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A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

ROYAL FREE HOSPITAL.

COMMINUTED FRACTURE OF THE RIBS FROM INDIRECT

VIOLENCE, PRODUCING EMPHYSEMA, HÆMOPTYSIS,AND DEPRESSION ; RECOVERY.

(Under the care of Mr. T. H. WAKLEY.)

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum etdissectionum historias, tam aliorum proprias, collectas habere et interse com-parare.-MORGAGNI, De Sed.et Caus.Morb.lib.14. Procemium.

WHEN we see a case of fracture of the ribs, the result ofdirect violence, such as a blow, it is generally situated in theiranterior half; if the cause, however, has been indirect, theymay be broken in two situations, as in the accompanying case,wherein the fourth, fifth, and sixth ribs were fractured at theirangles, and near the sternum, from the trampling of a dray-horse over the chest. A similar case was treated at St.Thomas’s Hospital, in July, 1856, under the care of Mr. LeGros Clark. In that case a load of coals fell over the poorman’s body, and not only produced the fracture of the ribs, buta wound of the lung, a dislocation of the collar bone, and frac-ture of the arm and leg, with sloughing of the latter, and yetthe poor man not only did well, but left the hospital, as weunderstood, cured of his injuries. In Mr. Wakley’s patientthere were emphysema, haemoptysis, and physical signs ofextensive implication of the lung, which was wounded.The peculiarity in the treatment consisted in the free admi-nistration of stimulants, which sustained the flagging powersof life, and materially assisted towards perfecting a cure

of the lung mischief, as well as the union of the broken ribs,which had been completely effected before the patient leftthe hospital. In the treatment of fractured ribs, one of theessential indications is to arrest or diminish motion by ban-daging the chest; that was attempted here, but, as in otherinstances, its application at first produced pain and uneasiness:it was, therefore, suspended for awhile, and finally reappliedwith good results. We avail ourselves of the notes of the

case, through the kindness of Mr. Edmund O’Loughlin, house-surgeon to the hospital.Wm. M-, a potato porter, aged forty-seven, was admitted

into A ward on the 30th of April. His history was, thatwhilst leading a dray-horse across the rails of the GreatNorthern station, the animal suddenly started, knocking himdown and trampling upon him. On admission, he was in astate almost approaching collapse; his pulse was hardly to befelt, and he complained of severe pain in his left side; his

breathing was very laborious, and his skin cold and coveredwith perspiration. On examination, the fourth, fifth, andsixth ribs were found to be fractured at their angles, and againabout an inch from their cartilaginous articulations; there wasslight emphysema, limited to the seat of fracture; and thecrepitation between the broken fragments of bone was so loudas to be distinctly audible to the persons who assisted in un-dressing him. Two ounces of brandy were ordered by thehouse-surgeon, a table-spoonful to be given him at intervals ofa quarter of an hour until reaction set in; abroad bandage wasapplied with a moderate degree of tightness around the chest,so as just to afford sufficient support to the fractured ribs, andrestrain in some degree the action of the intercostals, withoutembarrassing the respiration; and a draught containing twentyminims of tincture of opium, with the same of chloric ether, inone ounce of camphor mixture, to be taken directly.--ElevenP.M. His pulse was still very feeble, and he complained ofsevere pain at the seat of injury; the respiration was extremelylaboured, and the countenance pale, and betrayed great anxiety.

The stimulants were ordered to be continued, and warm bottlesapplied to the feet, which were becoming cold.May 1st.-The patient has passed a very bad night, and

seemed to be sinking; pulse 120, weak and thready; he com-plained much of his cough. A mixture was ordered every fourhours, consisting of half a drachm of tincture of henbane, tenminims of chloric ether, and twenty of wine of ipecacuanha, inan ounce of water.

2nd.- - Three A.M.: The nurse called up the house-surgeon,saying the patient was dying. He complained of a sense ofgreat suffocation, his countenance was blanched, and he wasgasping for breath, but did not complain of much pain; pulsealmost imperceptible. The broad bandage, which had beentightened during the day, was now altogether removed hewas placed in a sitting position, and some warm brandy-and-water was given to him. This seemed to relieve him consider-ably, and he said he breathed with much greater ease.

3rd.-Dyspnœa better, but still very considerable; there isgeneral mucus and sibilant rhonchi throughout the lungs;pulse 100, still feeble. A small quantity of florid blood hasbeen expectorated. He complains of the cough, and of the"pain and grating of the ribs." Mr. Wakley ordered thebandage to be again applied with a moderate degree of tight-ness, and to continue his mixture and as much nourishment ashe could take.

