learnt in respect to tumors, is how to remove them best by the knife. The more that is published on their external differential forms and features, and indeed on their intimate structure, the more rather than the less obscurity is thrown around them; and the multiplication of species and varieties has really seemed to be a multiplication of difficulties. It is to the operations on tumors, therefore, that Dr. Stevens turns, and we direct, for a few minutes, our readers' attention. We shall extract such hints as appear to claim our notice.

Extirpation of Encysted Tumors of the Scalp or Eyelids

"The most common mode of extirpating these tumours is by dissecting them out; but this is not always easily done, especially if the tumour be very small. I have known half an hour occupied in removing a tumour, not larger than a pea, from the upper eyelid. Sir Astley Cooper advises that they should be cut into, and then torn out. If the first of these opperations is attempted, the surgeon should be quite sure that he does not begin to dissect around the tumour until he has laid it quite bare. But I prefer the other method, and this is the way of proceeding that I would recommend :-It the first incision, I would cut freely into the sac of the tumour, seize the sac with the forceps, and pull it away either at once, or in different portions. If the sac resists, it will be because you have seized with the forceps one or more of the layers of cellular tissue which are always found surrounding the sac, and which are occasionally dense and strong. The connection of the sac with these layers is loose, but they adhere closely to each other. A few months since I removed, in two or three minutes, six of these tumours from the head of a young gentleman of this city. The rule, therefore, is this :-cut into the sac and turn it out; but do not attempt to tear away any thing else with the sac.

If it should happen that any portion of the sac has formed strong adhesions to the surrounding parts, an occurrence which is extremely rare, it is proper that you should understand that a perfect cure may be obtained by destroying the internal membrane (which is seldom thicker than parchment,) with a slight application of the kali purum, or of the nitrate of silver."

Extirpation of Solid Tumors

Dr. Stevens remarks that, in the removal of these, unless they be malignant, and the abstraction of much of the circumjacent parts is necessary, there is one rule which should be written in letters of gold. "Did I say one rule? Let me rather say two rules, the first of which is this :-cut down to the tumour. This may seem to be a simple matter, so simple that the necessity of it must occur to every one. Be this, however, as it may, I do aver that in some hundreds of tumours which I have seen operated upon, and often by very skilful surgeons, the tumour has seldom been fairly exposed and laid bare before its dissection has been commenced. Vessels have been unnecessarily divided, and the whole operation has been protracted by the loss of blood, and the necessary application of ligatures to the arteries. How this happens I will now attempt to explain. Let us take for illustration, the very common case of an enlarged lymphatic gland, in the neck. In its normal condition, this gland is supplied by one principal nutritive artery, and it is surrounded by an indefinite number of layers of cellular tissue. The layer next the gland embraces it like a shut sac; the exterior layers in contact with this, diverge and surround the adjacent parts. When the gland becomes enlarged from hypertrophy, or by becoming the seat of malignant deposits, the innermost layer of cellular tissue forms a sac, and its connection with the gland is usually loose, so that it may be readily stretched, or torn with the finger or the handle of the scalpel. The outer layers are also, in general, loose, and capable of being torn in the same way; but the manner in which they are applied to the gland, or rather to its sac, is worthy of parti

cular attention, as affording a clue to the difficulties which are often encountered in these operations. The external layers of cellular tissue which cover the gland become, in the progress of its enlargement, stretched upon the exterior surface of the sac, being sometimes adherent to it, and to one another; from this point they diverge, passing to the anterior surface of some muscle, nerve, or bloodvessel, or to the posterior surface of some of these or of other organs. The tumour itself, in the meanwhile, receives no new vessel, other than that which originally supplied it, even though it may have grown so as to completely surround the carotid artery, the internal jugular vein, and their branches. Even in this case the proper sac will be found interposed between these parts and the tumour. These vessels are, in other words, pressed into the side of the tumour, which, with its sac, becomes folded around them; thus, strictly speaking, they form no part of the tumour, being exterior to the sac.

