5. M. LISFranc on ulcers, simple and VARICOSE.

(LA PITIÉ.)

The distinguished surgeon of La PITIE has lately reported, through the medium of his pupil, M. Klimatis, an interesting memoir on ulcers, more especially of the lower extremities. M. Lisfranc does not accord in sentiment with those who attribute the frequency of ulcers on the legs to weakness of the vital powers in those parts. He places the cause of this affection to the account of "inflammatory irritation," determined by remora of blood in the saphena vein, which vessel presents between the malleolus and head of the tibia, in most instances, no valvular apparatus. When any valves are found, they are never seen between the malleolus internus and the calf of the leg. "It is precisely in this last place that the solution of continuity in question most frequently manifests itself." The reason is, he thinks, the difficulty which the blood encounters, in this place, in its return against gravity, unassisted by valves. The stasis of the venous blood becomes an irritant, and induces an inflammatory condition, which causes and keeps up the ulceration. The success which attends ligature of the saphena vein, in ulcers of the leg, irremediable by other means, is, he observes, an incontrovertible proof of the truth of his theory. The means employed by the partisans of atony and debility, furnish auxiliary proofs-as the horizontal posture, quietude, compression.

These ulcers are much more frequently situated on the left than on the right leg. How is this to be accounted for? The partisans of atony said it was because the left leg is naturally weaker than the right. But, of a number of ambidexters, or rather of left-footed patients, and consequently where the balance of strength was on the left side, it was still found that ulcers were infinitely more frequent on the left leg than on the right. M. Lisfranc accounts for the circumstance by the pressure of the sigmoid flexure of the colon, (so often distended with indurated fæces,) on the external iliac vein of that side. It is for the same reason that sarcoceles, cirsoceles, and hydroceles are more frequent in the left than in the right testicle, or side of the scrotum, the pressure of the sigmoid flexure acting on the spermatic cord, and retarding the retura of blood.

M. Lisfranc has some peculiar notions respecting the nature of these ulcerations of the legs. He considers them a kind of gangrenous affection, (une affection gangreneuse, sui generis). We humbly conceive that this is but a very slight improvement on John Hunter's term"ulcerative inflammation." Be this as it may, we all know the difficulty of healing old-established ulcers on the lower extremities, and the various means that have been tried in this and other countries for expediting such process. M. Lisfranc alludes to the real or supposed danger of closing drains of this kind long established. Many of the best observers in medicine and surgery have testified to the diseases which have supervened on such cures, especially to cerebral and pulmonary congestions; and consequently have recommended the opening of issues or other drains to prevent these accidents. M. Lisfranc

believes that the danger arises from a bad condition of some of the viscera at the time the ulcer is healed, rather than from any disease which could result from the simple incarnation and cicatrization of a discharg ing sore. With this view, he accurately examines his patients, and when he finds any visceral disorder, he first endeavours to put that out of the way, by the proper remedies and by proper diet. He next corrects the bad state of the ulcer itself, by reducing inflammation and irritation, through the medium of rest, leeches, poultices, and other proper applications. When the sore is thus brought to a condition of being healed, he applies bundles of charpie wetted with solution of chloruret of lime or of soda, and keeps the sore soaked with such solution, graduated in strength to the sensibility or irritability of the parts. By this application he avers, and appeals to the wards of LA PITIE for proofs, that he heals these old ulcers in a very short time, varying from five to eighteen or twenty days.

But when the ulcer is based on a lardaceous or disorganized substratum, this will not succeed. M. Lisfranc then tries ablations, by slices, of the disorganized tissue; or, more frequently he makes various incisions, crucial and perpendicular, into the parts. If these do not succeed, ablation of the whole is effected, by the knife or by the cautery, according to the extent and depth of the morbid structure. The actual cautery, in some obstinate cases, is substituted by M. Lisfranc, for the potential. When the ulcer is thus brought to a tenable condition, the chloruret is applied, and cicatrization soon follows.

Those who frequent LA PITIÉ are surprised at the astonishing rapidity with which this able surgeon heals burns and scalds in this way. Fortyeight hours are often sufficient for healing of burns of the first or second degree of intensity. Ulcers healed in this way are said to be infinitely less liable to break out again, than those treated in the common manner. He properly advises the laced stocking or other support, however, after the cure thus performed. And, in cases where there is any tendency to visceral or cerebral disorder, he establishes one or more issues on the upper or lower extremities.

