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I have made these observations no’.v, be-cause, having time, I thought it as well totake advantage of the circumstance to say afew words on this important subject.

WESTM INSTER HOSPITA L.

CLINICAL LECTURE

ON A CASE OF

E M P Y E M A,

Delivered November 3rd, 1835,

B DR. ROE.

EMPYEMA.—Paracentesis Thoracis.—Au-

topsy.—I intended to-day, gentlemen, to ad-dress to you a few observations on the im-portant subject of clinical medicine; but thedeath of Charles Dyson, who has been forsome months in the hospital, labouring underempyema, hns given us all opportunity ofexhibiting the morbid appearances whichare found in that disease, and I think it willbe more profitable to yon to take advantageof this interesting occasion, to direct yourattention to the symptoms under which thispatient laboured, and the morbid appear-

’ ances which the examination disclosed.In the month of June last I was requested

by our benevolent chaplain to visit this manin Regent-street, Westminster. I foundhim pale and emaciated, lying on his rightside, coughing frequently, and expectorat-ing a considerable quantity of frothy mu-cus. He told me that his case was con-sidered to be one of consumption, and thathe had been given over by his medical at-tendant. I recommended him to come intothe hospital, which he accordingly didin July, and the following is the report ofhis case at that time :-Age 48 ; by trade abricklayer, of a pallid countenance andsunken cheeks; complaining of cough, withfrothy mucous expectoration, difficulty ofbreathing on moving in bed, but not so

much so when he lies quietly ; great debilityand loss of appetite; his respirations wereonly twenty in a minute, but his left sidemoved very little on taking the full inspira-tion ; his pulse was 86, soft and feeble. On

percussion the left side elicited a very dullsound, both anteriorly and posteriorly, andover and under the left clavicle. The sonndon the right side was tolerably clear. The

respiratory murmur was inaudible at theleft side, except over a small space close tothe spine. On the right side it was bron-chial and puerile, and it was accompaniedwith a mucous rattle. The heart’s pulsationscould not be perceived at all in its natural

position, but it was felt distinctly on theright side of the sternum. The left sidemeasured about half an inch less than theright. Its intercostal spaces were obliterated,but no metallic tinkling could be heard. Itcould scarcely be said that any change of thesound elicited on percussion was producedby change of pasture. His tongue was redand moist, and his bowels were torpid. Hesaid he had enjoyed tolerable health untilwithin the last five years, since which periodhe had been troubled in foggy weather witha cough of an asthmatic character, early inthe morning and at night, but he had beenable to follow his employment, until fifteenmonths ago, when he caught a violent cold.He states that he has never had pain in theleft side, nor has he to his own knowledgeever had a pleurisy.Now what disease does the history of this

case indicate ? The dulness all over the leftside of the chest could only be produced byone of the following causes:—1st. A lungcompletely hepatised, or completely tuber.culated. 2nd. An extensive abscess occupy-ing the whole lung. 3rd. Effusion into thecavity of the pleura. Now the lung couldnot have become hepatised, nor could so ex.tensive an abscess have been formed, withoutvery severe preceding inflammation, but ofwhich we have no notice in his history. Itwould have been a very uncommon thingto find one lung so totally tuberculated, asto be dull every where on percussion, andto be void of respiratory murmur, whilethe other lung was free from disease, andthe expectoiation exhibited no appearancebut frothy mucus. Again, neither his coun-tenance nor his cough was by any meansindicative of phthisis, and though the lunghad been condensed by the deposition of tu-berculous matter, yet this could not explainthe cause of the displacement of the heart.We therefore concluded that the dulness on

percussion was not produced by any of theseconditions, and very extensive effusion wasthe only remaining cause. That would sa-

tisfactorily explain all the phenomena,-viz., the displacement of the heart on theright side, the general dulness on percussion,and the absence of respiratory murmurevery where except at the root of the lung,where it was probably pressed against thespine and was condensed by the pressure ofthe fluid. Now to this supposition therewere these objections,—effusion of serumor secretion of pus is always preceded byinflammation, of the severity and durationof which the patient usually gives a dis-tinct account. Now such things were

noticed in this patient’s history; but it is awell-known fact that the secretion of pus isnot only a consequence of very acute pleu-risy, running a rapid course, and terminat-ing in the secretion of pus in ten or elevendays; but it also arises from that chronicstate of inflammation of the pleura which

