operation, it is usually arrested at the edges or limits of the restored part. This was especially remarkable in the case of a patient operated on by Dieffenbach, at the hospital St. Louis in Paris.

M. Ricord also has published a similar instance. On the seventh day after the operation, the patient began to experience pain under the chin, and at this part an erysipelatous redness was visible. Next day this had extended over the entire face, the newly-made nose alone remaining intact; it was cold, insensible, and, as it were, indifferent to what was going on all around it. Although the local inflammation was very severe, it was ultimately subdued; yet at no time did the new nose participate in it.

Dieffenbach mentions that one of his patients, on whom he had operated, was attacked with jaundice, during which the entire face-with the exception of the nose, which remained white-became as yellow as a guinea."

M. Phillips insists very particularly on the necessity of keeping the newlyformed organ very cool with refrigerent lotions, and even of drawing blood freely from it as well as from the adjacent parts, and never of applying—as has too often been done-spirituous or other stimulating washes for the purpose of exciting the circulation. The condition of the transplanted tissues seems to be very nearly analogous with that of frost-bitten parts; in the case of which, it is well known, the application of heat and exciting substances must be carefully avoided. As illustrative of the same fact, M. Phillips goes on to state :—

"Dieffenbach remarked that in cholera patients, who recovered, the healing of wounds was effected with greater rapidity than in persons in perfect health; as if the diminished activity of the cutaneous circulation rendered it better fitted for any plastic processes. He observed that the wound bled very little, if at all, the dermis being almost void of blood; and that the edges of the incision were not red as usual, but rather of a yellowish-red colour... Again, if we call to mind the surprising unions of parts which have been entirely separated from the body, are we not led to conclude that the immediate union of wounds will be the more readily effected just in proportion as the parts are the least gorged with blood? The management, therefore, of rhino-plastic injuries should be so directed as to bring and keep the tissues in this state of vacuity."

M. Phillips proceeds to point out an error which is too commonly committed by most surgeons in the treatment of recent wounds, that of bringing the edges in contact as quickly as possible after their division, and before the oozing of blood has ceased. Now, it is not until this has quite stopped, that the secretion of the coagulable or plastic lymph commences; and it must surely be obvious that, if any coagula of blood are interposed between the lips of the wound, the agglutinative process must necessarily be impeded. Dieffenbach observed, in some experiments which he performed on rabbits, that the chances of union, after the transplantation of a portion of the integuments, were always greater when the flap was not replaced for several minutes after it had been

excised.

In most of the cases, too, of successful union of detached noses or fingers in the human subject, some time has accidentally elapsed between the occurrence of the accident, and the re-application of the part.'

"That a vitality continues for a considerable time in parts detached from the body, is often very apparent after some operations.

Thus in a case of hydro-sarcocele, where Dieffenbach removed a large portion of the skin along with the diseased mass, he noticed that, in about a quarter of an hour afterwards, this portion of skin had contracted upon itself, so as to exhibit the usual puckered appearance of the scrotum on leaving a very cold bath. On stretching it out, and pouring cold water upon it, it again contracted into numerous wrinkles."

M. Phillips proceeds to state that—

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"When a part is entirely detached, its natural red colour disappears, and it becomes very pale, although very little blood has flowed from it. The vessels of the surface contract, and drive the blood into the sub-dermoid tissues. In a few minutes after the separation, this great paleness diminishes, some dark blood oozes from the divided edges; and we may ascertain with a magnifying glass that it is expelled by the contraction of the vessels. If the blood be wiped away, the wound again becomes red; but the blood is now thinner, and if again removed it becomes quite watery, and the edges begin to be coated with coagulable lymph; they then contract upon themselves, so as to cause the centre to bulge out."*

Should the hemorrhage from any of the divided blood-vessels, after autoplastic operations, prove troublesome, torsion, and never the ligature, should invariably be had recourse to. The presence of a ligature, however minute, is always most unfavourable to immediate union. If the stopped blood-vessel seems gorged with blood after the hæmorrhage has ceased, one or two scarifications should be made, to remove the sanguineous congestion; which we have already explained is very prejudicial to the success of the reparative process.

M. Phillips thus points out some of the anatomical conditions of the flap taken from the forehead in a rhino-plastic operation, on which its success very materially depends.

Hence the

"It is indispensable that it should contain one artery at least. importance of prolonging the incisions to the angle of the eye, so that the pedicle of the flap contains the internal angular artery to supply it with blood. And then again, it is equally necessary that the blood, which is conveyed to it by the arteries, should be returned by veins, else the new nose will perish from congestive asphyxia. Indeed it is wonderful that this does not occur oftener than it really does, when we consider that not only are almost all the direct communicating branches between the arteries and the veins cut across, but that the blood in the divided arteries is prevented, in a great measure, from escaping, in consequence of the compression of the edges of the flap by the numerous sutures used to retain it in position."

"The destruction of the flap may arise from three different causes-from defective circulation, from excessive or superabundant circulation, and from suppuration.

