substance for which it has stronger attractions, and also to become soon dissipated on exposure. Hence, the watery solution is a pretty potent but transient application. Now, this is exactly what we want when we apply carbolic acid to the interior of a wound for the purpose of destroying any germs which may have been introduced into it. We require something that will act with energy for the moment; but which, as soon as it has extinguished the vitality of the septic particles, may disappear from the wound, in order that the tissues may be left free from all unnecessary irritation. The fixed oils, on the other hand, have so strong an affinity for the acid that they will mix in any proportions with it, and hold it so firmly as not to permit it to act with much energy on the tissues, or to become soon dissipated into the atmosphere. Hence an oily solution is comparatively bland but permanent in its operation. These are just the properties which are desirable for an external application. We wish it to serve as a reservoir of the acid, retaining it for twenty-four hours at least, so that it may remain constantly exerting its antiseptic influence upon the discharges that flow out beneath it. At the same time it is most important that it should be mild in its action on the surface to which it is applied, in order to avoid irritation and excoriation. It appears clear, therefore, that a watery solution is best adapted for the treatment of the interior of a wound in the first instance, while an oily preparation is suited for an external dressing.

We have next to consider the best form for the oily application. I have used various forms; of which some have proved trustworthy, and others not so. One that has shewn itself thoroughly reliable is a paste composed, like glazier's putty, of boiled linseed oil and whitening, but with the addition of about one part of carbolic acid to four of the oil. Even in the case of large abscesses, where there has been in the first instance a profuse discharge, the putty, if properly applied and retained securely in position, prevents with perfect certainty the spread of putrefaction into the interior. But the putty is a somewhat clumsy and inconvenient preparation, and I have been desirous if possible, to get rid of it. Within the last few months I have given a full trial to cloths dipped in a solution of carbolic acid in olive oil, but I am sorry to say that this method, though attractive from its simplicity, is not reliable. It is true, indeed, that we have had some beautiful cases under this mode of management; as for example the following.

Case of Compound Fracture of the Right Leg and Severe Contused Wound of the Left Foot, in a Person of Advanced Age.-On the 31st of January last, a woman aged 74 years, was admitted into the infirmary, having been run over by a heavily laden omnibus. The wheels had passed over both lower limbs, producing in the right leg compound fracture of both bones a little above the ankle, with a considerable wound on the outer side of the limb communicating with the broken fibula, and another on the opposite aspect, not directly connected with the seat of fracture. In the left limb the violence had been sustained by the foot, which presented at its inner aspect a large gaping contused wound, four inches long and two inches broad, while the skin was extensively detached, so that when a watery solution of carbolic acid had been introduced at the wound, pressure over the skin at the outer or opposite side caused some of the fluid to escape, showing that it had passed freely over the upper surface of the foot, beneath the undermined integument. She had also a wound on the forehead, two inches long, exposing the os frontis. From these various injuries she had lost a great deal of blood, and she was also suffering from contusions in other parts of the body. All the wounds were dressed with layers of lint soaked with a solution of carbolic acid in olive oil; the superficial layer, larger than the rest, being changed daily while the deeper layers were left undisturbed. Under this treatment the wound on the forehead healed without the formation of a drop of pus, and those in connection with the compound fracture were converted into superficial granulating sores, without any more disturbance, local or constitutional, than if the fracture had been a simple one; and the bones united in the usual period under the use of pasteboard splints. But the most remarkable circumstance in the case was the progress of the injury of the foot. Three

days after the accident, my house-surgeon, Mr. Appleton, observed that a considerable portion of the undermined skin on the dorsum of the foot had lost its vitality; and instead of adopting the usual course of applying wet lint or a poultice till the slough should separate, he extended the antiseptic dressings so that they over-lapped the dead portion of tissue for a considerable extent in every direction; after which, the daily changing of the superficial layer was continued as before. The result, though in strict accordance with the principles which I am endeavouring to enforce, was strikingly opposed to ordinary experience. After the subsidence of the copious sanious effusion which took place immediately after the injury, the discharge became reduced to about one minim in twenty-four hours, without any distinct appearance of pus, while the foot remained free from the slightest uneasiness, so that she moved it as usual in the bed, and imagined it perfectly recovered. Such being the case, knowing as I did, that to remove the deep dressings would be to induce, at the best, two large granulating sores which must, from that time forward, furnish a considerable amount of pus that would act as a drain upon the old lady's feeble system, I left the crust of lint and dried exudations untouched for seven weeks, at the end of which time it became spontaneously detached. On raising it, we found a narrow line of cicatrix along the inner side of the foot, complete healing by scabbing having occurred in, I suppose, the largest wound ever known to heal in that manner in the human subject. And on the dorsum of the foot, in place of the large slough, was a broad scar, a portion in the centre about as large as a fourpenny piece alone remaining unhealed; the dead tissue having, apparently, been absorbed, as none of it was found on the dressing. The superficial layer of antiseptic lint daily renewed, had answered the purpose of preventing putrefaction from spreading inwards, while the thickness of the permanent crust had kept the carbolic acid constantly supplied externally from penetrating to its deepest parts. Hence, the portion of the dressing in contact with the skin, having lost its original acid by diffusion into the circulation, before sufficient time had elapsed for granulation and suppuration to take place under the stimulating influence of the antiseptic, became a perfectly unirritating or neutral body, and the dead portion of tissue beneath it, being in like manner destitute of any stimulating properties, became amenable to absorption, like the bit of the external coat in the noose of the antiseptic ligature, or the dead bone in the case of necrosis, above related.

