OPERATIONS, BY J. W. GREEN, ESQ.

Amputation at the Shoulder Joint. ELIJAH BIRD, æt. 13, was admitted under Mr. Green, Sept. 6th, 1826, with extensive ulceration of the left arm, and anchylosis of the elbow joint.

It appears that, more than 2 years since, his arm was severely burnt by his clothes taking fire, when he was taken to St. George's Hospital, where he remained some time without receiving any benefit. He was then removed by his friends to St. Pancras Infirmary, where he remained several months. On his admission into the infirmary, he had anchylosis of the elbow joint, and the ulcer was about the same size as on his admission to St. Thomas's; when it extended, on the anterior part, from above the insertion of the deltoid, nearly to the wrist. Behind, it did not extend so high; and, near the elbow posteriorly, the skin was entire.

It would require much more space than is allotted to me, to decribe the various applications that were tried. Suffice it to say, that nothing produced even a tendency to heal, if we, perhaps, except the last application; which was the formation of a thick eschar by means of the lapis calaminaris. This was perseveringly employed for some time, and the ulcer showed some disposition to heal round the edges; but this improvement was very slight, and the patient became so extremely weak, from the continued discharge, with an inability to take sufficient nourishment, that nature must inevitably have soon failed under the exertion. It was therefore, as a last resource, determined to remove the arm at the shoulder joint, it being impossible to save sufficient integument any lower in the extremity. Accordingly, Feb. 16th, Mr. Green performed the operation.

* We recollect seeing this lad at St. George's, and we can state that a great deal of attention was paid him, and a variety of applications tried without success. At one time, under the use of the sulphate of copper (we believe) cicatrization took place to some extent; but the boy was of a miserably scrofulous habit, and the sore so extensive, that there was not the least chance of its ever permanently healing.-Ed.

The patient was seated in a chair, and on examining the limb, it was found that not sufficient integument could be saved for a flap anteriorly. It, therefore, became necessary to save it from the sides and behind.

Mr. Travers compressed the artery very effectually below the clavicle, it being found impossible to do so above, as the patient was unable to bear the pressure.

Mr. Green then made an incision, commencing from just below the insertion of the pectoralis major and to its inner side, extending it to the acromion process of the scapula; then proceeded from this point downwards and backwards, to the outer margin of the axilla (thus leaving attached to the arm a triangular por tion of the coverings, the apex of which, was at the coracoid process) the flaps were dissected off to either side-the anterior part of the capsular ligament was divided, and the elbow depressed, in order to throw the head of the bone from the glenoid cavity; but this was imprac ticable, from the soft anchylosis that had taken place. A catlin was therefore passed under the head of the humerus, and brought out between it and the glenoid cavity; then, by one sweep of the same instrument, (which was again introduced behind the head of the humerus) the muscles on the back part, to as low down as the base of the triangle, with the vessels and nerves, were divided, which completed the operation. The vessels being secured, the flaps on each side were brought together by adhesive straps.

March 15th. The patient is doing well.

1827.

Lithotomy.

Feb. 15th, JOHN BONE, æt. 65, was admitted into Isaac Ward under Mr. Green, with symptoms indicating stone in the bladder, which, on sounding, was found to be the case.

Feb. 23rd. Mr. Green having again sounded, performed the lateral operation. The transversalis perinei artery bled ra ther more freely than usual, and there was also a more than ordinary gush of venous blood; but not sufficient to prevent Mr.G. proceeding steadily in the operation, and extracting the calculus; having done which, he secured the artery by ligature

The instrument used was the gorget,

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which, in the hands of Mr. Green, has, in upwards of 70 cases, proved invariably successful.

The patient gradually recovered. The urine now (March 8th) passes entirely by the urethra; and he is allowed to sit up it a short time.

A circumstance occurred, about a week after the operation, which affords a useful lesson. The patient's bowels had been allowed to become rather costive, and he #passed some hardened fæces, with some difficulty. At this time, the urine nearly all passed by the urethra; but this exertion separated the slight adhesions, and it again passed freely by the wound, which, of course, somewhat retarded his recovery.

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OPERATIONS, BY F. TYRRELL, ESQ.

Popliteal Aneurism.