If the pedicle be twisted too firmly, the vessels must necessarily be compressed, and the circulation through them be consequently more or less interrupted: the flap in consequence becomes pale, loses its heat, and speedily mortifies. But this does not occur so frequently as the mortification from accumulation or congestion of blood in consequence of its obstructed return through the veins. Under such circumstances, the mortification usually takes place in that part of the flap which is furthest distant from the pedicle.

* The convexity of the flap exists even after the most successful union; it is the more decided when the substance of the flap is thin, and much less so when a layer of muscular substance has been detached at the same time.

This tendency of the flap to contract around its edges, so as to cause the centre to become convex, is of great utility in rhino-plastic operations; as it is by this invariable law that the surgeon is able to secure a proper prominence to the new nose. When a flap has a free edge, which is not brought and kept in contact within another incised surface, this edge turns inwards upon itself and contracts very close adhesions. It is in this manner that the nostrils of the new organ are apt to become quite obliterated, if precaution has not been taken to evert and secure by a stitch or two a portion of the flap, so as to induce an immediate union.

After the asphyxia now described, suppuration is the most formidable evil to be dreaded in the management of rhino-plastic operations. The destruction commences at the edges, which swell, puff out, and separate from each other. This calamity is more apt to occur when the twisted suture has been used."*—Bulletin Medical Belge.

M. TROUSOEAU ON THE POMMADE AMMONIACALE, AND ON HEAT AS

VESICANTS.

THE formula in the French Codex for the preparation of Gondret's Ammoniacal Pommade is as follows :-Take of mutton suet one ounce, lard one ounce, and liquid ammonia (of 250 strength) two ounces. Melt the suet and lard in a wide-mouthed bottle, and then, having added the ammonia, stopper it and shake the mixture well together. Keep the bottle closed in cold water-shaking it occasionally-until the pommade has become quite cold.

M. Trousseau observes, that the pommade made according to these directions is generally much too hard and consistent for use, at least unless the waether be warm. He proposes two different formulæ, one for Summer and the other for Winter. The former is to use three parts of lard, one of suet, and four of ammonia; and the latter to use equal parts of lard and of the ammonia.

The pommade, which is met with in most druggist's shops in Paris, is far too weak, in consequence of its having been prepared with ammonia of insufficient strength, and probably also from its being kept too long.

There may be another reason still; if the ammonia be added while the fatty matters are very hot, a great portion of it must be volatilised, and the pommade is necessarily weakened.

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In applying this vesicatory, some recommend that a portion be put into a thimble, or in a short glass tube, and held firmly on the skin for some time, to prevent the escape of the ammoniacal vapour; while others advise, that it be spread directly on the part which is then covered with a small portion of diachylon plaster.

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Mr. Trousseau disapproves of both methods, as it is indispensable," he says "that the effects of the application should be visible all the while." When first applied, the patient experiences a sense of coldness in the part; then a minute or two afterwards a slight burning heat, which gradually increases for three or four minutes, at which time it is at its maximum; it then remains stationary, and sometimes even begins to abate, although the escharification of the skin is going on all the time.

We must not, therefore, judge of the effects of the ammonia solely by the effects it produces.

The rule given by M. Trousseau, for regulating the length of time for its application, is to watch the appearance of the red circle around the part; whenever this is observed, the pommade should be removed. It is sometimes even not necessary or proper to wait until the red areola be observed, as the epidermis may be raised, before it appears.

The length of time necessary for the pommade producing its full effects,

* If the destruction from this cause be considerable, it may be necessary to perform a second operation, and re-transplant a fresh portion of healthy integument. But if it be only at one angle, we may succeed by the repeated application of the tincture of cantharides, in exciting the granulating process sufficiently to fill up the ulcerated space.

varies much according to the part on which it is applied; sometimes it will vesicate in two minutes, at other times ten or twelve minutes are required.

As the inflammatory areola does not always make its appearance, M.Trousseau recommends that the pommade be wiped off at the end of five or six minutes, and reapplied if necessary; this may be repeated until the epidermis begins to be raised. We are never to continue the application until any appearance of a vesicle or blister is observed; but only until we find that the epidermis can be detached by rubbing it gently with the finger. We frequently find that it can then be removed in one piece, and that the chorion beneath can be fairly exposed. Now this is the very condition that is desired. The dermis is not escharified in any degree; but continues to retain its absorbing energies, so that we may depend upon the success of any endermic medication that we may wish to try.

Should the pommade have been so long applied, that a complete bulla has been raised, it will generally be found that the dermis, from having been too much irritated, does not absorb very readily; and, moreover, that a cicatrix or mark is left after the blister has been healed. This latter consideration is not to be neglected, seeing that the pommade is so extensively used in the treatment of facial neuralgia in both sexes.

Heat as a Vesicant.

