fit from its application to such internal cicatrices as give rise to inconvenience. Of these, the most distressing and obstinate is the stricture following injury to the urethra. It may be dilated, very often, readily, but soon returns, unless constantly under supervision. Dilatation simply stretches the cicatrix, without in any way depriving it of that contractile power which is the essence of the disorder.

Some patients may be instructed how to introduce an instrument for themselves, but such a course, for obvious reasons, is not of universal application. Others may be permanently relieved by proceedings of a more strictly operative character, and with comparatively little danger; but from these we find they sometimes shrink. It is to meet such cases that I would suggest the use of belladonna.

The most convenient way of applying it is with the Oleum Theobroma of the Pharmacopoeia, which is sufficiently hard at ordinary temperatures to permit of its ready introduction into the urethra. I generally recommend two grains of the extract of belladonna to be used in this way twice a day, in conjunction with the regular introduction of the metallic bougie in gradually increasing sizes; the belladonna should be persevered in for some time after the bougies have been discontinued.

Very great and, I believe, permanent benefit has resulted from this plan of proceeding, and in cases where the bougie treatment alone had previously only effected but very temporary relief. I may also add that my observation is confirmed by others, who have given this plan a trial.

Administered internally, belladonna is one of the most valuable anodynes we possess, and it appears to me to be specially applicable to disorders of the urinary system. In reference to its alkaloid atropine, Dr. Anstie remarks, in the first number of the Practitioner, "that it is incomparably the best of all medicinal remedies for every kind of pain in the pelvic viscera. Nothing can approach it in this respect."

The rapidity with which the alkaloid atropia is eliminated from the system is very remarkable. Dr. John Harley, in his Gulstonian Lectures, mentions that he had repeatedly demonstrated the presence of atropia in the urines of different individuals, eighteen, nineteen and twenty minutes after the subentaneous injection of the forty-eighth and even the ninety-sixth of a grain of sulphate of atropia."

In addition to the general narcotic effects exercised by the drug, the actual presence of the alkaloid in the urine may further explain the benefit following its administration in urinary affections.

The inconveniences attending the use of belladonna are slight, compared with those of opium and other narcotics; the appetite is not interfered with, and, beyond sometimes a little temporary dimness of vision, no cerebral unpleasantness is experienced.

The cases in which the remedy is generally applicable are those which may be classified under the generic term of "irritable bladder." Its use may be advantageously continued, in conjunction with other expedients, for the removal of any exciting causes that may be present, such as the dilatation of strictures, removal of calculi, and other sources of irritation.

There is a form of irritation not unfrequently observed, both in males and females, more especially the latter, where there is great irritability, accompanied with the deposition in the urine of large quantities of epithelium. The symptoms sometimes resemble those of calculous disorders, but on iatroducing s sound, a roughened condition of the lining membrane is alone detected. These almost invariably do well under the influence of belladonna. The nocturnal incontinence observed in delicate children, in nearly all cases the results of a simply irritable bladder and nervous system, do well with small doses of atropine combined with general hygienic measures.

Ia reference to the mode of administration, I have little to add. I generally prescribe the extract of belladonna in grain doses, once or twice a day, in the form of pills; or the solution of atropine, 1-80 of a grain to 1-50. very gradually increased, until a slight degree of atropism-dryness of the throat, or dimness of vision-is produced.-Liverpool Medical and Surgical Reports, Oct. 1868,

2. 136.

SURGERY.

BONES, JOINTS, ETC.-AMPUTATIONS, FRACTURES, DISLOCATIONS. 41.-ON LIGATURE OF ARTERIES ON THE ANTISEPTIC SYSTEM. By JOSEPH LISTER, Esq., F. R. S., Professor of Surgery in the University of Glasgow. [The danger of secondary hemorrhage, when the ordinary ligature is used, arises from putrefaction, whereby the tissue of the vessel is softened and rendered friable.]