But, while I have mentioned this case as a good example of the behaviour of severe injuries under antiseptic management, I wish it to be distinctly understood that I do not recommend the mode of dressing adopted. For, as I have already stated, and as bitter experience in some other cases has but too clearly convinced me, it cannot be implicitly relied on. The reason why it. is less trustworthy than the putty is sufficiently plain. The lint, being porous, absorbs the discharge, which, as it enters, displaces the antiseptic oil, and may thus, if profuse, establish a channel of putrescible materials from the external atmosphere to the wound. Again, when the discharge has passed through the dressing, even though it have been imbued with carbolic acid in its passage, it gives it off into the atmosphere on exposure, when it becomes again liable to putrefaction, and, having putrefied, may soak back into the porous dressing, and deprive it entirely of antiseptic virtue. For carbolic acid and the products of putrefaction exert a powerful chemical action upon each other; and, on this account, the former is a deodorant as well as an antiseptic, and, conversely, the latter, if in sufficient quantity, neutralize the acid and render it inert. In this way, I have known a dressing, consisting of several layers of the oiled lint, lose all odour of carbolic acid and acquire that of decomposition within twenty-four hours of its application.* The putty, on the other hand, being impermeable to the discharge,

* If fresh oil is assiduously supplied at short intervals by night as well as by day, this objection to oily cloths as a dressing is removed. But this would in many cases be impracticable; and, as a general rule, it is obviously undesirable, from the trouble and uncleanliness involved in it. There are situations however, such as the perineum,-in which this is probably the best mode of management. And it may be added that, in any case where the discharge is very trifling, oiled lint, changed once in twenty-four hours, will prove sufficiently reliable.

retains the carbolic acid securely stored up, except in so far as it is exhaled from the surface to maintain a constant antiseptic action upon the blood, serum, or pus, that flows out beneath.

Impermeability to a watery fluid being thus evidently the essential cause of the superior efficacy of the putty, the chalk, which is its chief constituent, being of no other use than to give consistency to the mass, it naturally occurred to me that, if the oily vehicle of the carbolic acid were in a solid form, the chalk might be dispensed with, and the advantages of the putty might be obtained in a less bulky and more convenient form. I tried, in the first place, various kinds of emplastra; but these appeared objectionable on account of their adhesiveness, which is greatly increased by the admixture of carbolic acid, and which seemed likely to be mischievous by retaining the discharge. I next employed paraffine, mixed with a little wax to give it tenacity, and a little olive oil to confer the requisite softness. This certainly made, under ordinary circumstances, an effective as well as elegant substitute for the putty, being perfectly devoid of adhesiveness, while a comparatively thin layer proved secure by antiseptic. But the paraffine cerate had this great disadvantage, that, in situations where it was subjected to much movement, such as the groin, it was apt to crumble down and become useless. Meanwhile I learned that Dr. Watson, of Edinburgh, was employing soapplaster mixed with carbolic acid, and that, though adhesive, it appeared to work well; the discharge finding its way out beneath it. Thus I was again induced to try emplastra; and of late we have been using what seems to answer admirably; viz., emplastrum plumbi mixed with one-fourth part of bees-wax to give it sufficient consistence, the carbolic acid being in the proportion of about one-tenth of the whole.* This is used as a plaster spread on calico in a layer of about one-twentieth of an inch thick, and I can recommend it as thoroughly reliable. There is a case which I am dressing with it at the present time, which I may mention on account of its interest otherwise.

