90

tudina.1 incision, and dissecting the mass out. The wound wasthen closed with sutures, supported with strips of plaster.The tumour had the ordinary appearance of one of a fibro-plastic character, ""vith several small cysts filled with a greenish-yellow fluid.

3frer the operation she progressed favouraly, and was dis-charged about fourteen days afterwards. At the operationthe tumour was found to be pretty close to the popliteal vessels.

ROYAL FREE HOSPITAL.

CRUSHING OF THE HAND BETWEEN TWO ROLLERS ; FRACTURE OFTHE DISTAL PHALANGES ; LACERATION OF THE PALM; ERYSI-PELAS EXTENDING UP THE ARM; SLOUGHING OF ENDS OF

FINGERS; RECOVERY.

(Under the care of Mr. WAKLEY.)THE hand and forearm, of all parts of the body, are the most

liable to mechanical injury, from their necessary exposure asthe principal means of regulating and controlling the power ofmachinery. This rule applies more especially in towns wheremanufactories exist in great number, and very frequently thisclass of injury is seen in our London hospitals. When thehand has been injured, especially in the young, the surgeonmakes every effort to save either the whole or at least a part ofit, with as many fingers as he can. This we recently sawcarried out at this hospital in two instances, which at firstsight seemed only fit for amputation. A most praiseworthyeffort was, however, made to save them, which to some extentwas crowned with success. In the first of these, the extremi-ties of the four fingers with the integument of the palm sloughedaway..111’. Wakley found it necessary in the progress of thecase merely to remove the heads of the two fingers, and auseful hand was gained. In the other case, the laceration and

general injury were much more severe; the thumb was hangingby a mere shred, and some of the bones were extensively com-minuted ; free haemorrhage had besides produced much debility.Mr. Cooke removed the thumb and two neighbouring fingers,and a good recovery was made with the ring and little fingersremaining. In both of these cases the injury arose from biscuit-baking machinery. The abstracts of each were kindly furnishedus by llr. Turtle, house-surgeon to the hospital.

George S-, aged fourteen, biscuit-baker, was admittedSeptember 23rd, 1856, his hand having passed between tworollers. On admission, it was found that the distal phalangesof all the fingers were fractured, but there was no externalwound of the skin. The integument on the palmar surface wastorn up and lying on the fingers; the proximate phalanges ofthe middle and ring fingers were also broken, but the thumbhad sustained no injury. The flap of integuments having beenrestored as near as possible to its proper position, and retainedthere with sutures, the hand and arm were enveloped in cottonwool. Very little constitutional disturbance took place. Aboutthe fourth day, erysipelatous inflammation came on, and ex-tended np the arm beyond the elbow. This was subdued bythe application of lead lotion in about three days. The extre-mities of the fiugers and inj nred integument of the palm sloughedaway, and it was found necessary to remove the heads of themiddle phalanges of the index, ring, and little fingers, to obtainflaps to cover the bones.The boy was discharged on November 19th, the wounds

having nearly healed, and there was some amount of flexionand extension of the wrist.

COMMINUTED FRACTURE OF THE BONES AND EXTENSIVE LACERA-

TION OF THE INTEGUMENTS OF THE HAND; AMPUTATION OFA POPTION; PRESERVATION OF THE RIB G AND LITTLE

FINGERS; RECOVERY.

(]Under the care of Mr. WEEDEN COOKE.)D. R——, aged sixteen, was admitted, Sept. 30th, 1856, in

a collapsed condition, causud partly by the shock of an injuryjust sustained, and partly by loss of blood. He had been

assisting at a factory for biscuit-baking by steam apparatus,when the right hand became entangled in the machinery, andmuch laceration was the result. -Upon examination, it ap-peared that the thumb was torn from its attachments, andhung loose, the metacarpal bones of the index and middlefingers were much crushd, -,,,iad broken up into fi-aornients,and the integuments both of the back and palm of the hand,including the muscles of the thumb, were most severely Itice- ’Irated. When first admitted, there was free arterial haemor-rhage, which was checked by pressure with dry lint andbandage. After consultation with his colleagues, Mr. Cookedecided noithor to attempt to save the fingers, nor to amputate

