January, 1828, the irritability and the pains had entirely disappeared.

We need not detail any more of these cases: they were all pretty nearly of the same kind, except that in some of them the pain invaded the anus. These cases are not very rare-and there are many people who experience pains along the urethra and towards the anus, for years and years, whenever they make water. These pains are always increased when the urine contains bile, or an over-proportion of uric acid. There is perhaps no better plan of relieving these neuralgic affections of the bladder and urethra than bland diet-diluents-and the decoction of uva ursi with soda and hyosciamus. By these means the neuralgiæ in question will generally be removed or much mitigated.

LVII.

PHILADELPHIA INFIRM

ARY.

MALIGNANT INTERMITTENT. By Dr. JACK

SON.

The following case, reported in the American Journal of the Medical Sciences, is worthy of notice, as showing that very severe malarious intermittents will give way to low diet, change of air, and moderate local depletion, even without bark.

"Case. Chas. Cavenaugh, ætat. twentytwo, was admitted about 12 o'clock, reporting that he had intermittent fever. He had been engaged during the Summer at work on the canal at the Juniata, where he had contracted the disease; and of a gang of three hundred who left the city, he stated more than half were dead. It was originally tertian: for the last week it had assumed the quotidian type, coming on at two o'clock. This change has been effected by fatigue in travelling from the Juniata. Habits intemperate.

"When the chill was subsiding about two o'clock to-day, the fever commenced with the sensation of a violent blow upon the forehead, and immediately he jumped from

his bed, and ran about the ward with the wildness of maniacal delirium. Being overtaken and replaced, he appeared ignorant, on becoming better, that he had left his bed. At this period he was found labouring under a most violent excitement; he appeared almost distracted with the pain in his head; his respiration was exceedingly laborious; the skin very hot; and the pulse full, strong, and frequent; xij. of blood were immediately taken from his arm, and in a few minutes after he was completely relieved. 7 p.m. asleep, with his head covered; woke up alarmed; skin very hot; pulse full and frequent.

"5th.-Better this morning; the intermission is not complete; skin hot; pulse frequent; tongue moist and furred; eyes injected and jaundiced; absolute diet; hot revulsives to anticipate chill; the paroxysm in the afternoon was nearly as violent as that of yesterday; required two men to hold him in bed; his spleen was so engorged that it rose in a large ball under the hand; having some tenderness at the epigastrium, and a dry, furred tongue, he was ordered to be cupped freely.

"6th.-A tolerable intermission early this morning; tongue nearly clean. Ordered to take in solution a grain of sulphate of quinine every hour. Paroxysm came on an hour and a half earlier to-day; not so violent; mustard plasters were applied to his extremities when the chill threatened; tongue very much furred in the evening. Ordered cups again to epigastrium.

"7th. His stomach still irritable; tongue foul; omit quinine; sinapisms when chill threatens. 9 p. m. Had no paroxysm this day.

Discharged well, having had no return. -Case reported by Dr. JONES.

"Remarks.-This case was an intermit tent of malignant character, threatening apoplexy in the paroxysm. The intemperate habits of this man, it is most probable, gave to his brain the predisposition which invested its sympathetic irritation when, in the febrile stage, it began to be irradiated from the stomach, with its extreme intensity.

"A full bleeding immediately arrested

the violence of the cerebral irritation, and diminished the congestion of the brain.The same remedy would have been more freely urged, but for the habits of the patient, which always counter-indicate the very liberal employment of the lancet. The intemperate are very soon prostrated by general bleeding, and when they once begin to sink, it is almost impossible to re-excite them. This is one of the causes that render inflammations, and diseases requiring free depletion in their treatment, so generally fatal in those who abuse the employment of ardent spirits. They will not bear the treatment which can alone cure them.

"A circumstance in this case to be remar

ked, is the extraordinary suddenness with which the cerebral irritation commenced, and consequent raptus of blood to the brain. Cavenaugh insisted on it, he had received a blow, and for a time was unconscious of his situation. We have here presented the mode in which appoplexies, are induced, and which so commonly draw the cerebral irritation on which they depend, from gastric irritation.