4th.-Expresses himself easier this morning; still coughs agreat deal; sputa bronchitic, with now and then a spot offlorid blood in it; pulse 96, weak. To continue the treatment.5th.-He had an attack of dyspnoea and faintness in the

night, somewhat of the same character as that which tookplace on the 2nd; seems much feebler this morning. Says hefeels weaker than he has done yet. Expectoration very pro-fuse ; surface of the body much colder than usual. Mr. Wakleyordered five grains of carbonate of ammonia to be added to eachdose of his mixture, and to have some warm wine-and-water aswell as his brandy.6th.-Pulse decidedly better; had some sleep during the

night; does not expectorate so much; is now taking six ouncesof brandy and ten of port-wine in the day and night.8th.-A great improvement has taken place in the patient;

his pulse is much fuller, and has fallen to 90 ; he takes nourish-ment freely, but still complains of the pain in his side and thecough. To continue the medicine, &c.11th.-He is progressing favourably. The bandage was re-

applied to day. Mr. Wakley ordered the brandy to be dimin-ished, and two pints of stout to be given daily instead. Fromthis date he gained ground daily, and with the exception of acontinuance of cough and occasional pain in the side, whichwere present up to a short time before his discharge, no othersymptom of importance took place. He was discharged curedon the 30th of May.

This man seems to have led a charmed life. He had bothpatellæ broken on former occasions, for which he had beentreated in the London Hospital, and was also the subject ofdouble albugo, from an injury sustained some years ago, whichmuch impaired his sight.

CHARING-CROSS HOSPITAL.

SCROFULOUS PNEUMONIA.

(Under the care of Dr. WILLSHIRE.)WHAT is phthisis ? Most persons would answer, the deposit

of tubercular matter in the lungs, its softening, and accom-panying disintegration and destruction of the pulmonary paren-chyma. And, no doubt, in the greater mass of cases whenphthisis is presumed to exist, such is its anatomic character.But are all instances of phthisis of this kind ? Are all cases

which are marked by more or less of the usual physical andvital signs and symptoms of pulmonary consumption originallybased upon the deposit of tubercule in the tissue of the respiratoryorgans ? Some few pathologists assert that all are not so.

Graves, Addison, Rheinhardt, and Virchow have maintainedthis doctrine; and, lately, Dr. Willshire pointed out to us, atthe Charing-cross Hospital, a young man illustrating this viewof the question-a view which he himself had for some timeadopted, and in illustration of the truth of which Dr. Willshirestated he usually met with two or three cases every year. Thedisease which is mistaken for tutercztjctr phthisis, according tothe above writers, and to Dr. Willshire. is a form of srofulous

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pneumonia. (Scrofulous pneumonia, Graves; pneumonicphthisis, Addison ; chronic suppurative pneumonic infiltration,Rheinhardt and Virchow.) 1o tubercular matter is originally(or necessarily at any time) deposited in the pulmonary paren-chyma ; but inflammation of a scrofulous character invades thesubstance of the lung, eventuating in the exudation of an infil-trating induration-matter, which, instead of becoming absorbed,or remaining indolent, slowly softens, and breaks up, disin-tegrating the original pulmonary tissue, and giving rise to moreor less of both the physical and vital signs of tubercular con-sumption. It is not unlikely, however, that in the course ofthis form of pneumonitis, true tubercular matter shall also bedeposited, but such occurrence is not essential, and does notconst,’t?tt,2 the malady. The result may be said-speakinggenerally-to be the same both in pneumonic and tubercularphthisis-viz., cough, with purulent expectoration; dyspnceaon exertion; wasting and hectic, &c. But, according to Dr.Willshire, there are one or two symptoms which are worthy ofattention, as helping to differentiate the diagnosis. So far ashis experience goes, the physical signs are for a long while con-fined to one lung, and are only exceptionally located at the an-terior apex; the expectoration is peculiar, more like that insuppuration of the lung in ordinary pneumonia than in tuber-cular phthisis, but not mixed with sanguinolent matter, exceptoccasionally. Further, there is marked tendency to slightsphacelus or gangrenous destruction of the pulmonary paren-chyma, giving rise to a very fcetid odour of the breath and ex-pectoration. We were told that the patient we were examin-ing had once rendered the ward almost unbearable for a timefrom this circumstance, and that a few months back anotherpatient, under the same physician, had, though in a somewhatless degree, been productive of the same inconvenience. The

wasting is less marked and rapid, and more temporary advan-tage appears to result from treatment than in tubercular

phthisis. Dr. Willshire made the remark that in all the casesof this form of scrofulous pneumonia which had come beforehim, it was the right lung which was first and mainly affected.

HOSPITAL FOR CONSUMPTION AND DISEASESOF THE CHEST, BROMPTON.

TUBERCULAR CEREBRITIS AND MENINGITIS; PULMONARY

PHTHISIS ; CONVULSIONS AND DEATH.