The chlorurets will not be successful where the ulcer is connected with, or dependent on a varicose state of the veins of the limb. The ligature and section of the saphena vein have been often practised in this country and in France; but dreadful accidents have too generally ensued. The sides of the vessel are usually so thickened that they will not collapse when cut; and if air gets in, a rapid and destructive phlebitis is established. M. Lisfranc therefore abandoned this practice, and cut out two or more inches of the dilated vessel, trusting to careful compression of the vein above and below the resection, rather than to the ligature. In this manner he has operated a great number of times in LA PITIÉ, and no fatal accident has ever succeeded such practice. As success, in this operation, depends on the formation of a coagulum in the saphena, it is necessary to select a spot for the operation, where there are no collateral communications. M. Lisfranc generally selects the inside of the knee, near the upper extremity of the tibia, for the'

resection, the branches of communication being all below this joint. If the saphena be varicose up as high as the knee, this state almost always coincides with a chronic inflammation of the sides of the vessel. In such case, M. Lisfranc performs the resection on a sound portion of the vessel, on the inside of the thigh, but as low down as possible.

Operation. The patient is placed horizontally, and if it is the internal saphena that is to be operated on, the limb is laid, a little bent, on the external side. An assistant compresses the vein, by grasping the limb tightly above the part. The surgeon then, with a bistoury, makes an incision along the vessel, going only through the skin. When the vein is laid bare and insulated, the surgeon introduces the point of the scissors under the vessel, close to each angle of the wound, and snips the vein across. A considerable quantity of blood is then suffered to escape, if the vessel will bleed, in order to prevent inflammation; and if hæmorrhage will not take place, the patient is bled from the arm. Light, but careful pressure is then made above and below the wound, which is healed, if possible, by the first intention. Much pressure ought not to be made on the wound itself, for fear of irritation and inflammation. The patient should be kept quiet, and the utmost attention paid to diet and regimen. In less than thirty hours, the ulcer changes its aspect, from red or violet to pale-the purulent secretion diminishes, and assumes a healthy appearance. Cicatrization sometimes follows, in five, ten, or fifteen days, but the medium term is from twenty-five to thirty.

Phlebitis may occasionally succeed the operation. The saphena will become tense and painful, feeling like a cord under the finger. If not checked, the inflammation will run upwards, and death may be the consequence. M. Lisfranc, in such cases, abandons the inflammation of the saphena below the wound to itself, and covers the track of the vessel above the resection with leeches. When these fall off, a warm poultice with plenty of laudanum is applied. Since he trusted entirely to bleeding and poulticing above the wound, he has never lost a single patient. We shall close this paper with a case in illustration.

Cuse. Tellier, aged 40 years, entered LA PITIÉ on the 10th of November, having on the inside of the left leg a varicose ulcer, the size of a man's hand. This ulcer had continued for several years, and was accompanied by a multiplicity of varicose veins, and very callous edges. It had resisted all kinds of treatment, and therefore the operation was performed on the tenth of the same month, in the manner already described, an inch and a half of the vessel being removed. The upper extremity of the vein furnished a considerable quantity of blood, and slight compression was employed. 16th, The ulcer is pale-there is no pain-and the patient appears in a good state. 17th, The upper portion of the vein is painful and hard. Twenty-five leeches were applied, followed by cataplasms, with laudanum. 18th, No amelioration of the phlebitis. Twenty-five leeches again applied. 20th, Some traces of the phlebitis still remained, and another batch of twenty

five leeches were put on the track of the vessel, the cataplasms and anodynes being continued. 21st. The inflammation has completely disappeared. The poultices were still persevered with. The ulcer is red, the suppuration good, cicatrisation is commencing. 25th, The patient was so well that food was given him. He was discharged cured on the 27th January.-Revue Med. Decembre, 1826.

As a proof of the great success which attends M. Lisfranc's treatment of ulcers by means of the chloruret of lime, and resection of varicose veins, it is stated that LA PITIÉ usually contained about 50 of these cases constantly within its wards; whereas there are now very few seen there, so speedily are they cured and discharged. We think our hospital surgeons may take some useful hints from their Parisian confrere; and that they may profit by this paper, and an article on the chlorurets in a preceding part of the present number of this Journal.