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goes on without the patient being aware ofits existence. Again, where the pleura con-tains fluid, œgophony is often heard. Butthe absence of usgophony in this case wassatisfactorily accounted for by the im-mense quantity of fluid which his chestmust necessarily have contained, if it con-tained fluid at all. You know œgophonyis perceived in the commencement of pleu-risy, or, rather, in the commencement ofthe effusion of serum, before the quantityeffused has been considerable; as the ei-fusion goes on, the oegophony disappears,and, as the effused fluid becomes absorhed,the wgophony reappears; therefore, the ab-sence of osgophony constituted no groundof objection to the presence of fluid in thechest.Now, as to the measurement, it is true

that from whatever cause fluid becomeseffused into the chest, in an early stage, themeasurement of the chest is increased ; butif it continues long in the cavity, and anyattempt is made by nature to perform acure, then contraction of the chest takes

place, and you no longer find the enlarge-ment. A change in the sound elicited

by percussion is also generally produced bya change in the posture of the patient ; andthis is one of the most important signs, andone that is the most to be relied on, in ex-amining effusion into the chest. The partwhich sounds dull in a depending situationbecomes clear when the position is re-versed, from the floating of the respiratoryportion of the lung in the fluid. Now theabsence of this sign in this case is to beaccounted for under the supposition that thelung has been bound down to the spine, so thatit cannot change its position. On whatever

part of the chest, therefore, percussion isemployed, it must be over fluid, unless weexcept that part where the lung was com-pressed against the spine. The sound there-fore must every where be dull.From the consideration of all these cir-

cumstances, it seemed almost certain thatthe patient was sundering from the effusion ofa considerable quantity of fluid ixz the chest;and it was more than probable that this fluidwas purnlent, from the circumstance whichI have just mentioned, that it is acute pleu-risy, which, more generally than anythingelse, terminates in the effusion of serum.However, to make the matter perfectly cer-tain, I passed into the chest a needle, in-ventecl I believe by Dr. DAVIES of the LondonHospital, which may always be introducedwith the greatest safety. Sir BENJAMINBRODIE, 1 have been informed, has intro-duced this needle into the cavity of thejoints with perfect safety. It is made likea trocar, with a groove running through it,through which fluid may escape ; and onintroducing this needle into the chest in thecase of Dyson, a turbid fluid flowed out, ileaving no doubt that the disease was em-

pyema, or, in other words, that the cavity ofthe chest was filled with pus.Now the death of this patient took place

a few days ago, and we took out the ùig.eased parts for the purpose of showing themto you, because you cannot form a correctnotion of the manner in which this diseaseis to be cured, without a correct knowledgeof its pathology.The external appearances of the body

were not unusual. There was very greatemaciation. On removing the sternum, theheart was observed to be pushed completelyover to the right side, being seated beyondthe middle, and to the right of that bone.On removing the ribs of the left side, a largecyst was opened, which occupied the wholecavity of the left pleura, that viscus beingcompressed on the spine, and occupying aspace scarcely bigger than a closed hand.This cyst contained about eight pints of sero-purulent fluid. The walls of the cyst werethick enough to allow of its being dissectedfrom its costal attachments, and presentednumerous corrugations. A band of dense

membrane, as thick as the finger, extendedfrom about the sixth rib to the inferior edgeof the lower lobe of the left lung. It wasthis which, doubtless, prevented all thefluid from being drawn otf in the operation.No connection could be traced between anabscess* formed between the third andfourth ribs and the cyst. The abscessseemed confined to the muscular substance.The right lung was studded with minutetubercles. The liver was granular, con-