It is also to be observed, that the sulphate of quinine was not tolerated by the stomach, the irritation of which it augmented, and that the cure was affected chiefly by attacking the gastric irritation, by low diet, cooling demulcent drinks, and local depletion."

LVIII.

EDINBURGH ROYAL IN

FIRMARY.*

1. PRIMARY AMPUTATIONS.

Case 1. Robert M'Gregor, 15 years of age, was admitted late in the evening of the 28th of January, having had his right arm drawn in to the machinery of a paper-mill at five P. M. The arm was torn off from the body about the middle of the humerus, and the extremity of the bone projected from the muscles. The laceration extended on the

* Clinical Lecture, by Dr. Ballingall.

inside into the axilla, and destroyed the inferior margin of the pectoralis major and latissimus dorsi. The skin for a short way on the back of the scapula was destroyed, together with a considerable part of the clavicular portion of the deltoid. The artery was seen pulsating about three inches from its end, which was closed by coagulated blood. No hæmorrhage had taken place, but the extremities were cold and the pulse feeble.

Amputation at the shoulder-joint by making a single flap of the deltoid was performed by Dr. Campbell, and four vessels only required to be secured. An opiate was administered and the patient went on well till the night of the first of February, when much secondary hæmorrhage took place from a small vessel which was therefore tied. At half-past 2 in the morning the ligature came away from the axillary artery, and bleeding followed to a material amount before the vessel was secured. An anodyne was given and the pulse was reported at 130 but stronger than on the preceding evening. For several days the patient was considered in imminent hazard, some sloughing having taken place from the edges of the wound, with a copious discharge of ill conditioned matter, and the pulse ranging from 125 to 150, with occasional rigors, and profuse sweats. The local treatment consisted in daily dressing with resinous ointment: the general, in the free exhibition of opiates, beef tea, and small quantities of wine. The cure went on without interruption or untoward event, the lad's appearance amended greatly, and Dr. Ballingall, at the period of his lecture considered him as out of the wood.

The following remarks are so just, that we cannot refrain from transcribing them without abreviation.

"In my comments upon this case, I viewed it as illustrative of three important points, the spontaneous cessation of the hæmorrhage, in cases where limbs have been torn from the trunk; the question of primary and secondary amputation; and lastly, the mode of performing this operation at the shoulder joint.

"In illustration of the first point, I shew. ed you the portion of the humeral artery which was removed along with the remains of the arm, the internal coat of which was in some points slightly lacerated, while the external coat was over-stretched, and a considerable portion of it filled with coagulum. I referred you for farther illustration of the state of arteries after accidents of this kind, to a case detailed in the 19th volume of the Edinburgh Medical Journal, by Mr. Lizars, and to a very valuable paper, containing indeed all the information which we possess on this interesting subject, by Professor Turner, in the Medico-Chirurgical Transactions of this place. By the kindness of this last mentioned gentleman, I was also enabled to show you some drawings, exhibiting the state of arteries in accidents of this nature; where in some cases we find their internal coats completely torn through, and corrugated, or coiled up as it were, within the vessel, so as to prevent the effusion of blood.

"You must not, however, Gentlemen, expect to meet with the same proportional success in the amputations performed in civil Hospitals; at least, I am entitled to say, that the contrast between the success of primary and secondary amputations during the time that I have served in this house has by no means resembled that which I was accustomed to see and to hear of in the army. For these different results in military and in civil hospitals, many reasons, might, I think, be assigned, some of them more satisfactory than those mentioned by Sanson, who, in a recent paper upon this subject, has noticed the fact, but has, I think failed to give a very luminous or satisfactory explanation of it.

