CHARITÉ for fracture of the right fibula, during a period of five months, and experienced no constitutional indisposition while there. He was never afterwards able to walk without crutches. For the four months after leaving the hospital, he experienced often a diminution of appetite, chills, &c. and one month before coming to La PITIÉ, he fell down a staircase, and struck the right side of his chest against the wall, which was followed by some pain in that part, and slight cough. Two weeks before he came under the observation of M. Louis, the patient felt pain in the lower and inner side of the right thigh, which gradually extended to the groin, with swelling of the whole limb. There was nothing of the kind in the other extremity till a week afterwards, when it also swelled. 9th May. Both lower extremities are oedematous, but the left much more so than the right. There was neither redness nor hardness, nor pain along the internal surface of the limbs-immobility, without paralysis, existed in the left thigh for two days past. In the groin of that side there were two red bands-and the veins of both hypogastric regions were very much developed those of the thighs not at all apparent. There was no perceptible tumour in the abdomen; but pressure on the lower part could not be borne. There was no fever, though the pulse was 100 in the minute. There was a little embarrassment in the breathing; but the respiration was good, as was the sound on percussion throughout the chest. Venesectio ad 3xij.-diluents. There was a slightly inflammatory crust on the blood. 10th May. He was considerably relieved by the bleeding-the pulse fell to 95-there was less malaise, but a greater elevation of temperature. Some tincture of digitalis and nitre with the ptisans. In the evening a rigor, followed by heat and perspiration. 11th May. Heat natural-pulse 88left thigh softer-red bands still continue in the groin, but less marked-the abdominal veins more salient. Venesection to ten ounces. The blood was not inflamed. There was another rigor, with fever and perspiration this day. 12th. The epigastric veins still more enlarged than natural, and the blood evidently circulated in a retrograde direction-that is, from the trunks towards the branches, as ascertained by pressure. There was no particular alteration till the 16th May, except the disappearance of the febrile paroxysms above-mentioned, and the complaint of a pain in the left hypochondrium, and in the lower part of the chest of the same side. The patient coughed and expectorated a little; and on examination, there was no sound in the lower third of the left side of the thorax. From this time till he quitted the hospital, on the 7th of August-that is during three months, the following phenomena were observed. The oedema of the lower extremities progressively diminished, and, by the 6th of June, was scarcely perceptible in the right member, but more marked in the left. By the middle of July, there was no swelling in either limb. The state of the veins changed with that of the swelling. On the 26th of May, the right epigastric vein was much more developed than the left-by the 6th of June, both veins were considerably diminished. By the 14th, the right was nearly effaced-on the 15th, pressure made on the track of neither vessel caused turgescence. When he left the hospital, no trace of the epigastric veins on either side was visible. Leeches had been applied to the left side of the chest twice, soon after which the cough diminished, but the sound was not clear till the 6th June. On this day, the patient complained of pain in the right side of the chest, with an augmentation of the cough, but without any loss of sound in the corresponding part. This pain ceased on the 19th. There was but little thirst all this time, and the appetite never entirely failed though it was very much impaired. He left the hospital in a very enfeebled condition, not being able to walk even with the aid of crutches. M. Louis thinks that the phenomena above detailed-and especially the retrograde circulation in the enlarged epigastric veins, prove incontestibly that an obstruction had formed in the inferior cava. The ultimate diminution of these vessels, he thinks, is attributable either to removal of the obstacle in the cava, or to a more deep-seated collateral circulation having been established. We are inclined to agree with the talented physician of LA PITIÉ, and, as the poor man seems to be in no very promising condition of health, it is not improbable that the issue of the case, and the diagnosis of the disease, will be put to the test of post-mortem examination.