XI. Case of Compound Fracture of Both Legs, successfully Treated. By J. PEAKE, Member of the Royal College of Surgeons. IN N the night of the 2d of November 1812, I was desired to visit Michael Norris, a man about 36 years of age, who had been ran over by a waggon loaded with coals. Both wheels had passed over the legs, from three to four inches above the ankle joint. In the right leg I found a very extensive fracture, and the wheels here, it would seem, had passed in a direction to break a portion of the tibia, from three to four inches in length, in two places. This portion of bone could be felt under the integuinents, detached at both ends, and, indeed, to the extent of it, the leg seemed to be dreadfully crushed and bruised. In the left leg, both bones had been fractured about the same place, and protruded considerably through a wound upon the inner side. So soon as I could get my patient to bed, I endeavoured to replace the bones as well as the nature of the case would allow. In the left leg, where the bones had protruded, I had no very great difficulty to reduce the fracture, and to bring the ends of the bones into apposition, without dilating the wound. In the right leg, also, I replaced the fractured portions of bone, as nearly as I could. The difficulty I had now to contend with, was to put the limbs into such a position as would be favourable to their reunion; and from the very extensive nature of the accident, one alone could be chosen, and that was upon the heel, properly supported by pillows, &c. &c. The inflammation and fever resulting was, as may be expected, truly alarming. On the first day, he complained very much of pain; the pulse becoming hard and full, with great thirst and anxiety, and in the night delirium succeeded. Twenty ounces of blood were directed to be taken from the arm, and the antiphlogistic plan and regimen to be strictly attended to; the venesection to be repeated whenever symptoms night indicate its necessity, and to the fractures themselves were directed such applications as were best suited:-in the one leg, to promote a speedy union of the wound, and to the other, such as would best subdue the attendant inflammation. For the first week, these symptoms continued; the inflam mation and swelling in the right leg particularly extending up its whole course, and also up the thigh, attended with most severe pain at the fractured part, where, after a few days, suppuration took place, and matter made its way out from a wound, directly opposite to the superior end of the fractured portion of tibia already described. The next thing that presented itself, as may be expected, as the tension and swelling of the limb subsided, was the end of this piece of bone, denuded of its periosteum, pointing through the wound, nearly to the extent of an inch. The part from which it was broken below, could easily be felt and distinguished; a line could also be perceived by the touch, marking its separation. It seemed firmly attached to the integuments, beyond the part which was denuded of its periosteum. Still I was led to expect that the whole would eventually exfoliate. The discharge from the wound of this leg was very considerable; and as the symptoms of inflammation and fever subsided, a disposition to hectic fever presented itself; and there was as much difficulty now to support the patient's strength and power, as there had been previously to prevent the fatal effects of the inflammatory stage. A generous diet, together with decoct. cinchonæ, porter, &c. and an opiate at bed-time, was the plan observed. From the other leg, also, there was much discharge. The wound healed but slowly, although the bones were kept perfectly in apposition; and from this leg, from time to time, there were exfoliations of small pieces of bone, which, of course, retarded its healing. Things continued in this state for two months longer; the bone still remaining in the right leg, in the same position, firmly attached to the integuments over it, and appearing now not more likely to exfoliate, than it had been for weeks past; and that part of it which had already made its way out, and had been exposed for so long a time through the wound, still retaining its natural and healthy colour, from which I was led to expect that the bone itself must still be supplied with blood, and that probably a process of union might be going on between the detached parts below. This was also the opinion of an ingenious friend, who had from time to time rendered me his assistance in the treatment of this most intricate case; and in this we were well confirmed, for, on the 1st of February 1813, three months from the time of the accident, matters still remaining in statu quo, we determined to lay bare the fractured portion of bone, throughout its whole length, and were not surprised to find, as we had anticipated, that a process of union had taken place below, and that the bone itself, at that part, was firmly united. We had previously determined, should this prove to be the case, to remove all that portion denuded of its periosteum; an operation both tedious and difficult, but which we readily accomplished, by means of Hey's saw,—an instrument which Mr Hey of the Leeds Infirmary has introduced to public notice in his very valuable surgical book, and with which he has successfully operated in several cases of cancer of the tibia, and also in cases of frac tured skull. To this instrument, I think I may now very justly state, my patient owes the preservation of his limb, and very probably of his life. After dissecting away the integuments from the bone, and turning them back, I sawed through the tibia, exactly one inch below the projecting edge of the fractured portion of bone, and after having removed it, I carefully replaced the integuments, leaving more than two-thirds of the fractured bone behind; I then applied adhesive straps, to bring on union of the parts as soon as possible. The wound healed very rapidly, and the direct improvement in my patient's health was astonishing. The discharge from the