"On the subject of primary and secondary amputation, we now possess a series of valuable observations, from the time at which it was made the subject of a prize question by the French academy in 1756, down to the present day; when the advantages of primary amputation are, I believe admitted by every practical surgeon, who is now enabled to add to his own experience that of the French army surgeons, as detailed in Baron Larrey's writings, that of the English army surgeons during the peninsular war, as detailed by Mr. Guthrie and Dr. Hennen, and that of the naval surgeons, as detailed in Mr. C. Hutchinson's work. One of the most striking illustrations of the successful issue of primary amputations, is contained in an extract from a report made by Dr. Burke, inspector of Hospitals to his Majesty's forces in Bengal, which has been made public by my friend Mr. Annesley, in his splendid work on the diseases of India Dr. Burke states, that 'of eighty cases of amputation,' performed at Bhurtpore in Upper India, 'the whole recovered in 14 days.

"In speaking of the operation at the shoulder joint, I remarked, that, although this operation has undergone many modifications, to some of which the names of Morand, La Faye, Le Dran, Larrey, Lisfranc, Broomfield, Alanson and others, have been attached, yet these may all be resolved into two modes of proceeding, either by forming a superior and inferior, or an anterior and posterior flap. I have myself operated in both ways, but not sufficiently often to enable me to institute any fair comparison as to the best mode of operating; I may however be permitted to remark, that in a very large proportion of the cases requiring amputation at the shoulder-joint, the soft parts are so lacerated as to leave us no choice, but to compel us, as in the present case, to form the flaps as circumstances best will admit. We are now well aware that the apprehension of an uncontrollable hæmorrhage, which alarmed our predecessors and made them slow to adopt this operation, is altogether unfounded; the bleeding may always be controlled by firm pressure above the clavicle, by the hands of a steady assistant; and, in fact, this compression, as my distinguished predecessor Dr. Thomson ob serves, has been found easier in practice than it appeared to be in speculation.' It is necessary, however, to remark, that at the moment of cutting through the axillary

vessels and nerves, the patient is apt to give an involuntary start, and may throw the fingers of the assistant off the artery; an accident which once happened to a gentleman assisting me in this operation, and by which I nearly lost my patient. I was for a moment completely blinded by the discharge of blood into my eyes from the open axillary artery."

Case 2. Charles Cuthbertson, ætatis 71, was admitted on the 18th of December with a comminuted fracture of the radius and

ulna at their carpal extremities, an extensive lacerated wound of the left wrist, and a severe contusion in the lower part of the back, with a fracture of some of the ribs.

Although, as I stated to you in the theatre at the time of the operation, I entertained little or no expectation of this man's recovery, I determined, after a few moments' consultation with my colleagues, to remove the arm a little below the elbow. It was obvious, however, at the first dressing, that no prospect of union existed; the lips of the wound, instead of presenting that wholesome turgidity and tension which presents itself in a healthy stump, were flaccid, somewhat livid, and apparently tending to gangrene; the smaller vessels (if I may use the expression) had not taken up, but had poured out a quantity of grumous blood which flowed through the dressings; at the same time the patient began to complain of oppressed breathing, and symptoms of inflammatory action within the thorax, so that he had to contend with all those difficulties which you may suppose to exist in the case of an old man labouring under acute inflammation within the trunk, and gangrene in one of the extremities. Amidst a choice of evils, the abstraction of a limited quantity of blood was tried but without any good effect, and the patient died during my temporary absence in London, about eight days after the receipt of the injury. No report of the dissection appears to have been entered in the register, but I am told that the whole of the ribs on the right side, with the exception of the two inferior ones, were found VOL. XI. No. 21.

fractured, and some recent deposition of lymph on the pleura.

"This case, Gentlemen, I am induced to mention, not from any very instructive lesson to be gathered from its progress, much less for any thing very unexpected in its event, but to caution you against an acci dent which occurred during the operation. While passing the knife through the forearm, from the radial to the ulnar side, for the purpose of forming a posterior flap from the extensor and supinator muscles, its point slipped between the bones, which rendered it necessary to withdraw it and to pass it more carefully behind the ulna; this was perhaps owing partly to my inadvertence to the exact position of the bones, but partly, I believe also, to the connection between the lower extremities of the radius and ulna

having been broken up, so that in pressing the knife close to the back of the radius, with the view of obtaining a sufficiency of muscular substance to form a good flap, the parallelism of the two bones was in some measure destroyed, the radius was pressed forwards, and the interosseous space thus presented to the point of the knife."

