CULLERIER AND BUMSTEAD'S ATLAS (Now Complete.)

By A. CULLERIER, Surgeon to the Hôpital du Midi, &c. Translated from the French, with Notes and Additions, by FREEMAN J. BUMSTEAD, M. D., Professor of Venereal Diseases in the College of Physicians and Surgeons, New York. With 145 beautifully colored figures on 26 plates. In one very handsome volume, imperial quarto, of 328 double-column pages, strongly bound in cloth. Price $17. Also, in five parts, in stout wrappers, price $3 per part.

*Gentlemen who have procured portions of this work during its course of publication are recommended to complete their sets without delay.

The publisher has the pleasure of inviting the attention of the profession to this magnificent work, in the full confidence that it will be found complete in every respect. The names of the author and translator are a sufficient guarantee of its practical value, while no pains or expense have been spared to reproduce the very full series of illustrations in such a manner as to render them equal, if not superior, to anything of the kind as yet produced in this country.

The several parts, as they have appeared, have commanded the unanimous approbation of the medical press, a few extracts from which are subjoined :

It was with unmingled satisfaction that we heard the announcement that the French surgeon's magnificent treatise was to be reproduced in this city, in a style which would be in every respect worthy of the original, and yet which would be offered at such a price as to be readily attainable by every surgeon throughout the whole extent of the United States. The first portions of this splendid book have already formed the subjects of short bibliographical notices in the numbers of this Journal for April and July, 1868. But now that it is complete, and stands before the profession in its goodly proportions as a whole, it becomes our duty to offer our readers a more elaborate and a more critical review of its many

taken pains to compare, and not many fall below the standard of the French plates; so that this atlas must be regarded as a triumph of American chromo-lithography as applied to the illustration of medical objects, and will, we hope, serve as a pioneer.--St. Louis Med. & Surg. Journ., Jan. '69.

The present number completes this handsome work. Too much praise cannot be bestowed upon the publisher for the style and manner in which the work has been produced. It is unsurpassed by any other American publication, and should be in the library of every one who desires to make a thorough study of syphilis.-Leavenworth Medical Herald, Jan. 1869.

and elaborate treatises on venereal diseases ever

and great excellences. The 76 plates of the origi-
nal are here accurately reproduced on 26 plates
containing 145 figures. These we have very care-
fully examined, and have no hesitation in pro-
nouncing them to be the best illustrations of any
medical work in our language with which we are
acquainted. The most splendidly illustrated work
in the language, and in our opinion far more use-
ful than its French original. It is besides fur-
nished at little more than one-half the price of
the French edition, and must, we think, remain
for a long time the most desirable book on vene-
real diseases attainable by the American practi-ject.
tioner.-Am. Journ. Med. Sciences, Jan. 1869.

The fifth and concluding number of this magnificent work has reached us. It treats of constitutional syphilis; and we have no hesitation in saying that its illustrations surpass those of the previous numbers. Very great credit should be given to the publisher for the enterprise and liberality he manifests in incurring the pecuniary risk of reproducing so costly a work. We trust he will be sustained by the profession; and we feel sure that every physician will find these volumes invaluable for reference.-Boston Med, and Surg. Journ., Jan. 14, 1869.

Prof. Bumstead has not only furnished a masterly translation, but introduced very material and necessary improvements. His supervision of the artistic part of the work must have been an arduous and difficult task, for the result is far above the average of similar performances. The last two parts contain a few figures which, to our eye, better represent the affections portrayed in them than the original figures which we have

lent work. We have spoken hitherto of the merits The present number completes this most excelof this work, and can only repeat our unconditional endorsement of it as one of the most complete published. The plates in the present number are, if anything, more elegant than in previous numbers. No physician who pays any attention to this class of diseases can afford to be without this book. Taken in connection with Prof. Bumstead's previous work on the same subject, they would comprise all that is known on this important subThe publisher deserves great credit for the style of the work, it being by far the most elegant medical publication ever issued from the American press.--St. Louis Med. Reporter, Dec. 1, 1868.