The Antiseptic System places this branch of surgery, like most others, in a new light. One point which it has brought out in striking relief is that a portion of dead tissue is not necessarily thrown off by suppuration, but, unless altered by putrefaction or artificially imbued with stimulating salts, serves as pabulum for the surrounding living parts, which remove it by a sure process of absorption. Hence the death of a portion of the external coat included in the ligature does not of itself render it a cause of suppuration. And I conceived that if a silk thread, steeped in some liquid capable of destroying the septic organisms in its interstices, were tied round an artery, and left with short-cut ends in a wound dressed antiseptically, the foreign body, soon losing, by diffusion into the circulation, the stimulating salt with which it was saturated at the outset, and being in its own substance as unstimulating chemically as a pellet of lead from a fowling-piece, would either remain, like the latter, permanently encapsuled, or itself experience absorption together with the dead tissue in its grasp. In either case, being destitute of irritating properties, it should leave the primitive strength of the arterial coats unimpaired; when the objection to tying near a large branch would cease to exist. The wound meanwhile would, under proper management, close rapidly, without any deep-seated suppuration, and would be efficiently protected against the evil influences of impure atmosphere. In short, the ligature of an arterial trunk in its continuity would be brought to a state of perfection.

I have subjected these theoretical views to the test of experience, and though the results have not turned out in all respects exactly as I had anticipated, yet those finally arrived at appearing satisfactory, I now present to the readers of the Lancet an account of all that I have done in the subject.

Case of ligature of the carotid artery in the horse with silk thread, on the antiseptic system.-On the 12th of December, 1867, I tied the left carotid artery of a horse in the middle of the neck with a piece of "purse silk" saturated with a strong watery solution of carbolic acid, cutting the ends short and dressing the wound antiseptically. Healing toc place without any suppuration, and with remarkable absence of swelling or tenderness. Nearly six weeks after the operation I investigated the parts. On laying open the vessel, I found at the cardiac side of the ligature a firm adherent clot an inch and a quarter long; but at the distal side coagulation had been entirely prevented by the reflux current of blood through a branch about as large as the human vertebral, which took origin as close to the ligature as was possible. Under such circumstances secondary hemorrhage would necessarily have occurred had the thread been applied in the usual way. Here, however, the artery appeared as strong at the part tied as elsewhere. The cul de sac showed indeed some irregularity, in consequence of the puckering of the internal and middle coats; but the surface appeared completely cicatrised, and presented

the same character as the natural lining membrane of the vessel; and the ligature, which seemed as yet unaltered, was found lying dry in a bed of firm tissue; that within the noose being apparently a new formation in place of the portion of external coat killed by the tightly tied thread; while, externally, the constriction necessarily caused in the first instance by the operation had been filled in by a similar compact structure.

Thus far experience had proved precisely in accordance with my expectations, so that I felt justified in carrying a similar practice into human surgery.

Case of ligature of the external iliac artery with silk thread, on the antiseptic system. On the 29th of January, 1688, I tied the left external iliac artery in a lady, fifty-one years of age, on account of an aneurism of the upper part of the femoral, as big as a large orange, and reaching somewhat above Poupart's ligament. I was informed that it had existed for four years, growing more rapidly of late, and causing severe agony, which had made her keep entirely to bed for the last few weeks, and had deprived her of her appetite, and reduced her strength. A silk thread was applied, as in the last case, except that it had been steeped for two hours in undiluted liquid carbolic acid instead of the watery solution, to make sure of the destruction of all septic organisms lodged in its interstices. The wound, being dressed antiseptically, became superficial without suppuration, the patient meanwhile experiencing no febrile disturbance, her appetite returning as soon as the sickness from chloroform subsided. On the fourteenth day she sat bolt upright in bed without inconvenience. Four weeks after the operation, the superficial sore being completely cicatrised, she was allowed to walk about her room; and just six weeks from the date of the application of the ligature she went down three flights of stairs and walked for some time in the streets, and then up again to her room without over-fatigue. The aneurism was free from pulsation, and much reduced in size.

