period of time which these patients remained in the hospital before their stumps were completely healed was from forty to fifty days. Mode of Dressing the Stump.-When ligatures have been tied around the principal arteries of a stump, the hæmorrhage from the smaller vessels (which are also tied in cases where the dressing is proceeded with immediately) is arrested by covering the recently-divided surfaces with lint, soaked in cold water. This is removed and re-applied every few minutes at first, and then at longer intervals, until all bleeding has ceased; and in order to insure the actual application of the cold water to the bleeding surface, the coagula are from time to time gently removed. When the patient begins to recover the shock of the operation, one or two of these smaller arteries perhaps spout out afresh. These, however, if necessary, are easily secured, as the flaps are still separate and exposed: the greater number of vessels, on the contrary, become plugged up with fibrine, and retract within their sheaths. Thus all chance of disturbance of the dressing, by effusion of blood between the flaps, is prevented; and that without having so many sources of irritation present in the stump, as when many vessels are secured by ligature. Where the patient is unusually nervous and susceptible of pain, tepid water, changed more frequently, may be used in a similar manner. When all oozing of blood has ceased, and when the divided surfaces become glazed over, (which happens generally in from four to seven hours after the operation,) the wet lint and small remaining coagula are removed, and the dressing of the stump proceeded with. The flaps, which are in the most favourable state for union, are now brought accurately together, and retained by several points of interrupted suture. The number of sutures requisite for this purpose varies from two to four; but more than three are seldom used, even in amputation of the thigh. They are removed frequently in twelve or twenty-four hours; but if the flaps are large and heavy, and the threads cause no redness in the neighbouring skin, they may be left for several hours longer, to prevent any dragging on the recent adhesions. When the flaps are thus in apposition, the edges are more closely brought together by means of strips of plaster applied over the face of the stump, at a little distance from each other, so as to allow of the ready escape of discharge, and the abstraction of the sutures when necessary. Instead of using, for this purpose, the ordinary resinous plaster, which is a dirty application, readily loosened by discharge, and frequently causing irritation and erythema of the skin, a far more convenient material is found in oiled silk or gold-beaters' skin, spread with a solution of isinglass, which is allowed to dry. This plaster is sufficiently firm and tough to support the heaviest flaps; it is very adhesive, and being impervious to water, remains for many days without becoming detached; it does not irritate the skin; and, lastly, as it is quite transparent, the line of union may be seen distinctly through it, and additional support may, at any time, be given to a particular part, where it is seen that the lips of the wound are separating. This dressing is found perfectly sufficient for the first three or four days, or even longer in some cases; the stump being kept gently elevated on cushions covered with oiled silk. No bandage is applied at first, but the stump is left uncovered and cool. In general, very little inflammatory swelling takes place under these circumstances, and what little does occur is not accompanied with pain, because there is nothing to constrict the parts, and prevent their enlarge ment. A bandage is seldom applied before the third or fourth day, though occasionally it is made use of earlier, where the stump is large and heavy, and the union by the first intention not as extensive as usual. At first, however, the roller is not brought over the face of the stump, but is only allowed to approach the end by circular turns. By this means the discharge is not confined, and the strips of plaster are left undisturbed, these being quite sufficient to prevent the lips of the wound from separating. When suppuration is fairly established in those parts of the stump which have not united by the first intention, the plaster is usually removed, either entirely or in part, and the end of the stump dressed with lint dipped in tepid water, or in a gently-stimulating lotion, and covered with oiled silk. The bandage also is then brought over the end of the stump in such a manner as to support the flaps together as the plaster hitherto has done. This simple kind of dressing has the advantage of being cool and clean : and as it may be easily removed, without much pain to the patient, it may be renewed daily. Secondary Hamorrhage. In the sixty-six cases here collected, two instances occurred; both in amputation of the thigh. In one case the hæmorrhage proved fatal, as the patient was reduced to an extremely low