This completes the volume, which contains one hundred and fifty beautifully colored figures, which illustrate the whole subject most admirably. Dr. Bumstead has placed the American Medical Profession under lasting obligations by this translation, with his notes and additions. This work upon venereal diseases must rank with the first in the English language, and cannot be excelled in the truthfulness and beauty of its illustrations and in the accuracy and correctness of its teaching. The student must prefer it to all others, since it combines the most modern views of the nature of these diseases, with life-like representations of all their varied appearances; and the general practitioner will give it preference, since at a glance the whole subject is fully open before him. It is a very valuable book, and all who desire to know about the diseases in question should not fail or delay in obtaining it.-Buffalo Med. und Surg. Journ., Nov. 1868.

*Specimens of the text and plates will be forwarded to any address by mail on receipt of 25 cents.

I The size of this work prevents its transmission by mail, except in parts. On receipt of the amount, however, for the volume bound in cloth, it will be sent, freight prepaid, to any point accessible by express in the United States east of the Territories.

HENRY C. LEA, Philadelphia.

CLINICS.

CLINICAL LECTURE.

Clinical Lecture on the Treatment of
Carbuncle. By JAMES PAGET, D. C. L., F.
R. S., Surgeon to St. Bartholomew's Hos-met.
pital.

GENTLEMEN: You have recently had the opportunity of seeing four cases of carbuncle treated in my wards after methods which you would probably describe, if asked to do so, by saying that "nothing was done for them." Here are the patient's papers; and there is, to be sure, no medicine set down for them to take, and you know that no surgery was inflicted on them-and yet a good deal was done for them, though the treatment was what does commonly pass by the name of "doing nothing." They were carefully fed, washed, cleaned, and bedded; and their carbuncles were very

skilfully dressed and washed with proper
things, and every care was taken to shut
out all untoward influences from them.
And if any complication in their cases had
arisen, these would have been immediately
But no complications occurred; and,
therefore, the cases passed through their
course without treatment, as it is said-
that is, without medicine, and with no sur-
gery, no active surgery, no incisions or
anything of that kind. And since all
these cases passed through their course
very favourably, and all the patients were,
or will be, discharged at a comparatively
early time after their admission into the
hospital, I will take this occasion of giving
you some observations on the manner of
treating this disease.

Although you may not have seen much
of it, you must all have heard of the ordi-
nary manner in which carbuncles were

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VOL. XXVII.-3

treated formerly, and still are by some; a life;" self-dissatisfaction, “I did him no method which consists mainly in making good." The truer scientific temper, stands large incisions through them, and giving midway, and says, "I will wait for further very large quantities of food and stimulants, information on the matter-till I have seen as well as considerable doses of quinine, {more cases, and then decide whether, in bark, and other tonics. I do not at all the earliest stages of carbuncle, incisions mean to say that the things which in these are useful or not." After this time of three cases I left undone would have done any or four days I have seen sufficient numbers harm; but what I hold of them is, that of carbuncles thus divided, and have divided they would have been quite useless, and { enough for myself, to say that it will not some would have been sources of great hinder the spreading. I have seen carbundiscomfort to the patients. And in the way cles spread in as large a proportion of cases in which I speak of these things you may after incisions as in cases that have never notice that I exemplify that rule which I been incised at all. I have in my mind a have always impressed upon you, of asking striking case that occurred to me early in yourselves, when you seem to have been practice, when I followed the routine, and, successful with some medicine, "What in a friend of my own, divided a carbuncle would have happened if I had not given most freely. I cut it after the most approved it?" The apparent consequence of giving fashion in depth and length and width, and a medicine may be plain enough; but you{then it spread. After two or three days cannot too often repeat to yourself the question-as a rule, I will not say of practice, but of the study of your own practice-"What and again it was cut as freely. Then it would have happened if this or that, which § seems to have been successful, had not been done?"

more all the newly-formed part was cut as freely as the first, and then it spread again,