She continued for about ten months in fair health and strength; but, in the latter part of November, became affected with a peculiar spasmodic disorder of the respiration, and on the morning of the 30th of the month, while sitting up in bed, she suddenly exclaimed that something had given way within her, and that she was dying, and then immediately expired. Next day I made a post mortem examination, when the idea which she had expressed proved correct, an aneurism of the descending part of the aorta having given way, and discharged an enormous quantity of blood into the mediastinal and subpleural cellular tissue. The parts concerned in the operation having been removed and dissected, the following appearances were disclosed :-The aneurism was not entirely obliterated; but remained about the size of a cherry or a large filbert, of somewhat fusiform shape. The upper two-thirds were solid, being occupied by firm coagulum incorporated with the sac. The lower third, situated just at the bifurcation of the common femoral, had been kept free from coagulation by the regurgitant stream of blood from the profunda into the superficial trunk. This part of the sac appeared constituted by the wall of the vessel, very slightly distended. The external iliac artery was considerably shrunk throughout, and tapered from each end to near the middle, where it was only about a twentieth of an inch in diameter. In the greater part of its length the structure of the dwindled vessel could be distinctly recognised, with adherent coagula in the interior, decolorised and otherwise altered. But at the narrowest part the artery was reduced to mere fibrous tissue, constituting a dense white band five eighths of an inch long, from the middle of which was seen projecting at one side a round, buff-coloured appendage about a line in diameter, somewhat obscured by a trifling amount of inflammatory condensation of texture in the immediate vicinity. On scratching this little body with the point of a knife, I found it to be a very thin-walled capsule, containing the knot of the ligature, with two tapering ends, which were shorter than the thread was cut at the operation, while the noose had vanished altogether. The surface of the knot also showed clear indications of having been subjected to an eroding agency, similar, no doubt, to that exerted by granulations upon dead

In

bone absorbed by them. Besides the remnant of the ligature, the tiny capsule contained a minute quantity of yellowish, semi-fluid material, looking to the naked eye like very thick pus. Under the microscope, however, puscorpuscles were seen to form but a small proportion of its constituents, which were principally rounded corpuscles of smaller size, and fibro-plastic corpuscles, together with some imperfect fibres and granular material. addition to these elements were some which at first puzzled me; but which turned out to be fragments of silk fibre, of various lengths, and of jagged, tapering, or otherwise irregular forms, and many of them greatly reduced in thickness, contrasting strongly with the uniform bands of a fresh piece of silk from the same reel that had furnished the ligature.

Mingled with the puriform fluid were also some delicate filaments of silk, visible without the microscope; and these seemed to retain their natural elasticity. Nor was there anything about the more minute pieces into which the fibres had been so finely chopped up, to indicate that they were undergoing a process of solution or softening by the fluid that soaked the thread. They had rather the appearance of having been superficially nibbled so to speak; confirming the impression conveyed by the naked-eye characters of the knot, that the silk had been eroded by the absorbing action of the surrounding parts. Indeed, considering the organic origin of silk, the remarkable thing seems to be, not that it should be absorbed by the living tissues, but that it should resist their influence so long.

Why it was that the parts in immediate contact with the silk should have assumed so imperfect a structure is a difficult question, but one of great interest because, although that structure could not be called pus, it was certainly a very near approach to it; and it is impossible to say that we had not here an incipient abscess. There could be no doubt that the presence of the thread was in some way or other the cause, and I think we can hardly be wrong in assuming that, in order to give rise to such degeneration of tissue, it must have operated as a persistent, if trifling, source of abnormal stimulation. Now, as putrefaction is here out of the question, and as the substance of silk is not chemically stimulating, we seem shut up to the conclusion that the thread must have occasioned disturbance of a mechanical nature. Further, the effect in question seems to be essentially connected with the disintegration of the silk. For in the horse's carotid the silk ligature, having remained unaltered during the six weeks that had passed after the operation, was found surrounded on all sides by compact tissue; and in the present case, so long a period as ten months having elapsed before the puriform condition was observed in an apparently incipient stage, it is probable that the thread had lain for a long time inert, producing irritation only when partially absorbed. If then we inquire how disintegrating silk could prove a source of mechanical irritation, it seems not improbable that it may have been from the sharp and jagged fragments of the fibre perpetually fretting the elements of the living tissue around them. This view, if correct, would explain the curious fact observed by Lawrence and others, that when fine silk ligatures had been left with short-cut ends in a stump, though the wound might heal without their separation in the first instance, they were liable to make their appearance subsequently, sometimes at so late a period as seems to exclude the idea of putrefaction having occurred from organisms introduced in the threads. Indeed such ligatures occasionally showed themselves encapsuled in little nodules in the cicatrix, without suppuration occurring at all. In other words, the apparently soft silk, instead of remaining like a smooth leaden pellet permanently imbedded in the place where it was first introduced, made its way to the surface, with or without suppuration, like a sharp spiculum of rigid glass; the silk being in its minute structure comparable to the lead when in the primitive condition of smooth continuous fibres, and to the glass spicula when in the form of jagged fragments as the result of partial absorption.