state, by purulent discharge from the knee-joint, before he consented to amputation. The other patient recovered, after having, first the femoral and then the external iliac artery ligatured. This case is interesting, and may be related. Case. The patient, a swarthy middle-aged man, was admitted January 28th, 1839, with an immense ulcer over the front of the leg, which had existed for several years, and occasionally bled to a very considerable extent. There was also solid œdema of the lower part of the leg and foot, the skin and cellular tissue being greatly hypertrophied, and the epidermis developed into a kind of horny crust, similar to ichthyosis. Though the foot was nearly twice its natural size, it was perfectly hard, and did not pit on pressure. The patient was prevented from working, and was beginning to lose his strength and appetite, when he applied, anxious to be relieved of his useless limb. On the 4th of February he submitted to amputation of the thigh, the ulcer being too extensive to allow of the formation of sound flaps in the leg. On the 12th of February, eight days after the amputation, secondary hæmorrhage occurred, which was, however, stopped by cold and pressure. On the following day (13th) bleeding recommenced, but with much greater violence. Accordingly a ligature was placed round the femoral artery, just below Poupart's ligament. On the 15th of February hæmorrhage to the amount of several ounces took place from a small artery (superficial external pudic), wounded in the operation of tying the femoral. On the 27th of February the ligature came away from the femoral artery, without any bleeding, having been on only fourteen days. On the 15th of March rapid bleeding occurred from the wound in the groin, which had nearly closed. This was for a time arrested by compression; but in the evening it again returned, and as the patient was excessively weak from a sloughing back, the external iliac artery was tied, as a last resource. The following day several ounces of blood were again lost from the wound in the groin, but this was the last time of its occurrence. On the 1st of April the ligature separated from the iliac artery, and the wound healed slowy but gradually. The patient after this by degrees recovered his strength and health, and was discharged the 5th of August, 1839. He showed himself at the hospital about a twelvemonth afterwards in excellent health apparently, and in full work. A useful statistical contribution. XII. COLICA PICTONUM TREATED WITH WARM WATER. By John Wilson, M.D., Physician to the Middlesex Hospital. To relieve the constipation that attends this disorder, it occurred to Dr. Wilson that if an enema were given during the time the patient was in a warm bath, it might then possibly be allowed to pass up the intestinal tube, and be retained so long as to accomplish the object of evacuating the intestines of their morbid secretion, and ultimately of restoring to them their healthy action. Dr. Wilson relates six cases of constipation from lead, in which this plan was employed. One will be a sufficient sample of the whole. Case.-May 15, 1838.-Matthew Proctor, age forty-five, for thirty years has been a plumber and painter; il five days, with severe pain coming on in fits over the abdomen, so as to bend him double; has had no evacuation for five days past, though he has had mercury given, to which he attributes the present soreness of his mouth. Afterwards he had five doses of castor oil; yesterday he had three grains of opium in the morning and castor oil in the afternoon, when a mustard poultice was applied over the abdomen; still the bowels persist in the same state as they have been for the last five days. Now, abdomen very hard, but the severity of its pain is mitigated by pressure; tongue white; has had much sickness and frequent vomiting. This is his fourth attack of colic, but he has never had drooping of the wrists. On admission he was put into a warm bath, and when he had been in it for some time, an elastic injecting tube was given him, with directions to employ it in trying to inject the water of the bath gradually up the intestines, and to persevere, should he feel no pain, nor unpleasant sensation, till he felt a sensation of fullness of the abdomen. In this he succeeded while he continued immersed in the bath; shortly after, and before he quitted the bath, he had an evacuation of lumpy fæces. After leaving it, he was purged four or five times, and relieved from the pain. The next day he had an ounce of castor oil, m xx. tinct. opii, and a sinapism to the abdomen. The third day the bath and enema while in the bath were repeated; after which, while he remained in the hospital, his bowels never required more than the mistura alba (sulp. mag. 3 ss., carb. mag. gr. v., in mint water,) two or three times a-day. He had no relapse, and was discharged on the 27th. Dr. Wilson had used the same simple remedy in cases of constipation dependent upon other causes. He relates one. We think that the pro fession must feel indebted to Dr. Wilson for the hint. XIII.