-HEBDOMADAIRE. XLVIII. HOPITAL DES ENFANS. CLINICAL OBSERVATIONS ON THE DIS EASES OF CHILDREN⭑ M. GUERSENT, from his official situation, has a wide field of observation open to him, in prosecuting the study of infantile diseases. Like his brethren on the French side of the channel, he has cultivated the department of morbid anatomy with a diligence which does him credit. M. Guersent observes, that practitioners have considered the diseases of childhood in too exclusive a light. Growth and dentition are the scapegoats for all maladies, although children are not exempt from the same morbid processes that seize upon more advanced life, whilst they lay claim to others peculiar to themselves. Affections of the mucous membrane, and the class of ramollissemens are extremely common, and the morbid growths are not unfrequent. Phthisis pulmonalis, says M. G., is more frequent in infancy than at any other time of life; diseases of the circulatory system are rare, excepting, of course, malformations, and practitioners should be aware that the left ventricle is remarkably thick in early life, a circumstance which is often considered as an instance of hypertrophy; apoplexy is uncommon, but M. Guersent has seen a case of apoplexy of the spinal marrow, in a patient affected * Journ. Hebdom. No. 91. with diseased cervical vertebræ. He also maintains that many affections must be looked upon as nervous, inasmuch as no organic change is left behind. Children are subject to all kinds of neuralgia, and the genito-urinary system is liable to all the maladies which affect old age, excepting perhaps the chronic inflammation of the mucous membrane. Gangrene of the external parts of generation is frequent in young girls. The diagnosis of infantile diseases presents many points of difficulty and doubt. The general sonorousness of the thorax, which even remains when the lungs are hepatized, may, if not understood, be productive of serious mistakes. Diseases steal on in the most insidious manner, pneumonia being ushered in with cephalic symptoms, and what appears to be a slight enteritis ending in the most alarming cerebral affection. MEMBRANOUS INFLAMMATION OF THE CHEEK. This affection is particularly described by M. Guersent; it differs from the gangrena oris in being a much milder disease. It is more frequent in infancy than in adult age, on the right side of the mouth than the left. In the onset the mucous membrane of the cheek appears a little swollen, and beneath the epidermis there form little membranous patches, which run into one another, and spread over the cheek, the gums, the tongue, and the neighbouring parts. The glands of the neck are more or less enlarged, but as yet there is no ulceration of the cheek. In the second stage the cervical glands are more swollen, the face is tumid, the breath fœtid, the layers of false membrane become detracted and assume a greyish colour, and a copious sero-sanguineous discharge adds to the miseries of the little patient. There is usually little fever, the pain varies in different subjects, the salivary secretion is abundant. In the third stage the disease proceeds more slowly, and may terminate either in gangrene or in resolution. If the latter, the sloughs having come away the denuded surface is surrounded by a red dish areola, which contracts the sore from the circumference to the centre, whilst absorption appears to be at work on the border of the membranous exudations. In other instances, when the affected surface is extensive, absorption proceeds in various places, even from the commencement of the malady. The disease may disappear and again return several times in the same individual. When the disease extends to the submucous cellular membrane it is liable to end in gangrene, but this never possesses the malignity nor advances with the rapidity of the true gangrena oris. The disease is seldom attended with danger; is not, in M. Guersent's opinion, contagious; is chiefly developed in children debilitated by chronic affections, bad food, or hospital air; often follows the small-pox and other eruptive diseases; and appears to depend on a general alteration of the fluids. It seldom passes from the mouth to the pharynx, but one example of this kind was observed two years ago in the practice of M. Jadelot. With respect to the treatment, topical applications only are important. If much pain is felt and the glands of the neck are considerably enlarged, the employment of leeches is advantageous. A mixture of muriatic acid and honey in equal parts, or made stronger if necessary, is, according to M. Guersent, the best application. He is likewise very partial to the nitrate of silver, taking care not to break it in the infant's mouth. If other diseases coexist with that under consideration, the gene-ral treatment must, of course, be adapted to the particular case. XLIX. HOPITAL DE MONTPELLIER. M. DELPECH ON IMPERFORATE OS UTERI. brought by her parents to M. Delpech. She was much emaciated, and extremely feeble; complained of thirst, and had some pyrexia. In the hypogastric region was a rounded, moveable tumour, painful to the touch, and rising to about the level of the umbilicus; it created most uneasiness at the monthly periods, when it seemed to