treating those diseases than is due to that writer; some of Mr. H.'s cases are, however, very interesting and instructive. Cases of hip-disease follow. Among the complaints of the upper extremity, we have an interesting account of one which ended in anchylosis of the shoulder-joint: as our immediately preceding and present Numbers contain much about arteries, we transcribe the following account of

"Spontaneous Cure of an Inguinal Aneurism.

It was

"Stephen Lewis, aged fifty, perceived a small swelling at the left groin in September 1811. His attention was first drawn to the part by a throbbing sensation in it, particularly when standing up, which sensation he compared to a beating like a heart.' then not larger than a pigeon's egg. "It increased slowly till March 1812, when it had attained the size of a large orange. About this time the parts covering the tumor were attacked with erysipelatous inflammation; and, although this attack was, by proper treatment, soon relieved, he found the aneurismal tumor more frequently painful afterward than it had been before. Its pulsations were much aggravated in severity, and he also complained of more or less uneasiness and pain throughout the whole limb.

"His general health, however, being tolerably good, he was still able to move about the house, notwithstanding the swelling in the groin, continuing to increase, was, in September 1812, equal in size to a large melon, and was frequently productive of paroxysms of extreme pain and irritation.

"As the winter approached, these pains connected themselves with others of a spasmodic nature, shooting downwards through the muscles of the thigh and leg.

"In the early part of February 1813, he was upon the water. closet, and, in straining to pass a confined motion, he distinctly felt something give way within the tumor; and immediately afterward found that the scrotum, the upper part of the thigh, and the lower part of the abdomen, were swelling very extensively, while the projection of the original tumor apparently diminished in the same proportion.

"By the following day, the extent and quantity of the diffused swelling was enormous, and the pain, both in the aneurismal tu mor, and in the surrounding parts, was almost intolerable; added to which, a considerable cedematous enlargement of the whole leg and thigh now served to increase his general distress.

"The extreme severity of pain and irritation was from day to day relieved by the frequent administration of opiates, the effects of which were occasionally assisted by fomentations to the parts.

"After some weeks' confinement to bed, the severity of his suf ferings began to diminish, and by degrees he recovered so far as to be again capable of moving about the house.

"In November 1813, [at least eight months after the aneurism

had

had burst,] he took a violent cold and cough, with which, and an increased pain in the extended seat of the disease, he was confined to his bed for near three weeks, almost without sleep.

"During this attack he was seized with an unusually severe fit of coughing; when in a moment he felt something burst within the tumor, and, turning aside the bed-clothes, found the bed first, and immediately afterward the floor of the room, inundated with a discharge of excessively offensive, grumous, and putrid blood, which poured out from a part of the integuments that had given way.

“Mr. Heaviside, who had attended him regularly, visited him accidentally within a few minutes after the swelling had given way. The quantity of discharge was at least equal to several quarts, and it appeared very doubtful whether he could survive the first effects of so tremendous a crisis.

"For the space of three weeks after this event, the putrid contents of the aneurismal cavity continued to come away in such quantity, that it was found necessary to change his bed-linen every day. In the course of this period several new openings formed in the integuments, while the general parietes of the tumor became thinner and more flaccid from the frequent evacuation of large masses of grumous blood and lymph.

1

"By the end of the third week a quantity of sloughy mem branous matter made its appearance at the largest opening, and this with care was by degrees separated and brought away, and proved to be a very large mass of thickened, sloughy, and putrid, cellular membrane.

"The removal of this substance was productive of so much irri tation and exhaustion, that, notwithstanding every assistance, it was scarcely expected that he could live through the night; from that time, however, he began to mend.

"On the evacuation of the contents of this immense tumor, the principal object, of course, was to support his strength, so as to enable him, if possible, to bear up against so great a discharge of putrid matter. With this view warm jellies, soups, wine, &c. were exhibited in small quantities every half hour, with the most unremitting attention."

By these means the patient recovered, excepting that to December last the seat of the large opening has occasionally ulcerated superficially, the limb is also much weakened.

The remainder of the work contains remarks on diseases in the bones of the limbs and on dislocations. On these, we could dwell with much pleasure, would our limits permit, but we must now conclude with our most hearty thanks to Mr. Howship for the present he has made to surgery and to the public. If we have seemed to differ from the author, it will be understood that we have felt it our duty to select the only passages which we thought required our animadversion, which are few in so large a volume. It is much against our will, that we now feel obliged to express our re

gret

gret at the number of well executed plates, In many instances we found the description quite sufficient, where the plates must increase the expense and consequently injure the circulation of so truly valuable a work.

Some Practical Observations in Surgery: illustrated by Cases. By A. COPLAND HUTCHISON, late principal Surgeon to the Royal Naval Hospital at Deal; Member of the Royal College of Surgeons in London, and of the Medico-Chirurgical Society; one of the Consulting Medical Officers to the General Penitentiary, Mill-bank, Westminster, &c. &c. 8vo. pp. 167. Callow, 1816.