gested with blood, and myristicated. The

kidneys, in like manner, were a little palerthan natural. No other morbid appear-ances were observed. Here, gentlemen,are the parts. They have been steep’ing in salt, and are somewhat altered incolour. The lung is condensed and presseddown against the spine. The pleura isthickened, corrugated, and covered withlayers of coagulable lymph. Here is theband passing from the lung to the inside ofthe ribs. This lung was not impervious tothe air, for when it was taken from the

body it could be dilated by a pair of bellowsto some considerable extent. This other

lung is much more solid than it ought to be,and by cutting it open you will observe somefew tubercles in its substance. You ob-serve, therefore, the morbid condition ofthesa parts,- the thickened and inflamedstate of the pleura, the dense state of thelung compressed against the ribs, and thedistension of the cavity of the pleura withfluid, which pushed the heart completelyover to the right side.Now what is the mode by which a cure is

to be effected in such cases ? Whenever acure takes place, it must be by the adhesionof the pleura which covers the lung, to the

* Vide tast paragraph but one of the lecture.

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pleura which covers the ribs. You willtherefore see that it is indispensably neces-sary, in order to promote a cure, to takecare that the fluid be evacuated from thechest. You see always in a person who re-covers from empyema, that the shoulderfalls, and that the ribs are drawn in, so thatthe aclmeasurement of the diseased side ofthe chest becomes less than that of the otherside, and you will see by drawings the verygreat contrast that exists between them.Well, then, if you bear this in mind, you willsee the absolute necessity of getting rid ofthe fluid, and consider it as absolutely ne-cessary to biing the pleura pulmonalis incontact with the pleura costalis.Now, then, the first question is, how is

the fluid to be got rid of? There are three

ways of getting rid of the fluid, namely, ab-sorption, spontaneous evacuation, and theoperation of paracentesis. Now such athing has occurred as the absorption of

purulent fluid in empyema. BILLARD re’lates a case where it appeared that the fluidwas absorbed, and as the patient had beentaking acetate of ammonia, he attributed theabsorption to that medicine; but that is veryrare. Spontaneous evacuation is not so un-common, and it may take place in either of i

two ways,-by ulceration through the pleuracostalis, and discharging itself externally,or (which moie frequently happens) by iopening a passage into the bronchial tubes, Iand discharging itself by expectoration. I met with a very singular case of this kind in the month of February last. I was calledto see a servant living in South-street, Gros-venor-square, and the symptoms underwhich she laboured were these:.- great,difficulty of breathing, respirations forty a I

minute, frequent cough, expectoration ofthick mucus, pulse 120, skin exceedinglyhot, face flushed, great thirst, and loss ofappetite. She was bled immediately, andtook large doses of digitalis for three days,and at the end of that time, suddenly, anexpectoration of most offensive purulentmatter appeared. So offensive was it as torender it scarcely possible to remain in theroom with her. She was a person of a pe-culiar temper, and it did not occur to me atthe time to think it probable that this girl,after an attack of so short a duration asthree days, had such a disease as empyema.I did not examine her, therefore, with thestethoscope, but I gave her three grains ofthe superacetate of lead, one grain of digi-talis, and a grain of opium, three times aday, and to my great surprise the expecto-ration totally ceased in twenty-four hours.She recovered her strength, the difficulty ofbreathing subsided, and in three weeks fromthe first attack, she went down-stairs, weak,but tolerably free from disease. She thenbecame exposed to cold, the difficulty ofbreathing suddenly returned, and expecto-ration of the same offensive charact took

place almost immediately. Hectic- flushesof the cheeks followed, and a pulse exceed-ingly rapid and exceedingly feeble. I exa.mined her chest, and found it almost every-where duller than natural on percussion,and the respiratory murmur was only veryindistinctly to be heard, particularly at theposterior parts. Nevertheless it was heard ;but all around it, through the fluid ; cego-phony was very distinctly evident under theleft scapula. She was then in so perilousa state that I consulted Dr. Enwnsr HAR.RisoN-, who I believe to be the most skilfulphysician in London in detecting pulmonarydisease, and he confirmed the opinion that itwas a case of empyema. The opinion of SirHENRY HALFORD was asked bythe wiahofthegirl’s master, but Sir Henry, on the groundthat it was not yet necessary, objected towhat I very much wished to have perform-ed, that is, the operation of paracentesis,as there was possibility of the girl dying,even were it performed. I did not press itagainst such an authority as his. I examin-ed the chest very carefully, and found therewas some tenderness on pressure. I ap-plied cupping-glasses over it very exten-