(Under the care of Dr. COTTON.)IT will be clearly seen that the following case was one of

cerebritis and meningitis, following pulmonary disease. The

symptoms peculiar to cerebritis were the most prominent. Thecase belongs to a class of very infrequent occurrence at theConsumption Hospital. It seems to be the general characterof phthisis for the sufferer to retain his intellectual facultiesuntil the last; even a temporary delirium is an exceptionalsymptom, and the brain is one of the latest and most unusual

depositories of tubercular matter. It sometimes happens thatmasses of tubercle are found collected within the cerebrumitself, or projecting into it from some portion of its investingmembranes, without producing, for a very long time, anyacute or even any very obvious symptoms ; the patients pro-bably having complained little of cerebral inconvenience, untilsome rather active inflammation has brought on the fatal issue.In such cases the tubercular deposit seems to have been formedslowly, and the brain gradually to have accommodated itselfto its presence. In the present case, however, it is more pro-bable that the small tubercular spots were formed rapidly, andgave rise at once to acute symptoms; and such, we believe,has been the general character of the few similar cases whichhave been noticed at the hospital. Whether the spots oftubercle were the excitants of the cerebral and meningeal in-flammation, or whether they were secondary to the latter, inconsequence of its attacking a person of a highly tuberculousdiathesis, are questions open to discussion, hut, after all, notof much practical moment. It is but too probable that, in

spite of the best-directed treatment, all such cases must ulti-mately prove fatal. From the very onset of the attack Dr.Cotton suspected its character, and predicted its fatal termi-nation.

T. N-, a butcher, aged thirty-two, was admitted on the28th of May, 1858. He was of middle height; dull, heavy ex-pression of countenance; a red streak on the gums; fingers notclubbed: some emaciation. One sister had died of consnmp.tion. Symptoms of ordinary phthisis set in about two yearf

ago ; and since that period haemoptysis has occurred severaltimes. On admission, there was cough with abundant puru-lent expectoration, and severe night perspiration; the appetitewas good; the pulse 78; the respirations 32, and laboured;bowels constipated; tongue white and flabby. He complainedof heavy, dull headache, chiefly over the forehead. A physicalexamination of the chest revealed an advanced state of pul-monary disease. Beneath the right clavicle, humid cracklingrhonchi showed that softening was going on; whilst beneaththe left clavicle, the bruit de pot fele and amphoric respiration,told quite as distinctly that there was a large vomica in thatsituation.The following were the prominent symptoms during the pro.

gress of the disease :--May 30th.-Bowels very constipated; sickness; increase of

headache, and general torpor; pulse 64.31st.-Bowels have acted from aperients, but the headache

and drowsiness continue; speech is faltering, and he makes alow moaning noise; when roused he is partly conscious, butcannot express himself; breathing slow and laboured; pulse60, and full; pupils dilated and sluggish.June 2nd.-Leeches on the temple, followed by a blister to

the neck, with cold lotions to the head, have had no effect.Sickness continues; cannot articulate; pulse 68, full andlaboured; pupils still dilated and sluggish, especially the right;lies in a partly conscious state, but cannot speak. Whenroused, he places his hand over his forehead, and plainly indi.cates the seat of his distress.4th and 5th.-Symptoms increasing; both pupils dilated;

strabismus of the left eye. Is roused with great difficulty.Tongue protrudes in a straight line; no loss either of motionor sensation in the limbs; reflex movements perfect; pulse 52;feeble; deglutition very difficult; voice lost.6th.-Rather active delirium during the night; has torn his

shirt into fragments; moans, but cannot speak; both pupilsdilated, and uninfluenced by light; permanent strabismus ofthe left eye; tongue white; pulse 48; respirations slow andlaboured.

7th.-Convulsions came on this morning; lies comatose;breathing stertorous; pulse 60; no paralysis of the extremities;urine and fæces passed unconsciously.

8th.-Convulsions increasing; countenance much distorted.He died at six A.M.The post-mortem examination of the chest merely confirmed

the original diagnosis; broken-down lung and large vomicæbeing discovered. No other organ of the visceral cavities pre-senting abnormal appearances. It is unnecessary to refer to

anything but the head.On opening the skull, the membranes were seen to be very

vascular, and the cerebrum itself was much injected, althoughits consistence was normal. Both ventricles were fully dis-tended with clear serum. Upon the surface of the brain, andsituated either upon or within the pia mater, were a numberof white, consistent bodies, of uniform size, but not exceedingthat of the smallest pin’s head; they were irregularly scat-tered, and not arranged in patches. Under the microscopethey were found to consist of irregularly-formed cells, inter-mixed with granular matter.

CLINICAL RECORDS.

FALL OF A CHILD FROM A THIRD - STORYWINDOW.

WHEN we hear of such an accident as the fall of a child froma great height, we expect to learn that, if death has not beenimmediate, the injuries are of such a character as subse-quently to destroy life. Such an instance occurred in Novem-ber last: a male child, of two years and a half, got betweenthe bannisters of the stairs of a second floor, slipped through,and fell a great depth, the fall was partly broken, but theskull struck the floor with great force. Great swelling andeffusion of blood ensued, and the escape of a good deal ofbrain substance through a small scalp-wound, which was found,on his admission, under Mr. Wakley’s care, at the Royal FreeHospital, to communicate with a fearfully-extensive fracture.The child of course died, but it remained alive and unconsciousfor three or four days.A more remarkable accident than this is now under the care

of Mr. Alexander Marsden, in the same hospital. A little

! girl, two years old, fell out of a third-story window on to the