increase in volume, and fits of hysteria came on; its pressure on the bladder frequently impeded the flow of urine, and occasioned a fallacious desire of micturition. On examination per vaginam a projection was felt, which was clearly a portion of the tumour, and it was also distinguished by the finger in the rectum; at the bottom of the vagina, as well as in the hypogastrium, fluctuation could be felt with some attention, but no trace of the neck of the uterus or os tincæ existed. The patient had never menstruated. When young she had enjoyed good health, and even possessed considerable muscular strength. The preceding symptoms had been coming on for the last six years, and on two occasions she had been attacked with violent pain in the belly, attended with serious fever. M. Delpech had no doubt that the tumour was produced by retention of the menses in the uterus, and increased growth of the latter. After trying various means without success, the surgeon determined to open into the uterus and evacuate its contents. He procured a trocar seven inches in length and five lines in diameter, slightly and uniformly curved, and its canula perforated with several lateral openings in the upper third. The patient being placed as in the operation for lithotomy, pressure was made on the hypogastric tumour, in order to render the vaginal portion more prominent and fixed. The fore and middle fingers were then introduced into the vagina, and made to touch the tumour, whilst the canula carrying an œsophagus bougie was guided along the fingers, until the extremity also touched a favourable part of the tumour. The bougie was then withdrawn, and the trocar introduced through the canula into the tumour. On its withdrawal a Case. Margaret G. ætatis 22, was pint and a half of brown, inodorous, THE following case and accompanying observations are contained in the Mémorial des Hôpitaux du Midi, for March of the present year. and oily-looking matter was discharged, when the hypogastric tumour was quickly reduced to half its former size. The same matter continued to flow slowly for some time, but had ceased by the fourth day after the operation. A moderate mucous secretion followed, the volume of the tumour still farther decreased, and although much induration remained, there was no irregularity to be discovered. On the twentieth day after the performance of the operation the menses appeared, and lasted for six days. Pains in the hypogastrium and a paroxysm of hysteria succeeded, but these appeared to be rather the force of habit, than dependent on any existing disease. In another month the menses flowed again, and the uterus was now no larger than it commonly is three months after parturition. M. Delpech remarks that much difference exists between the obstruction of the os uteri from inflammation, and the congenital imperforation. According to the Professor there is infinitely more difficulty in keeping the opening pervious in the former than the latter, and more danger also in performing the operation. M. Delpech mentions the best mode of ascertaining a collection of fluid in the enlarged uterus, which consists in introducing two fingers of the left hand into the vagina, and resting them on the portion of the tumour which projects there, whilst the right hand is laid on the hypogastrium. Between the two fluctuation may be discerned. The Professor might have added, that this mode of examination is well adapted to all uterine tumours of any degree of magnitude. Poising the os uteri on the fingers of one hand the hypogastric tumour is pressed down with the other, which furnishes a very useful method of examination. M. Delpech observes that the best mode of operating is by using a long and large curved trocar, introduced in the line of the pelvic axis, and by not allowing all the fluid to escape by the canula at first. A certain quantity remaining behind, continues to flow gradually through the opening and obviates the necessity of a tent or other dilating medium. The point to be perforated should be the most dependent. In support of these statements, M. Delpech remarks that the operation of puncturing for imperforate anus almost always succeeds without any further measures to maintain the opening. Is this so universally the case? At all events, M. Delpech protests against the use of tents or bougies after this operation, condemning them as not only unnecessary but pernicious. In the obstruction of the os uteri from inflammation, it is best to use a speculum, and make a crucial opening with a bistoury. The edges of the opening should be removed with the same instrument, in order that there may be a loss of substance, instead of a simple puncture, which is all that is necessary in the congenital imperforation. Such are the opinions of M. Delpech. Practitioners see so few of these cases that the experience of the Professor is more valuable on this, than on ordinary points. We think, and have long thought, that cases of obstructed catamenia are generally treated in too routine a fashion, and that mechanical obstruction in the vagina or os uteri would be oftener found, if more frequently looked for. L. LA CHARITE. I. EXCISION OF A CARIOUS RIB.