sively, and abstracted a small quantity ofblood, only ten ounces. I supported herstrength by strong beef-tea, and gave heras much as her stomach would bear ofsulphate of iron. She immediately began

two improve, and her strength increased.The expectoration still continued, but atthe end of nine weeks it had almost totallyceased, the respiratory murmur had re-

turned in almost every part of the chest,and the dulness of sound on percussion wasnot altogether gone, but very much dimi-nished.

You will observe that this was a distinctcase, in which there could not be any pos-

sible question of the spontaneous cure of thedisease, empyema, by the evacuation of thefluid contained in the cavity of the chest,through the bronchial tubes ; but whetherthe cure takes place in such cases by ab-sorption, or by the spontaneous evacuationof the fluid, the cures are exceedingly rare,and if you wait for any considerable lengthof time, and the patient’s strength becomes

very much reduced, the operation of para-centesis may be performed with much lessprospect of success. It therefore becomesexceedingly interesting to inquire what arethe chances of recovery ; or, in other words,what does the result of observation teach usin those cases in which paracentesis hasbeen performed. Dr. DAVIES, who has per-formed the operation in ten instances ofempyema, gives a table in the " Cyclopædiaof l’ractical Medicine," in which he statesthat eight out of the ten cases operated on,recovered; five of the patients were undersix years of age, one was aged between

eighteen and nineteen, and two about

twenty-five years old. Now observe the

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proportions. Of those who were under six

Iyears of age, five cases recovered, and thereason is this, that the greater elasticity ofthe ribs, and the tender state, altogetherB ofthe bones, makes them much more disposedto yield to the pressure, so that the pleuracostalis and the pleura pulmonalis can bebrought the more readily into contact, whichis the point of cure.You see, then, according to this, that the

probabilities of recovery, when the operationof paracentesis is performed, are eight casesout of ten. In the medical journals of the30th of November, 1833,* there is a case

of a child, seven years of age, who wasoperated on by Mr. Wooi-EY, of Brompton,and he had the goodness to invite m6 to seethe operation. It was an exceedingly weakand emaciated child, and presented the

symptoms which I have just related, indi-

cating empyema. The operation was per-formed, three pints of purulent matter wereevacuated at once, and a considerable quan-tity of air entered at the operation, to whichfact I beg your attention. The wound wassuffered to heal, and the child was supportedby nutritious diet, but in the course of threeweeks there was reason to suspect that Qocnefluid had again been secreted in the chest.The operation was performed a second time,and a smaller quantity of purulent matterwas evacuated. Again air was admitted, andfrom that time the child went on graduallyimproving, so that in a short time his respi-ration became perfect on that side. Thechest on percussion was perfectly clear, andthe child is, I believe, at this moment, inperfect health.Now, as to the time of operation, I be° ’I

lieve that it should be as soon as possible after the disease is detected, and I think ’ithe instance which is before us is a clear

proof of the correctness of that observation.When fluid is allowed to remain a con-

siderable time in the cavity of the chest,it will of necessity compress the lung againstthe spine ; and if adhesion of the lung againstthe spine takes place, you will see the verylittle probability there is of ejecting a cure.It is, therefore, a matter of very great con-sequence to perform the operation as soonas you possibly can, because in the earlystage it is almost certain that no adhesionof the lung has taken place, that the lung isfree, and that the process of cure will, in allprobability, go on without interruption.Now the next question, and one of very

great importance it is, is this, whether thewound is to be allowed to heal immediately,or the canula to be left in. The reasons foradvising that a canula should be left in arethese, that the sudden evacuation of so largea quantity of fluid is apt to produce verygreat debility; and that, if you were to eva-cuate the whole of the fluid at once, you

* See LANCET, No. 535, page 358.

