that it retards rather than hastens the healing. When I speak thus of the incision of carbuncles, however, I do not mean to say that there is no condition of carbuncles in which an incision is not useful. Sometimes a carbuncle sloughs in its central part, with one continuous slough of integument holding in a quantity 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 carbunale."

If you ask why one may not cut a carbuncle 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. Carbuncles, for the most part, occur in persons broken down in health, exhausted by over-work, or by bad food, or in general deteriorated health-as sometimes in diabetes or albuminuria; and in all these states it is a good general rule to save the blood they need for healing, The loss of blood from the carbuncle itself would not be considerable; the hard substance of the carbuncle, 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.

Another measure in the treatment of carbuncles which is supposed to be necessary, is very high feeding and large quantities of stimulants. I learned the opposite of this in one of those cases which you will do always well to study-those, namely, in which the patient refuses to do what you advise him. It is from such cases that we may often learn what is commonly called the "natural history of disease "-its course undisturbed by treatment. A case occurred to me once of an old gentleman, eighty years of age, who had a carbuncle, as big as it could be, on the back of his neck, for it extended from one ear to the other, and from his occipital spine to the third cervical vertebra. He measured it for his own amusement, and it was fourteen inches over its surface transversely, and nine inches vertically-a carbuncle, then, of the largest size, and one it might have been supposed, attended with considerable risk to life. I urged him very strongly to take a large quantity of what is called "support," for I was at that time under an impression of its necessity. He absolutely refused however, and nothing would induce him to take it. I was therefore content to stand by and study the natural history of disease in this 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 quantities of food and stimulant, lived through a carbuncle of the greatest severity, and finally made a complete recovery, and lived for several years after.

Another case which impressed me very much was that of a friend of my own in the profession, who had a carbuncle on the back of his neck, of very considerable size. Sir Benjamin Brodie and Mr. Stanley attended him with me, and under their advice the carbuncle was cut. I watched its course afterwards, and felt sure that the cutting had done neither good nor harm. It went on as carbuncles do when not cut. 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 on full diet and abundant stimulant. He said then that he must leave off his stimulants and food, and we looked with some alarm at what would be the result on the progress of the carbuncle. I remember Mr. Stanley saying to him, in his distinct manner, "My dear fellow, if you don't take food, you will die." "Very well," he said, "then I will die, but I will not take food and increase my headache." According to his own wish, therefore, we reduced his diet to a very low level. The course of the carbuncle was not affected at all, unless it were for good; and after three or four days of this, which might be called comparative starvation, he described himself in his own emphatic fashion as being "as jolly as a sand-boy."

Since that time I have watched carefully all cases that I have seen, and I am certain that there is no good to be obtained by large feeding or abundant stimulants in ordinary cases of carbuncle. The whole of these cases that have been in the hospital were put on our ordinary meat diet, with a pint of porter daily; and I see that two of them have had four ounces of wine a day, one of these being a person aged 64 and the other 63, and both having carbuncles of considerable size. You will find that for patients in private life it will do very well if you tell them that they may have about two-thirds of their ordinary amount of food, and about the same proportion of their ordinary quantity of stimulants. But indeed there is scarcely any reason to change in any material degree the ordinary mode of life of a patient with carbuncle. So far as he can with comfort take that to which he is accustomed, so far he may. If his diet has been habitually low, so it may remain; if habitually high, so, within certain limits and somewhat reduced it may still

remain.

Now you may ask what I should set down as the things to be done for a carbuncle. These boards, nearly bare as they are, may tell you. In local treatment one of the best things you can do, if the carbuncle is small, is to cover it with emplastrum plumbi spread upon leather, with a hole in the middle through which the pus can exude and the slough can come away. That, occasionally changed, is all the covering a small carbuncle will need. It is difficult thus to cover the whole surface of a large carbuncle, and to keep it clean; therefore, I think that the best application for that is the common resin cerate. This should be spread large enough to cover the whole carbuncle, and over it should be laid a poultice of half linseed-meal and half bread. And, if you want to exercise your skill, learn to make that poultice well, and to put it on well, and to keep it in its place well. That mode of dressing the carbuncle, so far as the materials are concerned, will last through its whole course: but whilst the carbuncle is making progress and discharging its slough, you will find plenty of room for the exercise of considerable skill in dressing it, and filling up the cavities with soft substance spread with this ointment. Besides this, the carbuncles are to be carefully washed, and especially with some deodorising substance, as Condy's fluid, or weak carbolic acid, and the cavities may be syringed out with it. The importance of cleanliness is very great. You noticed in the man I showed you just now the spots of acne and boils round the edges of the carbuncle. This points out the necessity of care, which I suppose had not been taken there, to keep the surface of the skin adjacent to the carbuncle perfectly dry, and free from any contact with the discharge, which seems really to have the power of infecting the neighbouring skin, and so producing the boils which are apt to arise, sometimes in clusters, around the carbuncle. Of diet I have already spoken to you. Of medicines I say nothing. Quinine, bark, and other medicines of that class, may be given if you please, or in case of evident need, and so many aperients; but there is really no need of them in an ordinary case of carbuncle. But there is one medicine which you may find very valuable, and that is opium, especially in all the earlier painful stages of carbuncle, in which it relieves the suffering as thoroughly as incisions, or any thing I know. After the early stages, even that is unnecessary, except for some patient who may be unable to sleep.