Case of Old Fracture at the Ankle with Fixed Displacement of the Foot, Rectified by Aid of the Antiseptic System.-A young man, aged 29, was engaged in mooring a vessel on the 11th December, 1867, when one of the massive ropes, used for the purpose, slipped and struck him with violence at the outer and posterior aspect of the ankle, fracturing the fibula about two inches above the joint, and breaking off the internal malleolus at its base, driving the bones of the leg forwards and inwards with respect to the foot, or, in other words, producing displacement of the foot backwards and outwards. Four months after the receipt of this injury he came under my care in the infirmary, with the heel very prominent and the foot greatly everted, and firmly fixed in its abnormal position by osseous union of the fragments.

In making the plaster with the ingredients mentioned in the text, the emplastrum plumbi and the bees-wax are melted and mixed together, and allowed to cool, till the liquid begins to thicken; the carbolic acid is then added and stirred in, which has the effect of bringing back the mass into the state of a thin liquid, which is assiduously stirred till it thickens, to prevent the wax from separating in granules. This plaster, is, however, inconveniently soft, and cannot be kept spread in stock. have since found that by increasing the proportion of litharge, the lead-soap may be made of any degree of firmness that may be desired, provided that water be not used in the manufacture. When the litharge and olive oil are in the proportions directed by the Pharmacopæia, a certain quantity of water must be added to promote the combination of the fatty acids with the oxide of lead, and even then the process is a very tedious one. But it is an interesting fact chemically, that if the litharge is used in about four times the pharmacopoeial proportions, although no water be employed, the combination proceeds under a brisk heat with great rapidity. It is upon this fact that the following method of manufacture is based.

Take olive oil, 12 parts by measure; litharge (finely ground), 12 parts by weight; bees-wax 3 parts by weight; crystallised carbolic acid, 2 parts by weight. Heat half the oil over a slow fire; then add the litharge gradually, stirring constantly till the mass becomes thick or a little stiff. Then add the other half of the oil, stirring as before till it becomes again thick. Then add the wax gradually till the liquid again thickens. Remove from the fire and add the acid, stirring briskly till thoroughly mixed. Cover up close and set aside, to allow all the residual litharge to settle; then pour off the fluid, and spread upon calico to the proper thickness. The plaster made in this way can be spread by machine and kept rolled up in stock; and, if in a well fitting tin canister, will retain its virtues for any length of time. This I believe to be the most perfeet form in which an antiseptic lead-plaster can be obtained. It is supplied at a very moderate price by the New Apothecaries' Company, Glassford street, Glasgow. For almost all purposes, however, it is superseded by the lac plaster, which will be found described in the succeeding part of this address. These improvements in the materials for dressing have occupied a much longer time than I had anticipated; and have been the cause of the delay in publication.-J. L.

In this condition the limb was absolutely useless, and the question arose whether anything could be done to restore it. It was clear that the foot could not be replaced without breaking through the "callus" which could be plainly felt in both bones, and there seemed no prospect of being able to do this without cutting down and adopting means which, in the case of the tibia, would necessarily involve opening into the articulation, or producing artificially a compound fracture into the ankle joint. This I certainly should not have dreamed of doing without the aid of the antiseptic system, being well aware of the disastrous course such injuries commonly run under ordinary management. If I had operated at all, I should have made a point of removing the end of the tibia, and even then I should have felt that I was subjecting the patient to some risk. But feeling confident that I had the means of converting a compound fracture into a simple one, I did not hesitate to adopt the following procedure. On the 11th inst. (April 1868), the man being under the influence of chloroform, I made a curved incision behind and below the prominent end of the tibia; and, a solution of carbolic acid in about four parts of olive oil being dropped into the wound during the progress of the operation, I detached the soft parts from the bone sufficiently to enable me to insinuate behind the callus one blade of a pair of cutting pliers, smeared with the same oil, and then having placed pieces of lint, soaked with the oil, around the blades of the pliers, so as to prevent the chance of septic air entering the joint when the bone should give way, divided the callus, and at once covered the wound with the antiseptic lint. I then made a longitudinal incision over the seat of fracture in the fibula, and divided it with similar precautions. Having thus overcome the obstacle presented by the bones, I proceeded to draw the foot towards its proper position by pulleys acting upon its outer and posterior part through the medium of a skein of worsted passed round it, while a padded belt supported the opposite aspect of the leg above the ankle: the wounds being kept carefully covered with the oiled lint. When a considerable amount of force had been used there was a sudden sensation of something giving way; and now, on removing the apparatus, the foot was found to have resumed its natural place. The wounds were then dressed with layers of lint soaked with a weak oily solution of carbolic acid, and covered with the antiseptic plaster; after which, a Dupuytren's splint was applied at the inner side of the limb to prevent eversion, and Mr. Syme's horse-shoe splint anteriorly to obviate the tendency to displacement backwards. Fresh plaster has since been applied daily; and the result has been that, while the foot has retained its position satisfactorily, the patient has not suffered at all either locally or constitutionally, during the six days that have elapsed since the operation. His pulse has remained 68 or 70, he has not lost his sleep a single night, his tongue has been quite clean, and his appetite good. In fact, he has taken his food with better relish than before, because he has been freed from his previous gloomy prospect of hopeless lameness, while the operation has caused him no anxiety; as the assurance which I felt justified in giving him, that it was entirely free from danger, has been confirmed by the absence of pain or other annoyance. The discharge which was sanious and copious in the first instance, has of late been only about three minims of clear serum in twenty-four hours; and judging from our previous experience with compound fractures, there is every reason to expect that in a few days more it will cease entirely.