THIS is one of the publications which have remained too long on our shelves, whether we consider the importance of the subjects, or the manner in which they are treated. To give a just notion of the whole, we shall consider each chapter in its order. That on amputation treats "Of the proper period for operating in gun-shot wounds." Here the author makes no scruple to recommend the immediate amputation of a limb which cannot be saved. The principal arguments are, that time for deliberation on the part of the patient only adds to his despondency; and that the mischief already done is likely to be more injurious than a wellconducted operation. Some hints are thrown out on the: supposed superiority which the medical officers in the armyare apt to assume over those of the navy. We hope they are ill-founded. One writer is often alluded to, whose work, by its date, should have preceded this. Copious as the arguments and remarks are, we will venture to suggest one which we do not recollect to have been sufficiently insisted on. It is urged that military men, particularly privates, are usually in the flower of youth, and in a condition of high animation, both which are causes to induce high inflammation. Is there not, then, too much care taken to prevent the loss of blood in some instances of operation after wounds which have been readily staunched? We have often remarked, when a surgeon has related a successful am-' putation, under circumstances particularly unfavourable, that, among the latter, has been the great loss of blood either before or during the operation. Has not that very loss of blood been among the causes of success? and, when it has not occurred, should not blood be taken away by means of the lancet?

The second consideration is "On the application of the tourniquet."

tourniquet." These remarks we shall give in the author's words.

"The proper distance for the application of the tourniquet, whether the part intended for operating on be situated above or beneath the knee or elbow, should, in my opinion, be nearly the same; namely, a hand's breadth below the groin or axilla. The next circumstance that claims our attention will be the kind of pad or cushion, to be applied underneath the strap or web of the instrument, for compressing the artery. I am in the habit of using a pad considerably smaller than is commonly employed by surgeons in general, being not thicker than a finger, and which I place somewhat obliquely over the artery, to preclude the possibility of its being displaced, by any direction that it may subsequently be found necessary to give the limb during the operation. It may be made by taking a few turus with a bandage about a rounded piece of deal of the circumference of a goose-quill, au inch and a half in length. After the pad is thus prepared, it should be stitched, to prevent any embarrassment from unrolling during its application; with about a yard of bandage left hanging from the compress, for the purpose of passing round the limb.

Surgeons usually place the screw of the tourniquet immediately over the pad for compressing the artery; but I am of opinion that a more convenient situation for this part of the instrument, both as it regards the operator and assistant, will be on the outside of the limb, nearly opposite the course of the artery to be compressed; for, by this position, the pad will be less likely to be displaced by the web of the instrument, than when the screw part acts immediately upon it. I have seen gentlemen, who rank deservedly high in the profession, make use of a pad of a rolled-up five-yard bandage: at one period I was myself in the habit of using such large compresses, and might have continued in the use of them to this day, had not a very embarrassing circumstance occurred to me on one occasion.

A principal objection to the placing of a large pad over the artery is, that the web of the tourniquet passing over a surface so much elevated above the circumference of the thigh, a considerable angular space on each side of it will be left slightly, or not at all, compressed by the circular band of the tourniquet, however closely the instrument may be screwed. This will not only endanger the loss of a large portion of blood, from the divided ends of such vessels as may happen to traverse that space, a circumstance to be particularly guarded against in cases of debility; but the emission of blood must also embarrass, and obscure the view, of the young surgeon, in the subsequent parts of the operation."

In dividing the parts, Mr. H. proposes the largest possible quantity of flap; and that, before the retractors are removed, the bone should be scraped with a blunt scalpel, which he prefers to the knippers or file.

On securing the blood-vessels, the author is as minute in

his

his direction as the importance of the subject demands. We shall recapitulate them, and add our own remarks. The including the vein in the ligature is objected to, from the danger of overlooking the nerve. Some other cautions follow, showing the difficulty of discovering the nerve when the parts are bloody, and particularly if previous adhesions have taken place. On the mode of tying the ligature, much stress is laid that the noose should be at right angles with the artery. This we highly approve, and, in addition to the cogent reasons suggested by the author, shall add another, the inattention to which we strongly suspect once proved the cause of a secondary hæmorrhage. If the noose is not at right angles, the part of the ligature within the knot is longer than is necessary; and, should it by any means become at right angles, it may not be small enough to close the area of the artery. If arteries are wounded longitudi nally, they should be cut transversely. When ossified, or if the operator discovers a calculous deposition, they require the needle, to include some surrounding parts.

"It is of essential importance (continues Mr. Hutchison) in amputation, that every artery from which there may be the slightest probability of an after-hæmorrhage should be tied, previously to bringing into final contact the wounded surfaces; for, should a small branch escape detection, it may, when warmth and re-action take place, bleed profusely, occasion the removal of the dressings, the re-opening of the stump, additional pain to the patient, and increase the general irritation, by the alarm usually resulting from unexpected hæmorrhage.

"With this view, therefore, it will be requisite that every coagulum of blood shall be carefully removed, as I have frequently discovered the mouths of very formidable vessels concealed by coagula, which stop the bleeding only till the parts become heated, and this substance is broken down by the constant impulse of the circulation. The sponge I have often found insufficient to remove these coagula from the orifices of such vessels, and I have been frequently compelled to employ the nails of the fore-finger and thumb to detach them from their adhesions.”

The practice of washing the bleeding stump in cold water is objected to. One end of the ligature is advised to be cut off about an eighth of an inch from the noose, excepting those on the two principal arteries. These should be distinguished by knots at the extremities of each; and, if the noose is not detached at a proper time, the ulcerative process should be hastened by twisting the two ends together, so as to tighten the noose. The modern practice of cutting all the ligatures close to the noose is objected to; but the question is left undecided, excepting in cases of aneurism, where it is altogether reprobated.