But there is one measure in the treatment of carbuncle which is seldom employed, and yet is of great importance, and that is letting the patient have very free air. The general idea that carbuncles are very dangerous diseases has commonly led to the patients being entirely confined to bed and kept shut up in their rooms. There is in that an unnecessary care; and this, too, I learned from a patient who refused to comply with injunctions-a gentleman with a large carbuncle on the back of his head, who would not keep his bedroom. He had been accustomed to an active life, and after seventy or eighty years of that custom he was quite indisposed to remain in his room. So with that carbuncle he daily came down stairs, changing his room and moving about the house as well as the pain and weakness would allow him. No carbuncle could go on better; all the stages were passed through without

66

any risk or trouble, it healed with unusual speed. After that I had a yet more striking case. A lady came to London "for the season," as she called it; and she had not been here more than a week or ten days before a carbuncle came out on the back of her head, just under her hair. It was a great vexation to her that she had to give up all her amusements; and so, as she did not mind the pain, she would go out. And it was then that, for the first time and last, I saw any value in a chignon." She dressed the carbuncle under the chignon, and she went to the park, to the theatre, and to dances unharmed, and with her carbuncle quite unseen, and no trouble whatever followed. It healed up after the ordinary fashion and in about the ordinary time. But, indeed, you may see cases of this description on a much larger scale if you watch the carbuncles that come to us in the out-patients' room. There we often see them of considerable size, and they do as well among the out-patients as among the in-patients; and yet these out-patients are freely in the air all day, and many of them continue at their work. So you may set it down as one point to be attended to in the management of carbuncles that patients should not be confined to their room. They should at least have change of air in their own house; and, unless they, are too low, they should not avoid exposure to the fresh open air.

Treating your cases of carbuncle upon this plan, I believe you will find that the great majority will pass through their course well.-Lancet, Jan. 16, 1869, p. 73.

SYPHILITIC DISEASES.

84.-OBSTINATE CASES OF ACUTE AND CHRONIC GONORRHEA, SUCCESSFULLY TREATED BY INJECTIONS OF GLYCERINE OF TANNIN.

From cases under the care of J. D. HILL, Esq., at the Royal Free Hospital, London. Perhaps no surgical disease is so frequently observed in hospital (out-patient) practice as gonorrhoea, and the treatment which is advocated by surgical authorities cannot in many instances be surpassed; occasionally, however, troublesome cases will arise, both in the acute and chronic form of the disorder.

In these cases, previous to the employment of any kind of local or constitutional treatment, whether alone or in combination, several circumstances, Mr. Hill thinks, have to be considered.

First, it is necessary to determine the occupation, habits, and constitutional peculiarities of the patient; or, in other words, what assistance, both from within and without, can be brought to bear upon a purely local affection. Secondly, to overcome local difficulties, which are both physiological and mechanical in character; and these may be briefly said to consist in the mobility of the affected part, its dependent position, and the occasional contact of an irritating fluid-the urine.

The treatment which Mr. Hill tells us he has extensively employed in hospital and private practice was, he believes, first introduced by Dr. Ringer, of University College, who has kindly favoured him with the following remarks: For some time past I have been making observations with an injection of glycerine of tannin in chronic gonorrhoea and gleets, and have found it of great use, especially in gleets, which I believe may be removed more quickly with this injection than perhaps any other. In the acute stage of the disease a little care is necessary, or great pain is caused. This may be prevented by diluting the glycerine of tannin with equal parts of mucilage. Another point to attend to is that the injection should not be injected too far, or it causes a great and frequent desire to make water."

Mr. Hill is therefore enabled to support the experience of Dr. Ringer, not only by recent cases, but also by observations on the treatment of gonorrhoea by tannin and mucilage injections extending over some years. These

injections he first used in the proportion of ten grains to the ounce, but latterly, as suggested by Dr. Ringer, he found the glycerine of tannin more serviceable, slightly modified, however, as to the diluting agent.