-MALPOSITION OF THE KIDNEYS; ABSENCE OF THE VAGINa, UteRUS, AND FALLOPIAN TUBES; DISEASE OF LEFT OVARY. By R. Boyd, M.D., Resident Physician to St. Marylebone Infirmary, and Lecturer on Medicine. Sarah Richardson, aged 72, died in the St. Marylebone workhouse of chronic disease of the brain and lungs. The renal capsules were in their usual position, on either side the spine, immediately below the diaphragm. Right kidney situated in the right iliac fossa, below the cæcum, partially concealed by the right ovary, which had a slight peritoneal attachment to it. The renal artery was given off from the right iliac, close to the aorta. Left kidney in the pelvis below the psoas muscle, resting on the sacrum and origin of the pyriform muscle. An artery which arose from the aorta at its bifurcation, in the situation of the middle sacral, entered the upper end of the kidney; another larger branch from the internal iliac artery, entered the kidney in the usual situation. Kidneys, ureters, and bladder, in a healthy condition. Right ovary, when divided, presented the natural structure; to its upper or free extremity was attached, by a thin neck, small oval sac. A round ligament connected the ovary to, and was lost in, the cellular tissue behind the neck of the bladder. The situation of the left ovary was occupied by a fibrous tumor of an irregular globular shape, connected by a round ligament smaller than that on the right side, but which took a similar course to the bladder. The Fallopian tubes were not present. There was a slight projection of the peritoneum, behind the bladder, from cellular tissue beneath it. A careful examination of the parts in their recent state was made by Dr. R. Lee, also by Mr. Kiernan, afterwards by Mr. Perry,-no vestige of uterus could be discovered. The external parts of generation presented no unusual appearance; the mons Veneris but thinly covered with hair: a cul-de-sac, about half an inch deep, beneath the orifice of the urethra, is all that exists of vagina. Mammæ were well developed for so old a person. As regards the previous history of this woman, the only information obtained was, that she had been married, but did not live on amicable terms with her husband. In the case of Hannah Brown, murdered by Greenacre, the absence of the uterus was observed as in this instance. XIV.-PATHOLOGICAL AND SURGICAL OBSERVATIONS ON THE DISEASES OF THE EAR. By Joseph Toynbee, Esq. Mr. Toynbee has been led to believe that deafness must very frequently depend upon a morbid condition of the fibro-mucous membrane lining the cavity of the tympanum. He refers to the observations of Mr. Swan, who relates the particulars of three dissections in which the mucous membrane of the cavity of the tympanum was diseased and thickened, so that the nervous plexus of Jacobson could not be distinguished. One of these cases occurred in an old woman, the second in a man, and the third in a very young woman. In the second case there was also some roughness of the bone. After detailing these appearances Mr. Swan writes-"I believe deafness does not so often depend on a disease of the auditory nerve as has been supposed, but much more frequently on an inflammatory action attacking the membrane lining the tympanum, and involving the small branches of the tympanine nerves." He adds, "although many of the noises may depend on the disordered functions of the auditory nerve, I think they may arise too from these small branches of the glosso-pharyngeal and their communication with the sympathetic in the carotic canal." Mr. Swan goes on to remark : "The consideration of the distribution of the tympanine branch of the glossopharyngeal nerve, leads to the conclusion that the tympanum performs more important functions in the production of hearing than have been usually ascribed to it, and that the failure of remedies in cases of deafness which have been termed nervous, may have proceeded very much, not only from the obscure situation of the tympanum, but from the misapplication of the remedies themselves. And I conceive, therefore, as a thickening of the membrane lining the tympanum and involving such delicate nerves, can be so often observed, that many diseases of the ear may be more within the reach of art than has been contemplated, and that by subduing the inflammatory action at its very onset, before the structure of the delicate parts has become so much changed as permanently to impair their functions, many of the worst cases might be prevented." 193. Mr. Toynbee relates forty-one dissections of which the following is an abstract. 1 In a healthy state 2 With simple thickening of the investing membrane 10 6 4 4 With slight thickening of the investing membrane, accompanied by the existence of membranous connecting bands 13 5 With considerable thickening of the investing membrane and with membranous bands 6 With suppuration of the cavity of the tympanum 7 With anchylosis of the base of the stapes to the circumference of the fenestra ovalis 51 2 41 |