The ope

1827. Feb. 1st. GEORGE GRAHAM, æt. 32, of spare habit and debilitated constitution, was admitted under Mr. Tyrrell, with very distinctly marked popliteal aneurism. On further examination, in order to ascertain any other existed (which Mr. T. invariably does before proposing the operation, and the plan is worthy of imitation) he thought, as also did Mr. Green; that he could distinctly feel an aneurism at the bifurcation of the aorta. ration was therefore not proposed, till, on examining very attentively a few days after, no traces of the supposed aneurism at the bifurcation could be felt. This examination was again repeated, a day or two afterwards, with the same result. Mr.T, now ascertained that he had an anterior curvature of the spine, and thought it probable, though by no means certain, that the aorta being thrown forward by the curvature, and the patient being, on the first examination, agitated, it was the vessel itself which was felt pulsating.

After repeated examinations, however, since the operation, the tumour has at length been again felt at the bifurcation, and on the application of the stethoscope, the peculiar "thrilling" or "whizzing" sound, denoting an aneurism, can now be distinctly heard. T.H.S. N. B. This whizzing sound is now acknowledged to be no positive proof of aneurism.-Ed.

Feb. 6th. The femoral artery was taken up in the usual place (where it is crossed by the sartorius muscle) and it completely commanded the pulsation in the tumour, which has gradually diminished, and is now, (March 10th) not perceptible. There is still, however, a numbness in the extremity; but the temperature of the limb is natural.

The ligature has separated, and the wound in the thigh is nearly healed.

Amputation.

DENNIS BURNS, æt. 29, was admitted, under Mr. Tyrrell, into William's ward, July 29th, complaining of a long-continued pain at the upper and anterior part of the head of the tibia, where, on examination, an elastic tumour was perceived, on pressing which the pain was not increased.

Strict antiphlogistic measures were instantly adopted. By bleeding locally and generally, frequently repeated, followed by counter-irritation, the pain was nearly conquered; but the swelling still continued, and, at length, (in about five months) the integuments covering the part ulcerated, and a considerable quantity of bloody matter escaped. On examination, it was found that the ligamentum patellæ was ulcerating, and the tubercle of the tibia partially exposed. The ulceration extending, and the patient's strength suffering materially, (although every exertion was made to support it, by nourishing food and tonics) it became necessary to remove the limb, which was done, by Mr. T. on the 9th of March.

There was nothing worth remarking in the operation, if we except, perhaps, the necessity of taking up the femoral vein.

March 15th. No pain in the stumppatient is going on well.

Examination of the Limb. The ligamentum patella was found completely ulcerated through, so that the rectus, crureus, and vasti muscles, having nothing to antagonize them, had drawn the patella above the articulating surfaces on the femur. The tubercle of the tibia was exfoliated to a considerable extent. though so much mischief had been produced in the immediate vicinity, the joint was perfectly healthy.

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THOMAS H. SMITH. London, 15th March, 1827.

II.

it to that tribunal which we are not less

Review.

SIR.-Dr. David Barry has published, in your Number for January, (p. 292) an appeal to the "literary integrity of the country," and a demand of an "amende honorable," by which, it may be presumed, he understands an apology, from the editor, or the author of a criticism on his "Researches on the Influence of Atmospherical Pressure," published in the Edinburgh Journal of Medical Science for October last.

The following seem to constitute the whole grounds stated by him for this not uncommon claim on the part of authors who feel themselves ill at ease under the remarks of their reviewers. Dr. B. complains

1, That the writer alluded to has not employed Dr. Barry's own words in delivering a brief view of his doctrine.

2, That the six propositions in which he comprehends that condensed view are not pure: i.e. are mixed up with foreign

matter.

3, That the reviewer "charges his book with asserting, that atmospheric pressure is the sole cause of the blood of the veins moving towards the heart, and has also charged the illustrious philosophers, Cuvier, Dumeril, &c. with abetting this assertion."