The precaution alluded to as to injecting is probably a most important one, whatever be the lotion employed; for although in some few instances the fluid may be injected too far, in the larger number it will not be injected far enough. Now in either case the surgeon is blamed for a fault which in reality rests with the patient; and here it may not be out of place to describe the method which Mr. Hill recommends to all patients using the injections:

The bladder having been first emptied, the bottle containing the lotion is to be well shaken, and about two drachms of it briskly poured into a saucer. This must be quickly drawn into a glass syringe with a bore in the nozzle equal to a No. 6 catheter. The penis is then to be held in the left hand, with the thumb and little finger respectively placed upon the superior and inferior portions of that organ close to the symphysis pubis, and the fore and middle fingers resting in like manner upon the superior and inferior surfaces of the glans close to the meatus urinarius. The syringe, with the piston withdrawn, is now to be taken up with the right hand, and the nozzle as far as its shoulder carefully passed into the urethra. Previous to injecting, the thumb and little finger of the left hand must compress the root of the penis, in order that the urethra be closed against the passage of any fluid beyond this point. When a sense of tension is felt, the syringe may be withdrawn; but the front fingers must previously be so applied as to compress the glans, and thus prevent any escape of fluid from the meatus. Next, with the thumb and forefinger of the right hand the fluid in the urethra is to be set in motion, and so kept for four or five minutes. This will be attended with a gurgling noise from the mixture of air and fluid. Thus, when the injection has so insinuated itself within the folds and lacunæ of the urethra as to saturate the openings of the follicles and mucous glands, and permeate the whole of the affected structure, it is allowed to escape."

It is conceived that by these means the bladder is protected on the one hand, and on the other there is a certainty of the fluid being applied to the affected surface of the urethra.

Mr. Hill has furnished us with the notes of six cases in which the glycerine of tannin would appear to have been of great service. In several, injections of zinc, lead, and alum had been employed without much benefit. The formula employed was the following:-Glycerine of tannin, three ounces; olive oil and mucilage, of each one ounce.-Lancet, March 20, 1869, p. 398.

LIX.-13

MIDWIFERY,

AND THE DISEASES OF WOMEN AND CHILDREN.

85.-ON IMPROVED METHODS OF INDUCING AND ACCELERATING LABOUR.

By Dr. ROBERT BARNES, Lecturer on Midwifery at St. Thomas' Hospital.

[The results of the modes of inducing premature labour usually followed have not appeared to Dr. Barnes to be very satisfactory. There is for instance no certainty about the time at which labour comniences, and when it comes the child is liable to be expelled somewhat suddenly in the absence of the medical man. Moreover, owing to the frequent excess of liquor amnii when the child comes to present, it is liable to assume an unfavourable position, or the cord falls through. Hence it follows that it is desirable to keep control over the whole course of the labour.]

Assuming that it is both desirable and possible to control and to regulate the entire course of labour prematurely induced, I will describe the method after which the proceeding should be conducted. It is convenient to divide the act of artificial labour into two stages. The first stage is provocative and preparatory; this includes some amount of dilatation of the cervix uteri, and implies a certain amount of uterine action, and lubrication of the cervix and vagina. The second stage is the accelerative or concluding stage; it consists in the expulsion or extraction of the foetus and placenta.

The ordinary modes of conducting an induced labour almost ignore the last stage, or the means of accelerating delivery.

1. The provocative,and preparatory stage. The means of preparing the uterus for the task prematurely thrown upon it are numerous. I will not discuss their relative merits in detail, as I have done this in a memoir on "The Induction of Premature Labour," in the Obstetrical Transactions, 1862; but I think it important to repeat an emphatic warning against one of them. I mean the plan of injecting water or other fluid into the uterus. This was introduced by Schweighäuser and Cohen; and is sometimes described as Kiwisch's plan. But Kiwisch's plan is simply to inject water into the vagina, playing the stream against the os uteri, not into the cavity of the uterus. Now Kiwisch's plan is generally harmless, but it is certainly often useless. On the other hand, Cohen's intra-uterine injection, although far more certain in its action, is fraught with extreme danger. Both in this country and abroad several cases of severe shock and of sudden death have been caused by it. Of course no advantage, or conveni ence, however great, can counterbalance such a danger. The plan, therefore ought to be rigorously discarded. There are means that are perfectly safe and effective.

It is important to recognise, in limine, the essential difference between

provoked premature labour and labour at term. In the premature case, labour finds the uterus in an imperfect state of development. This condition involves imperfection in the contractile power of the body of the uterus, and greater resistance in the cervix. These things must be taken into account. They call for artificial aid. The uterus is called upon suddenly,