Then it is said that carbuncles are relieved of their pain if they are thus very

spread again, and was not cut. Then, in a natural time, it ceased to spread, and all went on well. These are only general imFirst, with regard to the incisions made pressions that I give you, because one canin carbuncles. The ordinary plan, still re-not count the cases in which cutting has commended by some, is, as soon as a car-been practised, and those similar cases in buncle is seen, to make two incisions cru. which it has not; nor even then could it be cially from border to border. It is said that { said whether those in which the cutting they must go even beyond the edges of the was practised would have spread if left carbuncle into the adjacent healthy textures. alone. On a very strong general impresI have not followed that method of practice {sion, however, I say that carbuncles will very often, but I have followed it quite spread after cutting in as large a proportion often enough to be sure that it does not of cases as they will spread in without cutproduce the effects which are commonly ting. assigned to it. It is commonly said that if you will thus make crucial incisions into a carbuncle, you will prevent it spreading. {freely cut. Here, again, however, is only If you can find a carbuncle two or three a partial truth. A carbuncle of two or days old, and cut that right across in both three days' standing, which is hard, tense, directions, I think it very likely that you and brawny, is very painful; and cutting it will prevent it spreading. But even therein will relieve, in many cases, a considerable is a fallacy; for there is no sign by which,{ portion of the pain. But after this, when on looking at a commencing carbuncle, you the carbuncle begins to soften, and when can tell whether it will spread or not, pustules begin to form upon its surface, and whether it will have a diameter of an inch, pus in its interior, it ceases to be painful of or of three, six, or ten inches. The ques-its own accord, and without incisions. tion, therefore, that I spoke of comes back, { Thus there are two distinct stages of car"What would have happened if I had not buncle in reference to the pain; the early made these incisions?" And the answer stage, when it is hard and still spreading, to that question will be rather according to and is generally intensely painful, and the temper than according to knowledge. For latter stage, in which that pain nearly as I watch men in their conclusions upon such cases as that, I generally find that self-satisfaction says, "I saved the man's

ceases. A carbuncle divided in the first stage, in the first two or three days of its existence, may be relieved of some of its

and which now merely remain to be healed
like the cavities of small abscesses. In
that way you narrow greatly the extent of
wounded surface to be healed. Indeed, it
by no means always follows that the whole
carbuncle, or its whole base, sloughs.
Carbuncles, if not divided, not unfrequently
only suppurate about their centres, and
slough only in their central parts, and the
borders merely clear up by the softening
and dispersion of the inflammatory pro-
ducts in them. In every case of that kind
you save greatly the amount of healing
which has to be gone through. Nay, in
some cases carbuncles completely abort.
One of these cases, of which I have the
paper on the table, was that of a woman,
aged sixty-four, who came in with a car-
buncle nearly as large as this, in a condi-
tion which, it might be said, required inci-
sion at once; but, with the exception of
two or three small points, no suppuration
or sloughing ensued. That carbuncle dis-
persed, aborted, cleared away.
This case
shows the more ordinary course of events
the sloughing of the central part, the
gradual discharge of the sloughs, and the
comparatively small spaces which are left
in the centre of the carbuncle as the sole
space in which the process of healing has
to be achieved.

pain; if divided in the later stage, what stance of the carbuncle fairly exposed, and little pain may exist is altogether unaffected also under the necessity of healing. But by the cutting. And even cut as you may, you will observe that the whole of the space you cannot always put aside the extreme that now remains to heal is a series of openpain that a carbuncle sometimes has, evenings in the middle of the carbuncle, through to its later time. Some two or three years which the sloughs are to be separated, ago, I was called to a member of our pro-through which, indeed, nearly the whole of fession with a large carbuncle in the middle the sloughs have already been discharged, of his back. His friends had been much alarmed about the state of his mind, for he had been suffering great mental anxiety for some time, and they were in fear lest the excessive pain of the carbuncle should, in its disturbed state, do his mind permanent damage. So they persuaded me to cut it, and I cut it after the old plan, very wide across, and far into the adjacent textures, as freely as could be. It did not in the least relieve him. I never saw a carbuncle through its whole course so painful as that was, and up to the last, till the healing was nearly completed, he suffered more or less pain in it. So that the conclusion in reference to pain must be this: if they can be divided in the first three or four days, while still hard and brawny, it may relieve some measure of the suffering; at a later period the incisions have no influence at all. The third point is stated thus, that by the incision of carbuncles you accelerate their healing, giving facility for the exit of sloughs. But herein is the greatest fallacy of all. When the cutting of carbuncles was more customary in this hospital than it is now, when I did not cut them, and some of my colleagues did, I used to be able to compare the progress of cases cut and of cases uncut, and time after time it was evident that the cases uncut healed more readily than those cut. A man who is now in the hospital I have brought round here that I may illustrate the point to you. This is the man, Timothy C—, aged fifty five. When he came in, his carbuncle had a length of more than six inches, and a breadth of three and a half; and it formed the ordinary hard, compact, tense, and brawny mass that a carbuncle usually does. It had at that time already taken to suppurate, and little pustules were pointing on the surface. If I had followed the practice of incisions, I should have had to make a The kind of incisions that I have been cut in one direction of about seven inches, speaking of is the old plan of crucial inciand in the other of about five, and after that sions. Another method which I have occaI should have had not only the woundssionally tried, but of which I can only state wide, open, and gaping, and having them- the same general results, is that of subcutaselves to heal, but a great part of the sub-neous incision. This has been supposed to