II. SECONDARY AMPUTATION.

Case 1. Helen Coghill, æt. 21, was admitted on the 8th of October, with the left knee swelled, hot and painful; severe pain. in the condyles of the femur on moving or pressing the patella; limb retained always extended; pulse natural; tongue clean; bowels regular. She stated that after a fall, received ten years previously, the joint was first inflamed, and eighteen months ago, after a similar accident, the inflammation was much increased, and had been more severe than even in the seven weeks preceding her admission. Leeches, opium, moxas, &c. were the means employed, but without the least effect in arresting the disease. The sufferings of the patient were very severe, the constitution sympathised, and under these circumstance that dernier resort, amputation, was performed on the 5th of December. The joint, on examination, was

37

found to be extensively diseased, its cartilages being either completely destroyed, or detached altogether from the bones. The patient for some days was harrassed with nausea and occasional retching, with her pulse varying from 136 to 140. The general appearance, not witstanding, was improved, and although superficial ulcerations took place upon the back, the stump put on a very promising appearance, and the greater part united by the first intention. On the 3d of January she left the house, but after this, small phlegmonous swellings formed and burst in the line of the cicatrix.

"You would observe, Gentlemen, that in amputating this young woman's thigh, instead of forming two lateral flaps, as I had hitherto been accustomed to do, I formed an anterior and posterior flap, the one from the extensors on the fore part, and the other from the flexors on the back part of the thigh. This is a mode of operating which I first saw practised by Mr. Liston in the cases of two boys whom he operated upon in the house last autumn; and in the case

of such young subjects who cannot readily be made to retain their stumps in a desirable position, but are constantly inclined to elevate the point of the stump, it appears to me to offer decided advantages; in the first place, it obviates the projection of the bone between the lateral flaps, which I am told has sometimes occurred, and, in the next place, you will see that the more the point of the stump is elevated, the more are the extensor muscles relaxed so as to afford a covering for the point of the bone. Other collateral advantages attendant upon this mode of forming the flaps are pointed out in a paper of Mr. Creasers, formerly of the Bath Infirmary, in the 22d volume of the Edinburgh Medical and Surgical Journal, although he indeed recommends the flap to be formed by cutting from the surface towards the bone, instead of transfixing the limb and cutting outwards.

"The plan of dressing stumps after the common circular amputation of the thigh, so as to place the line of the cicatrix transversely, instead of perpendicularly, you will find advocated both by Mr. Guthrie and by Mr. Copland Hutchison, the latter of whom,

in the first edition of his Surgical work, gave a marginal sketch well calculated to illustrate his valuable remarks upon this point."

Case 2. J. Browne, æt. 37, a seaman, having lost all his toes in consequence of exposure to great cold twelve months previously, on the coast of Norway, was admitted with extensive ulcer and destruction of skin on the under surface of the left foot. Dr. Ballingall being satisfied that no firm or permanent cicatrix was likely to be formed unless the metatarsal bones were removed

performed an operation for that purpose on

the 4th of November. It consisted in making an incision convex anteriorly from a little beyond the base of the first metatarsal bone to the most extreme point of the base of the fifth, and forming a flap from the integuments on the dorsum of the foot. The four outer metatarsal bones were then disarticulated, the internal cuneiform sawn through, and a corresponding flap formed from the integuments of the sole. The two flaps thus obtained were united by three points of the interrupted suture. "Partial union by the first intention was procured, but an attack of the erratic erysipelas suc ceeded, which protracted the cure. However, he was able to leave the infirmary on the 5th of January, for London. Had the great destruction of the soft parts in the sole not proved a bar to such a proceeding, Dr. B. would have greatly preferred a large single flap from that part turned up over the anterior extremities of the tarsal bones, to the double one, which circumstances forced him to adopt. The cicatrix on the dorsum of the foot is much the least liable to injury in walking.

III. RECTO-URETHRAL FISTULA.

Every one must know how troublesome a class of cases are these fistulous communications between the pelvic outlets of the body. The recto-vesical, recto-vaginal, and