I would allow a quantity of air to be admitted,

which is considered to be highly dangerous.Now with respect to the evacuation of a

quantity of fluid. Here was a child in anexceedingly emaciated condition (I am nowalluding to Mr. WOOLEY’S case), where allthe flnid in the cavity was evacuated, with-out the child sun’eriug in the least from theevacuation. Again, we have had severalcases in this hospital,-one a very remark-able case, in which six pints of serum wereevacuated from a man’s chest, without anyinjury being produced from it. Certainly,therefore, as far as my experience goes, andas far as I have been able to examine thecases that have been published, I see no

reason to believe that the sudden evacu-ation of fluid is, of necessity, at all danger.ous. Nay, more, 1 believe that the spacewhich the fluid occupies is filled, in a verygreat measure, by the air that is admitted,and the presence of this air does no harmwhatever. In Mr. WOOLEY’S case, on bothoccasions of the operation, a considerablequantity of air was admitted, and neithertime did any bad symptom follow. In thecase of the man who was operated on inthis hospital, a very considerable quantityof air entered, and occupied the place whichsix pints of fluid had recently occupied,without any symptom of inflammation su-pervening. But in the course of two orthree days it appeared as if a greater accu-mulation. of air had taken place. Thelungs on that side afforded less marks ofrespiratory murmur, the sound on percussionwas preternaturally clear, and the breathingbecame exceedingly difficult. Mr. WALSH,who is now practising at Worcester, deviseda most ingenious little canula, to which apiston was attached, not much larger thanthis needle. This was introduced into thechest, and the air was pumped out. No in-convenience followed the use of the instru.ment, and the patient went on to a perfectcnre. I see no reason, therefore, for con-cluding that the presence of air is necessa-rily a source of danger.Now as to the place of the operation.

LAENNEC advises that it should be perform-ed between the fifth and sixth ribs ; and thereason he gives for the advice is, that whenthe lungs are diseased, the attachment takesplace more frequently between the superiorlobe and the pleura, immediately under theclavicle, and between the lower lobe andthe diaphragm, and the centre lobe is gene-rally the freest. Again; it happened to

LAENNEC to pass a trocar into what he

supposed to be the cavity of the chest,without flnid following the introduction,find it was found upon examination, thatthe trocar had not passed into the cavity ofthe pleura at all. Now on the left side thereis not so much need of precaution, but onthe right side you must always be aware,that sometimes the liver is very greatly eu-

287

larged, and rises a great way into the regionof the pleura; and as dulness of sound onpercussion may often arise from the liver

being pushed up, and without any fluid be-ing present, it will be necessary in perform-ing the operation on the right side to bevery cautious, remembering that you arein the neighbourhood of the liver, but youwill be almost certain to pass the instru-ment into the cavity of the chest, if it beintroduced between the fifth and sixth ribs.

But this is not all. Adhesions frequentlytake place between portions of the lung andthe ribs, and, therefore, even this directionis not sufficiently minute. In Mr. WooLEY’scase the lung adhered posteriorly, almostcompletely, so that on putting the ear to thatpart of the chest, you heard the respiratorymurmur distinctly, but as the ear was broughtforward, you found the respiratory murmurwas almost inaudible. It therefore becamenecessary, instead of puncturing betweenthe fifth and sixth ribs, close to the latis-simus dorsi, to bring the instrument stillfurther forward, and to choose that partwhere all sound of respiratory murmur wasabsent. Therefore, before you attempt toperform the operation, you ought to ex-amine with great caution, and ascertainthat no respiratory murmur is present, andto be perfectly aware of the possibility ofadhesion between the lung and pleura.Now having said so much upon the nature