wound soon became inconsiderable, and a deposit of ossific matter soon also filled the space left in consequence of the removal of the piece of bone. In the course of a month he was able to sit up five or six hours every day, and the leg upon which I had operated became even stronger than the other. From this time he continued progressively improving, and was not only enabled to sit up during the day, but very soon to bear upon his legs with as much firmness as if no accident had occurred. The stiffness and weakness both of the ankle and knee-joints, resulting from the confined position in which, for so long a time, they had been placed, and during which they had been altogether in a state of disease, was a difficulty to surmount which time alone could effect. This he has now so far recovered, that, for some time past, he has been able to walk with the aid alone of sometimes one and sometimes, two sticks. Slight exfoliations of bone have also, from time to time, proved troublesome, and have retarded, in some degree, the progress of cure, but he is now so far well, that he can walk the distance of half a mile from his own house, and I have no doubt but that he will be enabled eventually to resume his former occupation, which has been that of a labourer. Chipping Ongar, Essex, August 15, 1814. XII. Case in which a mass, resembling a Placenta without a Fœtus, was discharged from the Womb. By M. LEMON, Member of the Royal College of Surgeons in London. THE following case being considered very important, I have been advised by many eminent professional gentlemen to give it publicity. With diffidence, therefore, I submit it to your consideration, and beg you will insert it in the next num ber of your valuable Journal. Mrs Cunningham, æt. 24, has had three children, besides a miscarriage, which happened about two years ago. The extreme rudeness of a licentious fellow having, on Thursday the 11th of August, required her to make violent exertion, she, on the following day, perceived a slight flow of blood from the vagina, which ceased on Saturday evening. On Sunday night, when in bed, it returned with increase, and continued, (gradually diminishing) till Wednesday. All this time she suffered no pain, nor was she prevented from managing her domestic affairs-There was a slight tenderness of the abdomen only. After having had two or three pains, in every respect like those experienced during the time of parturition, she, about half past five in the evening, was seized with a profuse hæmorrhage. The pains and hæmorrhage continuing, my immediate attendance, for the first time, was requested. It was half past nine when I saw the patient, who told me she had advanced near four months in her pregnancy; and that the discharge was alarming only during the presence of a pain. Examining per vaginam, I found the os uteri dilated to the extent of a halfcrown and a bag, protruding through it, distended, as I thought from its elastic feel, with the liquor amnii. eleven o'clock, a fleshy cake, three inches in diameter, possessing every character of a natural placenta, and having a membranous bag connected with it, was expelled. The shape of this mass was oblong. Slitting up the bag, which was then flaccid, the contents gave an appearance (not with regard to colour) similar to that which is presented on the exposure of the thoracic and abdominal viscera of a very young foetus. But the * * There was no fluid found when the bag was cut into. About expansion of the placenta rendered the nature of this appearance evident. Its whole surface was covered with tumours. There were about twenty-two distinct, besides many inconsiderable ones, of various size, shape, and colour; some in clusters, (with broad bases) all seemingly connected by veins. The largest tumour was equal in magnitude to a small walnut; but this was easily, though not completely, divisible into two. Many were of the size of grapes; some were flat-sided; others conical, oblong, irregular, and convoluted. Most were livid; some fleshy-brown, and two or three light yellow. There was one, larger than the rest, semitransparent, membranous, and globular, with its base surrounding the largest of the latter. This appeared to be formed by the raising of the covering of the foetal surface of the placenta, which, after affording a tunic to all the tumours, was continued from the circumference of the placenta to form the bag. This membranous continuation had another imperfect fatty layer proceeding from the uterine surface of the placenta. The livid tumours generally had condensed fet at the extremity. All had the same feel, except the yellow, which consisted of a compact fatty substance, resembling that found on the other side of the placenta. The livid and brownish had not the firmness of fleshy tumours, nor the elasticity of those containing fluid. They contained coagulated blood; and, pressing it out, a substance of a placental nature was left betwixt the fingers. Such is my idea of these tumours, that, were my opinion of the formation of them demanded, I should say it was probable that the blood, being extravasated from the vessels of the placenta, or having accumulated in its cells, that tuberculated surface was produced by an irregular and great distention, or, perhaps, rupture of them. Notwithstanding, I presumed it was evident that some of the veins, or sinuses of the placenta, had degenerated into these tumours, as their regular progression could apparently be traced. The woman, during the growth of this mass within the uterus, had every symptom of pregnancy. The breasts, when she is not pregnant, are scarcely observable; now, they are rathér prominent, and distinctly marked. About the third month of gestation, a soreness was always produced by pressure; this she felt at this time, under the same circumstances. She had the same feelings,-the same nausea, and the same capricious appetite, she always had when with child. There was a promi * I cannot say whether this vesicle contained air or water, as it was relaxed before I could attend to it. |