[The subsequent progress of the case has been, on the whole, very satisfactory. But for reasons to be soon referred to, healing by scabbing did not take place as was anticipated. The discharge instead of drying up, showed rather a disposition to increase, and assumed a somewhat puriform character; and, although the renewal of the superficial plaster once in two or three days did not involve much disturbance of the limb, I thought it best to expose the wounds when sufficient time had passed to ensure the secure coalescence of their deeper parts. Accordingly, on the 1st of May I removed the lower portions of the dressings, disclosing two superficial granulating sores, with very prominent granulations which explained the want of disposition to cicatrise. These, though treated with astringents, proved rather indolent, so

that they were not completely healed till the 4th of June, though the bones were firmly united a fortnight before.

When he was allowed to walk, though he placed the sole fairly on the ground, he experienced inconvenience from a contracted state of the sural muscles, produced by the long continued displacement of the foot backwards and consequent downward pointing of the toes, so that he could not bend the ankle beyond the right angle at which it had been maintained since the operation. I hoped that this inconvenience would be overcome by exercise; but in this I was disappointed; for though his power of walking improved, it was by no means satisfactory. It also appeared that the abnormal position of the foot had led to an exaggeration of the curve of its arch, to such an extent as to make the foot half an inch shorter than the other, while the plantar fascia was felt as a rigid band. I therefore divided that fascia and the tendo Achillis subcutaneously on the 26th of July, and this had the immediate effect of restoring the foot to its natural length, and permitting the ankle to be bent at an acute angle. Had I the case to treat over again I should perform the tenotomy at the same time as the main operation. But except the loss of time that has occurred, the result is nearly all that could be wished. Under the use of a Scarpa's shoe he has continued to improve steadily, and when I last saw him, in the early part of September, he could walk firmly and well, and complained only of some remaining stiffness of the ankle.]-British Medical Journal, July 18, and Oct. 31, 1868, pp. 53, 461.

46. A SUPPOSED PSOAS ABSCESS OPENED IN MR. LISTER'S METHOD.

Case under the care of Mr. CHRISTOPHER HEATH, at University College Hospital.

The case was that of a young woman who was sent to the hospital to have a psoas abscess opened. She was the subject of angular curvature of the spine, and on the inner side of Scarpa's triangle there was a soft fluctuating swelling, which received a distinct impulse on coughing, and increased in tension when pressure was made between the umbilicus and Poupart's ligament. No doubt was therefore entertained about the diagnosis. The operation was performed in strict accordance with Mr. Lister's directions; the kuife was dipped in carbolic acid, and after the fluid had escaped a pad of lint soaked in carbolic acid and oil was immediately applied. The contents of the tumour proved not to be purulent, but consisted of serous fluid tinged with blood. The result of the treatment by the carbolic acid was most successful, no inflammatory action being excited, and no pus formed. As the fluid is gradually accumulating again, it is proposed to repeat the tapping with the same precautions.-Medical Times and Gazette, July 4, 1868, p. 5.

ORGANS OF CIRCULATION.

47.-ON TORSION OF ARTERIES.

By Dr. G. M. HUMPHRY, F. R. S., Surgeon to Addenbrooke's Hospital, Cambridge.

[The principle of torsion and of the ligature is the same, namely the rupture of the brittle inner and middle coats of the vessel by a force which leaves the tough outer coat unimpaired. By the ligature the coats are divided evenly and cleanly, by torsion the division is irregular, and is more properly a laceration.]

Entertaining so high an opinion of the ligature, I was long unwilling to resort to any other plan. Still, I could not be insensible to the importance of improving our treatment of wounds, and to the effect which the ligature threads and the strangulated portion of tissue included in each knot must have