of the disease, and the mode which is adopt-ed in order to effect the cure, we will con-clude the history of Dyson’s case : -On the9th of July a flat trocar was introduced be-tween the fifth and sixth ribs of the left side.On pushing it in, at first it seemed to carrythe pleura before it, for on withdrawing thetrocar from the pleura no fluid followed;but by plunging it suddenly in, the pleurawas punctured, and about twenty-eightounces of a turbid yellow serum, with flakesof floating lymph, were thrown out. Thechest emitted no clearer sound after theoperation had been completed than it didbefore. On the llth, the patient is reportedto have remained much in the same condi-tion ; his breathing was somewhat good,and his general health was improved, butthe left side was not in the least degreeclearer on percussion than it was previousto the operation. Severe ptyalism came onafter that, from a small dose of calomel andrhubarb given on the 14th, the effects ofwhich continued to the 31st, after whichtime his general health seemed daily to im-prove, and he was able to sit up for severalhours in the course of the day.August 15th. He is reported to have

continued much in the same state. Sincethe operation the breathing has been quieter,and the general health much improved, butno increase of respiration has taken place onthe affected side. On the 1st of Septemberhis cough became very troublesome, and his

breathing somewhat short. On the 7th ofSeptember he was ordered iodine and hy-driodate of potass. On the 27th of Septem-ber a tumour was observed, between thefifth and sixth ribs, on the left side, soft,elastic, and fluctuating, and of about thesize of an orange. BRODiE’s needle gaveevidence of purulent contents. A setonneedle was passed through it, armed with askein of silk, and the contents of the tumourwere evacuated. A discharge was kept up,supposing the tumour to be connected withthe interior of the thorax. Four days after-wards he was reported to feel much easier.The seton went on discharging, but not insuch quantities as to warrant a suppositionthat it communicated with the chest. Thedischarge was of a thin purulent character,and the patient now seemed to be losingstrength daily. On the 15th he was con-

siderably worse; he could not then sit up,and he suffered much from difficulty ofbreathing. On the 19th there was lividityof the countenance, blueness of the lips,coldness of the extremities, and depressionof breathing, which symptoms increaseduntil the 22nd, when he died.The one thing of chief importance in this

case was, that, when the operation was per-formed, though such a considerable quan-tity of fluid was in the cavity of the chest,only about eight-and-twenty ounces werewithdrawn. We felt at a great loss to ac-count for this, for there was not the slightestdoubt that a great quantity of fluid still exist-ed in the cavity. We thought it possible thatthe circumstance might be accounted for bythe pleura having been sacculated. You willfind cases published by Dr. TOWNSEND in theCyclopaedia of Practical Medicine,-there are eone or two mentioned,-in which the adhe.sion took place at different parts, formingthree or four distinct cysts containing fluid.We thought this might have been the casehere, for on passing the needle higher up, ashort time afterwards, the fluid again es-

caped, showing clearly that there was still aconsiderable quantity remaining ; but I nowbelieve the explanation of all this to be, that,from the position in which the man was lying,the canula must have come against this band,which, as I have already shown you, existed,and which prevented the evacuation of thefluid. But you may ask then,-" Why nothave performed the operation again ?" Why,the reason was this; the man took twograins of calomel, combined with ten grainsof rhubarb, to open his bowels, throughwhich ptyalism came on, and the man be-came so exhausted as to make it evidentthat all hope of recovery was gone; wedid not, therefore, think it right to sub-mit him to the further pain of anotheroperation, because, even though we hadsucceeded at this time in evacuating the

fluid, it could not have been attended withsuccess. His strength was then supported

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as much as possible, and nothing more wasdone than to alleviate, as far as we could,symptoms as they arose, until his death. Imust, however, say, that if a similar casewere to occur again (and this is admittingthat we did not do all we might have done),I should certainly perform the operation,because I believe there could be no possiblehope of curing the man except by the eva-cuation of the fluid from the chest.

ON THE

TREATMENT OF FRACTURES

WITHOUT THE AID OF SPLINTS.

By W. C. RADLEY, Esq., Surgeon, NewtonAbbott, Devonshire.

(Concluded from page 251.)