the hand, but to remove only the thumb, index, and middlefingers, nipping off the corresponding fractured ends of themetacarpal bones, and obtaining as good a flap as possiblefrom the palm of the hand. This he did, and everything pro-gressecl favourably. The boy was extremely weak, and re-quired high feeding. The healing process went on partly byadhesion and partly by granulation, and was complete on the1st of December. The two remaining fingers admit of flexionand extension, and when educated, and aided, perhaps, by anartificial thumb, will be of the greatest service to the pooryouth in writing and even prehension.

Medical Societies.ROYAL MEDICAL & CHIRURGICAL SOCIETY.

TUESDAY, JANUARY 13TH, 1857.

DR. WEBSTER, F.R.S., V.P., IN THE CHAIR.

MR. SOLLY said that since the last meeting of the Society hehad obtained further information respecting his case, whichwas then read. He had seen the gentleman who had attendedthe woman in her confinement with the child, and from himhad received an account and drawing of the case, the latterbeing executed three weeks after birth. A careful examinationhad been made of the child, and no connexion whatever couldbe traced between the tumour and the occiput. Mr. Vincenthad, after examination, come to the same conclusion, and hadregarded the case as one of spina hifida.ON THE DETERMINING CAUSES OF VESICULAR EMPHYSEMA OF

THE LUNG.

BY WILLIAM JENNER, M.D., F.E.C.T.,PHYSICIAN TO UNIVERSITY COLLEGE HOSPITAL, AND TO THE HOSPITAL FOR

SICK CHILDREN.

After referring to the importance of ascertaining the deter-mining cause of pulmonary vesicular emphysema as a guide forits prevention, and to the predisposing influence of all changesin the structure of the lung which impair its contractility, theauthor adverted to the fact, that the only force capable of un-duly dilating the air-cells called into play during respiration isthe pressure of air on their inner surface. He then briefly re-capitulated the inspiratory theory at present generally received,and quoted the following passage from the latest exponent andmost powerful advocate of that theory :-" The act of expira-tion tends entirely towards emptying the air-vesicles by theuniform pressure of the external parietes of the thorax uponthe whole pulmonary surface; and even where the air-vesiclesare maintained at their maximum or normal state of fullness bya closed glottis, any further distension of them is as much outof the question as would be the further distension of a bladderblown up and tied at the neck by hydrostatic or equalizedpressure applied to its entire external surface."* " The objectof his paper, Dr. Jenner stated, is to show, in opposition tothese views, that the force called into play by powerful expira-tory effort is by far the most common and efficient cause ofvesicular emphysema of the lung. Powerful expiration is, Dr.Jenner affirms, infinitely the most frequent determining causeof acute vesicular emphysema, and of the chronic vesicularemphysema which accompanies chronic bronchitis. It is pro-bably the constant determining cause of the vesicular emphy-sema which supervenes on chronic congestion of the lungs andbronchial tubes, and on diseased heart, and of the atrophousemphysema of the aged, and the invariable determining causeof vesicular emphysema whenever it is general, or occupieschiefly or only the apex and border of the lung, and wheneverthe dilatation of one or more vesicles is extreme. Dr. Jennerdenies that during expiration every part of the lung is equallysupported and equally compressed, and he affirms that theapex, the anterior margin, the margin of the base, and someparts of the root of the lung, are at once imperfectly supported,and comparatively or absolutely little compressed only duringexpiration. The thoracic parietes covering those parts of thelung, which are the least supported and compressed, are thosewhich are seen when a person makes a powerful expiratory effortwith a closed or imperfectly open glottis, as in hooping-cough,croup, and hypertrophous emphysema, to be driven outwards.These same parts are the most common seats of emphysema.Three cases are detailed by Dr. Jenner in illustration of his

, * Dr. Gairdner’s MomMy Journal of Medical Science, vol. xiii. p. 10.