On these three points, which are the grounds that have been assigned as reasons for cutting carbuncles, I have now given you the evidence on which I have ceased from the practice. I fully believe that cru{cial incisions do not prevent extension; that it is only a limited set of cases in which the incisions diminish pain; and that with regard to the time that is occupied in healing with or without incisions, the healing without incisions is very clearly and certainly a great deal the quicker.

huge carbuncle; and the natural history of it was a history that one would have wished to witness in every carbuncle of its size, for no case could pass through its course in a better method. He led his ordinary abstemious life, took moderate

have the same general effect as the other; amusement, and it was fourteen inches over and I think that the same general conclu- its surface transversely, and nine inches sions may be drawn respecting it: that it vertically—a carbuncle, then, of the largest is a measure unnecessary in the treatment size, and one, it might have been supposed, of carbuncle, and that it retards rather than attended with considerable risk to life. I hastens the healing. When I speak thus urged him very strongly to take a large quanof the incision of carbuncles, however, I{tity of what is called " support," for I was do not mean to say that there is nó condi- at that time under an impression of its netion of carbuncle in which an incision is cessity. He absolutely refused, however, not useful. Sometimes a carbuncle sloughs and nothing would induce him to take it. in its central part, with one continuous I was therefore content to stand by and slough of integument holding in a quantity study the natural history of disease in this of pus. In that case you would cut through the slough, or through any adjacent part of the carbuncle, to let out the pus, as you would open an ordinary abscess. But this is not a measure which is commonly understood by the "incision of a carbuncle." If you ask why one may not cut a car-quantities of food and of stimulant, lived buncle though it may do no good, I reply that you should never be actively useless, and that there are some cases in which the cutting does considerable harm. Carbun- Another case which impressed me very cles, for the most part, occur in persons much was that of a friend of my own in the broken down in health, exhausted by over-profession, who had a carbuncle on the work, or by bad food, or in general dete-back of his neck, of a very considerable riorated health-as sometimes in diabetes size. Sir Benjamin Brodie and Mr. Stanley or albuminuria; and in all these states it is attended him with me, and under their a good general rule to save the blood they advice the carbuncle was cut. I watched need for healing. The loss of blood from its course afterwards, and felt sure that the the carbuncle itself would not be considera-cutting had done neither good nor harm. ble; the hard substance of the carbuncle, It went on as carbuncles do when not cut. when cut into, does not bleed, or bleeds but little. But to carry out the incision perfectly, you have to cut into the adjacent healthy texture; and this sometimes bleeds very profusely, so as to lead to all the distress and pain of plugging the wound with this or that substance to arrest the blood.

through a carbuncle of the greatest severity, and finally made a complete recovery, and lived for several years after.

But the gentleman was subject to intense headaches, of which he knew by experience the only possible remedy was almost entirely to leave off food, and absolutely and entirely to leave off stimulants. One of these headaches occurred during the course of the carbuncle, at a time when we had put him upon very full diet and abun

66

Another measure in the treatment of car-dant stimulant. He said then he must buncles which is supposed to be necessary, leave off his stimulants and food, and we is very high feeding and large quantities of looked with some alarm at what would be stimulants. I learned the opposite of this the result on the progress of the carbuncle. in one of those cases which you will do I remember Mr. Stanley saying to him, in always well to study-those, namely, in his distinct manner, My dear fellow, if which the patient refuses to do what you { you don't take food you will die." Very advise him. It is from such cases that we well," he said, "then I will die, but I will may often learn what is commonly called not take food and increase my headache." the "natural history of disease"-its course According to his own wish, therefore, we undisturbed by treatment. A case occurred reduced his diet to a very low level. The to me once of an old gentleman, eighty course of the carbuncle was not affected at years of age, who had a carbuncle, as big all, unless it were for good; and after three as it could be, on the back of his neck, for or four days of this, which might be called it extended from one ear to the other, and comparative starvation, he described himfrom his occipital spine to the third cervi-self in his own emphatic fashion as being cal vertebra. He measured it for his own "as jolly as a sand-boy."