But whatever may be thought of this explanation, it is clear that if there is any chance of silk, though used antiseptically, giving rise, even in exceptional cases, to abscess in the vicinity of an artery tied with it, this is a

serious objection to its employment; and as the near approach to suppuration in the present instance was undoubtedly occaisoned by the persistent presence of the thread, the case, while interesting as affording evidence that silk is susceptible of absorption, suggests the expediency of substituting for that material some other substance which can be more readily taken up by the tissues.

The use of "animal ligatures," of cat-gut leather, or tendon, was long since tried and abandoned as unsatisfactory; but after the experience which the antiseptic system has afforded of the disappearance, without suppuration, of large dead pieces of skin and other textures, there could be little doubt that threads of animal tissue, if applied antiseptically, would be similarly disposed of.

And even if chemical processes should have been used in preparing such threads, it did not seem likely that this would interfere with their absorption; for I knew that the free action of carbolic acid on blood and sloughs had no such deterring influence, and I have long been satisfied that the injection of a strong solution of perchloride of iron or tannic acid for the cure of nævi produces subcutaneous sloughs, which are imbued with the ingredients injected, and yet disappear, as a rule, without the formation of pus.

In order to put the antiseptic animal ligature fairly to the test, I made the following experiment:

Ligature of the carotid artery in the calf on the antiseptic system, with threads composed of animal tissue.-On the 31st of Dec., 1868, I tied the right carotid artery about the middle of the neck in a healthy calf a few days old, the animal being under chloroform. Ligatures of two different kinds were employed, at an interval of about an inch and a half, the sheath of the vessel being left undisturbed in the intervening part. The cardiac ligature was of home manufacture, composed of three strips of peritoneum from the small intestine of an ox, firmly twisted together into a three-fold cord. The distal thread was of fine catgut, called "minikin gut" by the London makers. Both had been soaked for four hours in a saturated watery solution of carbolic acid, which swelled and softened them, so that the thread of my own making was too large to enter the eye of the aneurism needle except near the ends, where it was thinner than elsewhere. This substantial ligature bore the strain of tying well, but the fine catgut broke as I tightened the noose. I did not, however, remove it, but, having a second piece at my disposal, passed it round at the same place, and with gentle traction completed the knot. There were thus two ligatures of the gut at the distal side. All were cut short, except one end of the catgut, which I purposely left about three-quarters of an inch long, to give a better opportunity of ascertaining what would become of the foreign material. The antiseptic arrangements were as follows:-Before the operation the hair of the part was cut short, and a solution of carbolic acid in four parts of linseed oil (preferred for its cheapness) was rubbed well into the skin, to destroy any putrefactive organisms lying amongst the roots of the hairs, for any so situated might escape the action of the external antiseptic dressing, and communicate putrefaction to the discharges, and thence to the interior of the wound. The sponges used in the operation were wrung out of a watery solution of the acid (1 to 40), and all instruments introduced into the wound, together with the fingers of my left hand and the copper wire used for sutures, were treated with the same lotion, some of which was poured into the wound after the introduction of the last stitch, at one of the intervals left for the escape of discharge, to make sure against the chance of any fresh blood which had oozed out during the process of stitching having regurgitated and taken living germs in with it. The external dressing was a towel saturated with the oily solution, folded as broad as the length of the neck, round which it was wrapped so as to extend freely beyond the wound in all directions, prevented from slipping backward and forward by being stitched to a halter round the head, and to a girth behind the forelegs, while the bandage rolled round it kept it applied accurately to the surface. A sheet of guttapercha tissue, to prevent contamination of the antiseptic towel from without,