4, That the reviewer has committed the latter misreport, by mistaking the application of the French word "unique

ment."

shall endeavour to shew him, in a few words, however, that the accusations are entirely void of foundation; and, in doing so, we hope he will excuse us if we pass over a number of lesser charges made by him, in the same reclamation, and which affect neither our industry nor our good faith, without reply or retaliation. Thus, it is of no consequence to the public whe ther the reviewer be "nameless" or renowned, provided he have spoken the truth. Neither does it matter much that he hath written, after the manner of other such critics, in the plural number: nor that he thought proper not to perplexi simple numerical calculation, "by apply ing to it the lights of modern science:" still less would your readers be edified by learning, that the Edinburgh reviewer most heretically believes in the infallibi lity of the multiplication table, applied as above, and that he aggravated this offence by writing Q. E. D. at the end of this arithmetical argument. We must explain, however, to the unmathematical part of your readers, that Q. E.D. are not the initials of Quod Extingerit Daridem, as some have supposed, but a common contraction the reviewer learned at school, for quod erat demonstrandum. la fine, your readers will care nothing for being told the reasons why the reviewer speaks of "sugescent power, suction, rotundity," &c. and occasionally in a very elliptical manner, as a man may sometimes be supposed to do, who is forced to condense the marrow of a book of 175 pages, and his own criticisms, into some thing less than three pages of a periodical. I

We proceed, then, to the major charges

Charge 1. The reviewer did not em ploy Dr. Barry's phraseology, for two reasons. He preferred his own; and he! could not have condensed that of Dr. B. into less than a sheet and a half.

Charge 2. The six propositions, with their authorities now added, are as follow 1. The moving force of the arterial blood, whatever it is, becomes extinct in the extreme arteries.

AUTHORITIES.-" As the blood passes through the greater veins during inspi ration only, while it is incessantly traversing the arteries, it follows that an ac cumulation must take place somewhere between these two orders of vessels." 36.

"There are three quantities of blood: one passing through the arteries, one which is sucked up by each expansion of the thorax, and a third which is collected between these two points." 36.

2. The movement still exhibited by the blood in the veins, is entirely owing to the sugescent power exerted by the right side of the heart.

AUTHORITY.-See the answers to the second charge.

3. This sugescent power originates in the removal of atmospheric pressure by inspiration.

AUTHORITY.-See the same as in the last. 4. We need not repeat this and the following three propositions, which refer merely to the influence of diminished atmospheric pressure upon the absorbent system, according to the views of Dr. Barry, and are so evidently paraphrases of his notions, that we must take the liberty of requesting him to favour them with another perusal. He will then see good reason to praise, rather than to impugn their comprehensive accuracy. As Dr. B. has only stated the impurity in one of these six propositions, namely, the second, it may be inferred that the impurities of the other five are merely illustrative, which afforded him no argument against his reviewer, and, therefore, however much they may offend the purity of the Doctor's taste, call for no reply.

The second proposition is asserted to be vicious in attributing to Dr. Barry the loctrine, that the power by which the blood in the veins is moved onward to the heart, is solely the result of atmospheric pressure. That gentleman has not teemed it necessary to state, in his reclamation, how far this was from his real opinion when he wrote the Researches, and from the tenor of the researches hemselves. We shall, therefore, lay a ew short sentences of that work before your readers. "Of these supposed powers, sources of impulse to the blood) some are so little susceptible of being demonstrated by direct experiment, others must be so uncertain in their operation, and the theoies which they have been brought to upport are so opposed to each other, that he evidence against is, á priori, nearly as trong as for their existence." 3.

runs contrary to its own gravity arrives at the heart only during inspiration; and the power which impels it at this moment is atmospheric pressure," p. 35. But circulation goes on in any position of an animal-nay, the heart of an animal may easily be made the highest point: consequently, the atmospheric pressure becomes, in such a case, the sole moving power of the venous blood!

Again, "Of these powers (which move the blood), the pressure of the atmos-> phere is by far the most intense in its degree, the most constant in its influence, and the most unvarying in its amount. It is that, without which the circulation' could not be maintained beyond a few moments." p 57.