We shall only mention the application of boiling water under this head. By far the most convenient method of using it is in the manner suggested by M. Mayor, and known in France under the somewhat droll appellation of M. Mayor's hammer. It consists in simply immersing the iron part of a common hammer in water boiling on the fire for a minute or two, and then applying its round disk on the part which we wish to vesicate. The pain is sharp, and when the hammer is removed, the skin is observed to be discoloured and as it were somewhat sunk in. M. Trousseau very justly remarks, that the great objection to the use of heat, applied in any way, for the purpose of inducing vesication, is that the part is very generally more or less completely escharified-in consequence, perhaps, of the albuminous portion of the animal fluids being necessarily more or less completely coagulated. He approves of M. Mayor's hammer as a very good means of producing an eschar, such as may be desired in the neighbourhood of diseased joints; but rejects it altogether as a vesicant in cases where we wish to try the endermic effects of remedies in neuralgia and such like diseases.-Journal des Connoissances Medico-Chirurgicales.

ON THE GREY DEPOSIT UPON URINARY CALCULI, BY M. CIVIALE.

The main object of M. Civiale in the following remarks (derived from the third volume of his recent work on Calculous Diseases) is to shew that the use of chemical remedies is not only quite inefficient, but positively pernicious, in a multitude of cases, by promoting the deposite of additional matter on the calculi which are in the bladder.

After alluding to the great variety, in point of chemical composition, of calculi, he says:

"We cannot ever know exactly in the living subject the species of stone which exists in the bladder; it is not possible to do more than acquire merely vague notions, which are quite insufficient to direct us in the choice of our remedies. (This assertion is far too positive and dogmatic: the English surgeon knows very well that he can generally predict the nature of the calculus, before it is extracted. (Rev.)

Hence there must happen one of two things; either the remedies employed are inefficient, or they must exert some real effect, which may be useful in one case, but injurious in another. In my opinion, there is not a single decisive instance on record of the solution of a calculus in the bladder. Alas! there are, on the other hand, too many in which the disease has been aggravated by the use of chemical solvents. If the use of these remedies does not tend directly and immediately to promote the deposit of further matter on the surface of the existing calculus, it is, in a multitude of cases, apt to induce various morbid conditions of the urinary apparatus, under the influence of which the grey or white layer, of which I am about to speak, is generally secreted. No one, indeed, who is in the habit of seeing much of calculous diseases, can fail to be struck with the frequency of this layer or calculi, when alkaline remedies have been taken for a length of time."

M. Civiale, like so many of his countrymen, is apt to carry all his doctrines a l'outrance. The abuse of alkaline remedies has, we are ready to admit, often done harm; indeed it must do so on chemical principles. The rule of practice, which is invariably followed by the scientific surgeon, is every now and then to test the urine of a calculous patient, and never to continue the employment of either alkalies or acids beyond the neutralization of the acid or alkaline condition of the secretion. It is therefore scarcely necessary for M. Civiale to condemn the use of alkalies in the phosphatic or oxalate of lime diathesis, or to take any credit to himself for having pointed out the evils of such a practice: no one in the present day is so foolish as to regard alkaline remedies as universal solvents of calculi.

M. Civiale, indeed, mentions the names of Brodie and Prout, as men who have paid attention to the occasional alkaline state of the urine, and the circumstances which are apt to induce it: but his notice of these distinguished practitioners goes no further; and he takes the sole credit to himself for having showed that a diseased state of the bladder and kidneys has a marked influence on the nature of the deposit from the urine. We do not mean to rob M. Civiale

of his share of the credit of having improved the treatment in calculous diseases; but let him be satisfied with his own portion.

In illustration of his particular views he makes the following remarks on a case, where it had been alleged that the mineral waters of Vichy had begun to exert a solvent effect on a urate of soda vesical calculus, in consequence of its surface exhibiting a layer of white deposit :

"Now this white layer, which our confrere imagined to be the effect of the mineral waters, was solely the result of a new deposit, which had taken place in consequence of the inflammatory action on the mucous coat of the bladder. Whatever be the nature of the calculus, no sooner is a vesical catarrh induced,. than this white or greyish deposit inevitably supervenes, whether alkaline or acid remedies be taken or not. I could quote a thousand cases in proof of this point: let one suffice. In an old gentleman, the bladder was the seat of a purulent catarrh, which ultimately proved fatal. Twenty-six minute calculi-all of uric acid or urate of ammonia-were found, on dissection, in it: these were all invested with this ash-coloured deposit. The left kidney contained so large a number of red granules of uric acid that it took a considerable time to count their number. But they were all of a lively red colour, and not one of them exhibited the greyish surface observed on the vesical calculi.

Surely then we must admit that this greyish deposit was the result of the vesical catarrh, as all the calculi, vesical as well as renal, were essentially and primarily of the same nature."

M. Civiale next alludes, in illustration of his views, to the deposit which is apt to take place on the extremity of a sound or catheter, when left so long in the bladder as to give rise to irritation of its mucous membrane: this being always of the greyish character, such as we observe on the surface of calculi. No. 81.

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