THAT donkey-like emulation which makes" every ass think his own bray the best,"

would he extremely diverting, were it nottrue that struggles for place and prece.dence cause the great interests of humanityto be neglected or forgotten in the contest.In our noble profession it has long appearedto me, that whatever is written, which doesnot either directly or indirectly tend to thealleviation of suffering, is so much timewasted, and so much talent misapplied.

It is sickening to observe the rage withwhich novelty in medical science is pursued,while every-day cases are little understood,and therefore ill treated. Yet in spite ofneglect, how frequently do we discover casesthat have gone on unassisted, or have evenbeen maltreated, which, with a little settingright, have ended happily ! The vis medica-trix naturae in the case of fracture,-a causeof suffering that daily furnishes abundantsources of observation, and for the cure ofwhich so little has been done in the way of

improvement since the days of Hippocrates,-is that portion of our art to the considera-tion of which I am now striving to directattention. How often have I seen acci-dents made wcrse by meddling ignorance,or by the supererogatory offices of mis-taken aid, yet ultimately triumph over allthose retarding checks ! I This voluntarypower of reparation is the true rnaflni Deidatum to human nature, and not cinchona1>are," as a popular doctor once said. Thispower, however weakened, is always readyto assist us in surgical ciarations, and onlywaits to be guided or followed aright, tofulfil our intentions.

In the former part of my paper, cases offracture in a middle-aged man, in an old andfeeble woman, and in a very robust subject,were detailed, all of which were cured bythe splintless method.CASE 4.-The next case I shall mention

occurred in A"gMSt 1830, in a weak little

girl,’ about five years old, who was beingcarried in the arms of her sister, when bothfell together, and the younger had her thighsimply fractured. The name of the childwas Towse, and she lived in Newton Bushel.The bones were brought into apposition ona pillow, a bandage was applied, and someisolated slips of thin mahogany veneer, werelightly placed here and there over the courseof the fracture,-for show, not for use, notexerting any effect. My reason for placingthem so, was to propitiate the ignorance andprejudice which always strenuously con-

tend for retaining old forms. 1 thus affectedat that time to do as others did; but not sonow. The child remained under the eva-

porating action of a moist bandage, in aneasy state, for four days, sometimes half

sitting, resting on her elbow in bed, and

playing with her fellows. She ate and drankas usual, and slept without disturbance, forthe limb was placed in the natural position,which I in a great degree had let her chooseat the first, and which she said was easy toher. Would she have so lain at ease with herlittle thigh outstretched upon a splint? Oreven with a rather tight bandage aroundit? Certainlv not. Where there is the least

feeling of restraint in such cases, I havenever found ease. Observe a child asleep,and note its natural and " easy positions."What an admirable passage is this on posi-tion in fractures !--" The most easy positionof the limb is that which is usually chosenby a person who is sleeping : for then allmotion is suspended, and every part assumesthat posture which is most congenial to thelimb." This passage presents a foundationfor a superstructure of rational arguments infavour of sound practice in the treatment offractures. But sound reasoning, and a sirn-ple, natural, and therefore a correct prac-tice, founded thereon, are very different

things ; for Mr. S. Cooper and other sur-geons recommend the thigh to be put in thestraight position of Dessault, - a positionwhich must be irksome to many, because itis unnatural to those who through wearinessretire to rest. It is not the position of thetired sleeping child, who is almost bent intothe form of a ball. But to return to my little

patient.An evil-minded old woman on the fifth day,

seeing the child so easy under a fracture ofthe femur, slirewdly suspected that the bonewas not broken at all, and that the surgeonwas only "malting a job of it." Shewhisper-ed her suspicions to another old crony (thechild had lost its mother), and these wretchestook off the bandage, and actually placedthe child upon its feet! The bone of coursewas displaced. The mischief-workers sawand felt the crepitns, the child shrieked,and, conscience-stricken and alarmed, Mr.Gaye was sent for, who replaced the band-age, and, secieri(7e;n artem, splinted it up withthe pieces of veneer, though with more