removing the limb, as had beenproposed before the patient’s admission intothe hospital. The improvement in herhealth was attributable to constitutionaltreatment, but more especially to the cir-cumstance of the joint having been keptsteady, with the view of favouring anchy-losis. In bringing about this desirabletermination, however, they had been dis-appointed. They must have often observedthe rapid improvement of patients, whenthe constitution was relieved from such asource of irritation. Operations on jointscould not be performed without loss ofblood, and were often apparently formidable,from the necessity of examining the parts,after cutting down upon them, to ascertainthe extent of the disease. The plan of pro-ceeding he should adopt, he considered pre.ferable to others that had been recom-

mended and followed by some surgeons.OPERATION.-An incision was made about

four inches long on the back of the arm, andforearm, a little to the radial side of theulnar nerve. A transverse incision wasmade across the joint, meeting the formerat a right angle on the radial side. Theflaps were then dissected back, and theulnar nerve turned aside, along with theother soft parts, and protected by a spatula.The joint was then easily dislocated, and theneck of the radius, and the olecranon,immediately below the coronoid process,were divided by a small straight saw fromwithin, outwards. The condyles of thehumerus were divided by sawing frombehind forwards. The flaps were replaced,and retained in their position by a fewpoints of suture.The joint was filled with a gelatinous

substance, which was likewise infiltratedinto the surrounding tissues. The ligamentsand cartilage were destroyed, and there wasextensisve ulceration of the olecranon, andthe condyles of the humerus.

After the operation, Mr. LisToN went overthe plan of proceeding on the dead subject,a proceading which is entirely new in clini-cal instruction, but one of which the studentsdemonstrated their approbation.

WESTMINSTER HOSPITAL.

PHI,EGJB1ASIA DOLENS.

On Tuesday, the 28th of February, Dr,RoE, having visited the in and out-patients,proceeded to offer some clinical remarks onthe following case of phlegmasia dolens:-