6. INJURIES OF THE HEAD.

[Middlesex.]

In the February No. of the Medical and Physical Journal, the subject of injuries of the head is continued, and some interesting cases are brought forward, shewing the difficulty of ascertaining the precise condition of the brain and its membranes in these accidents. notice some of these cases.

We shall

Case 1. A boy, 11 years of age, had fallen from a considerable height, and was taken up senseless. He was bled, and then sent to the hospital, 6th Dec. 1826. He was still insensible, after an hour had elapsed. He was cold, pale, and pulseless, with dilated pupils, and tranquil respiration. There was a denuded portion of cranium on the vertex, the size of a shilling. In the course of another hour, he shewed returning sense, and cried loudly when his head was touched; but when unmolested he sunk into a state of stupor. His right leg was found to be fractured. The pulse had become perceptible, and animal heat was returning. Head shaved, and eveporating lotions applied. Calomel and jalap administered. 7th, Much the same. Moans, and is very irritable. More purgatives, as the medicines had not acted. In the evening, the bowels were freely opened. Saline medicines with antimony. 8th, Has been noisy in the night-talks incoherently-pulse still weak, and only 76. Leeches to the temples-calomel and antimony at bed-time. 9th, Is constantly crying-passes his urine and fæces involuntarily. Pulse sharp, though weak. Leeches to the tem ples-a dose of calomel and jalap. 10th, Face flushed-skin hot and dry-tongue foul-pulse thrilling, 85 and stronger. Venesection to 4 ounces and 12 leeches to the temples. 12th, Still continues noisy and sleepless-pulse softer after the last bleeding, but is again vibrating. V. S. 3vj. From this time he gradually improved.

Case 2. A boy, aged 10 years, was admitted, 24th Aug. 1826,

with all the usual symptoms of compression, caused by the fall of a heavy piece of timber on his head. He was pale, cold, motionless→→→ pulse small and feeble-constant vomiting. Scalp contused over the middle of the parietal bone, without wound-no irregularity in the bone to be detected by pressure. Head shaved-cold lotions-purgatives. 25th, Bowels have been well opened-lies comatose-skin has become hot and dry-face flushed-pulse quick and strong-breathing perfectly easy-irregular action of the irides-can be roused for a moment by loud speaking-thighs and legs drawn up-asks for drink, or the pot de chambre-rolls about his head and moans-often raises his hand to his head. Venesection to ten ounces, which partially restored his senses; but the favourable change was only temporary. The vomit ing still continues. Sulphate of magnesia in small doses. 26th, Became convulsed at 4 o'clock to day, and died.

Dissection. The parietal bone was found to be fractured, and a small portion slightly depressed. From this part a fissure could be traced backwards along the parietal bone, and terminating near the base of the skull. About two ounces of dark coagulated blood were found on the dura mater, under the fractured and depressed portion of the skull. Two branches of the meningeal artery had been torn, but the dura mater was not perforated. The part of the hemisphere under the coagulum was flattened, and softer than the surrounding parts. "There was a dark spot on the surface of the brain, which corresponded to the depressed portion of bone." There were no marks of inflammation in the brain.

It is remarked here that experience has failed, hitherto, to point out the distinction between concussion and compression. It may be so. But, when such symptoms as the above take place, with an obvious contusion of the scalp, are we not authorised to cut down and examine the state of the bone at least; and even if no external fracture can be detected, are we not authorised to trephine, under such circumstances as the above? Can it be asserted that the removal of a piece of bone, and also the ablation of the coagulum pressing on the brain, would not have saved this boy's life? Surely such pressure was adequate to the production of the symptoms detailed, and may be fairly considered as the cause of death.

In the same number of the Medical and Physical Journal, there is a case related by Mr. Boyle, Surgeon of the Middlesex Infirmary, which bears upon this point. A boy, nine years of age, was thrown from a horse, on the pavement, and was supposed to have fractured his skull. On examination, a large open space was seen, commencing at the situation of the anterior fontanel, and widening as it ascended on the right side, in the course of the sagittal suture. This was stated to have existed since birth. "The symptoms were, a total suspension of the mental powers, stertorous breathing, dilatation of the pupils, with insensibility to light, a low, rapid and irregular pulse, coldness of the extremities." Marks of external vio lence were detected behind the posterior superior angle of the right parietal bone. On pressure being made here, a depression was felt. The integu