* Case. Louis Evrard, shoemaker, aged 38, was admitted into La Charité on the 23d of March, with a fistulous opening on the right side of the chest, leading down to the fifth rib. The latter, when examined by the probe, felt rough, denuded, and carious. A considerable quantity of puriform matter was discharged from the fistulous opening; the patient was debilitated, thin, and suffered from a troublesome cough, with expectoration of thick mu cous sputa; but no positive sign of phthisis pulmonalis was present. On the 24th of April M. Roux pro * Journ. Hebdomadaire, No. 86. ceeded to remove the rib. All the soft parts covering it were included between two semi-elliptical incisions, extending from the border of the axilla to near the sternum, and passing immediately under the mamma. By these incisions and the removal of the integuments included between them, the rib was exposed for the extent of five inches; the limits of the carious portion ascertained, and the latter, four inches in length, cut out by means of the chain saw; another small portion near the sternum presenting a suspicious appearance was also taken away. The pleura costalis adhered as usual to the inferior border of the bone, but above it was thrust inwards by a moderate collection of pus, which had no communication with the pleural cavity. The rib was quite carious, the superior border in particular and the internal surface being rough, deprived of its superficial lamina, and chiefly affected about midway between its two extremities. The wound was simply dressed, and for two or three days the patient appeared to be doing well. Then, however, dyspnoea and symptoms of pleuritis on the right side appeared, and death speedily super vened. Sectio Cadaveris, The right side of the chest contained a considerable quantity of sero-purulent fluid with some flakes of recent lymph. The fluid was confined to the two lower thirds of the pleural cavity, the upper being closed from old and firm adhesions. The upper part of the lung contained many large and half-softened tubercles, principally situated opposite the second, third, and fourth ribs, which were all carious and broke with the greatest facility. The pleura at this part still continued sound. The apex of both lungs was loaded with tubercles, chiefly of the granular kind; some of them were softened, others were not; there was nothing like a vomica. No disease was discoverable in other organs. The reporter remarks that he is not aware of the operation having been performed more than once in France, which was by Richerand in 1818. The patient died. Joshua Aymar, a surgeon of Grenoble, twice excised several carious ribs with success. The first patient was a woman, forty years of age, in whom the eighth and ninth ribs were diseased; the second, a captain, whose fifth, sixth, and seventh were affected. M. Cittadini has more recently published five cases of successful excision of one or more ribs. In all he opened the cavity of the pleura, and one patient nearly died from the admission of air into it. In the present case of M. Roux's, the tubercles of the lungs must undoubtedly be considered as contributing essentially to the unfavourable character of the case, and the fatal pleuritis. At the same time, the result is calculated to point out the uncertainty that must always hang over this operation, and deter practitioners from engaging in it wantonly or without the most cautious deliberation. We have witnessed one unsuccessful attempt at excision of part of a carious rib, complicated, as it turned out, with an opening into the chest. The patient died, but whether from the immediate effects of the operation we cannot positively say. II. REMOVAL OF GREAT PART OF THE LOWER JAW-IMPROVEMENTS ON THE COMMON OPERATION. Case. A country woman, ætatis 27, was admitted into La Charité, on the 1st of May, with a knobbed, irregular tumour of the gum and body of the lower jaw on the left side. It was hard in some parts, soft in others, and appeared to embrace both sides of the jaw from the symphysis of the chin to the last molar tooth. The mouth was distorted, the tongue pushed over to the opposite side, deglutition difficult, and the articulation of some words impaired. It had commenced with violent pain in the teeth of the left side, which continued for several years without any permanent amendment. The maxillary tumour had been coming on for two years prior to her admission. On the 8th of May, M. Roux proceeded to remove the diseased portion of the jaw. He began the operation by thrusting the point of a straight bistoury through the cheek, about half an inch below the edge of the lower lip, prolonging the incision as far as |