Where then, and we appeal to Dr. Barry himself, are we to find an expression for the force of those other powers? The arguments against their existence are as strong as those in their favour; they could only act for "a few moments" if they act at all; and they might be annihilated, by making the heart the highest point of the system, and are always annihilated when opposed to gravity. They are, therefore, less than that force, which, however, in its most efficient mode of influence, produces NO sensible effect upon the functions of circulation, and are, therefore, less than any assignable quantity. Where, then, was the impropriety of considering them as nothing, in a general view of the theory of Dr. Barry? They are efficiently nothing in Dr. Barry's own words; and that every one else understood the Doctor in the same sense, the following passage, from Dr. B.'s own translation of the report to the Institute, as published in his Researches, will sufficiently demonstrate. To make verbal quibbles upon the difference between a sole cause and a principal cause, coupled with other smaller causes, of which the effect is insignificant, would be nodum in scirpo quærere—in short, to make a distinction without a difference.

ING THE ACT AND TIME OF INSPIRATION : and that this venous movement was always placed under the influence of the action of atmospheric pressure." p. 69. "Upon a comparison of the relative velocities of venous and arterial blood," the author founds the notion, that "the pressure of the atmosphere is the principal power which impels the venous blood to the heart during inspiration." p. 70.

We must declare, that the mere idea of the pressure of the atmosphere being the principal cause, was not first taken up by him." 71.

M. Barry attributes the dilatation of the heart itself, and of its auricles, to the tendency to a vacuum, which takes place in all the cavities of the chest during inspiration," p. 71.

The report from which these extracts are taken, is signed by Cuvier and Dumeril, and, with the approbation of the Academy, countersigned by their secretary, Baron Cuvier. The Edinburgh critic was not, therefore, alone in this only rational interpretation of Dr. Barry's memoir.

Charge 4.-Is but a grammatical onea conjecture that the reviewer of Dr. Barry mistranslated the French word "uniquement," in Dumeril's report. That word occurs only thrice in the re port; and in the two which Dr. B. has thought proper to translate, he expresses its sense in English, by the word solely. In that sense, precisely, was the word understood by the reviewer; and he also thought he understood why Dr. Barry, in his translation, chose to omit it in the passage below. "In fine, although the greatest number of physiologists attri buted the progression of the venous blood towards the heart (solely), to a vacuum formed in this organ," &c. p. 65.

The omission is such as a man would make, who was very anxious to secure the patent right of this sole propelling power to himself, and who trusted to the good sense of his readers for their avoid ing the bore of comparing his translation with the original! At all events, his reviewer has no where made the least use of the word "uniquement," either for or against his theory, and therefore it can be made no fair ground of complaint by

the author.

Churge 5. The reviewer has misunderstood and misapplied the ealculation

of Haller.-Let us see. Dr. B. himself confesses, that, by approximation, it shews how little the pressure of the air can impede the current in the pulmonary arteries! It therefore must afford us approximate measures of the force of that pressure, and of the momentum of the blood rushing through the lungs, and, consequently, of their proportion to each other. The calculation, to be sure, only affords a mininum proportion, and is distinctly stated by the reviewer to express merely, that the relation of the diminished atmospheric pressure to the action of the right ventricle is not greater than 1 to 355. The ratio ought to be increased a little, by the difference between the ve locity of the blood in the vena cava, and in the pulmonary artery, but the result would only produce a trifling difference, not worth the pains of multiplication. But had the reviewer been even as much in the wrong as he is in the right, Dr. Barry had no more reason to demand satisfaction for his belief in the doctrines of Haller, than for his being a presbyterian.

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Charge 6. Misrepresentation and disrespect of Cuvier, Dumeril, and Laennec. The only sentence in which they are luded to, except barely for the purpose of being named, is this: "It would seem, even the illustrious Cuvier, Dumeril, and Laennec, still persist in attributing the whole of an effect to respiration, of which it can but at most, in the nature of things, produce the part."-Edin Journ. Med. Science, No. V. p. 463. The passages formerly extracted from their report will enable the reader to perceive, that there is virtually no overstatement here: and he will possess es traordinary tact, if he can pervert any portion of it into incivility or disrespect. To these eminent foreigners we owe mere ly the tribute due to genius and science, respect, and we pay it cheerfully, but we see not how it should ever prevent us from stating the simple fact.

We have now refuted the whole of Dr. Barry's charges with little trouble. We wish, indeed, he had rather entered on the argumentative part of the review he condemns, than amused himself and us with groundless imputations, and cla mour for an amende honorable," which he must now see is due by him to us for his unsound doctrines and unseasonable

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