Keeping in mind the close application of several layers of cellular tissue, over the most superficial portion of the tumour, (the first and greatest enlargement of the tumour being in this direction, because it is there least opposed in its progress by the pressure of the surrounding parts.) and the separation of these layers on the lateral and deep-seated portions of the tumour, it is easy to understand:

Ist. That important blood-vessels, nerves, and other organs may be brought into close proximity to the morbid growth without absolutely touching it.

2nd. That if the surgeon, in cutting down upon the tumour, does not divide each and every layer investing the tumour before he begins to dissect around it, he cuts outside the sac, gets into some of the folds of cellular tissue, and encounters parts which ought not to be meddled with. He finds his knowledge of normal anatomy of little service to him; he gets away from the tumour, and makes a tedious and bloody operation in a case, where a different method of pro⚫ ceeding would have made every thing plain and easy.

Finally, when the tumour is removed and examined, folds of cellular tissue, perhaps portions of muscle, or of other parts, are found to have been removed with it, which can be torn off, and that very readily, from its external surface. Had the surgeon, in the first instance, cut down to the tumour after dividing every layer investing it, no more difficulty would have been experienced in tearing these layers from the tumour before it was removed than afterwards."

Sometimes, so transparent are the layers of cellular tissue, that it is very difficult to tell when the tumour is exposed. It is better for a young surgeon, and even for an old one, if he has any doubt in the matter, to cut a little into the tumour, in order to be sure that he has fairly cut down to it. Having reached the tumour, Dr. S. continues, if the cellular tissue can be torn by the fingers or by the handle of the knife, tear it; in cases where it cannot be so torn, cut in this manner: put the tumour upon the stretch, and cut lightly upon it near its points of attachment. Thus you avoid the possibility of any large blood-vessel or nerve being brought under the edge of your knife without being seen.

If the tumour is very large, or is deeply seated, it will, sometimes, be advisable, after having separated the attachments of the exterior portion of it as deeply as possible, to remove this portion. The removal of the remaining portion is thus much facilitated.

"In this manner, I safely removed a large tumour situated beneath the mastoid muscle, and which embraced the ninth pair of nerves in one part, and the common carotid artery, the internal jugular vein, the par vagum and oesophagus in another part; after very little cutting the sac was separated from these parts. I have never taken up the carotid artery for the removal of a tumour in the neck or face, nor do I believe that it is ever necessary If the principles already laid down are carefully observed, there will be no danger of hemorrhage, nor yet of sloughing, from the nerves and blood-vesseis being extensively laid bare ;-laid No. 81.

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bare, indeed, they are, but their sheath still covers them, and is sufficient for their nourishment. I have, on several occasions, left them plainly exposed, from the sternum to a point above the bifurcation of the carotid artery, and have never known secondary hemorrhage to follow."

"In some cases of malignant tumours, not only the superficial, but other portions of the sac will be found closely adhering to the adjacent parts. If the tumour is in the vicinity of important parts, as in the axilla or neck, the plan I would recommend is this:-cut down until the knife fairly enters the diseased parts, then, by the sight and touch, decide where the tissues, adjacent to the disease, are entirely healthy; make a slight incision into them on the distal side of the tumour; continue to separate them with the handle of the scalpel and the finger. If you are among healthy parts, as you proceed the cellular and other tissues will yield to a very moderate degree of force; the separation of the veins, arteries, and, lastly, the nerves, will require more force, increasing in the two last named. These parts will be felt like strings holding the tumour, and are not easily separated. Be careful not to use much force in the separation of a large artery, and still more in the separation of a large vein. It is a great mistake to suppose that arteries when torn never bleed: I have often seen them bleed, per saltum, after having been torn by the finger. Still, they do not bleed so freely when cut, and, moreover, their orifices are usually easy to be found, and as easily secured. They also stop bleeding much sooner, if an attempt is made to check the hemorrhage by pressure. A nerve no larger than a silk thread is half as strong; yet I have broken them when nearly as large as a small crow quill. My practice is to bring the resisting cord, be it vein, artery, or nerve, into view upon the palmar side of the fore-finger of my left hand, and then to seize it with the forceps, and divide it half an inch on the distal side of that instrument. If it is an artery, its patulous mouth will be seen, and a ligature may be applied before the forceps is removed. Thus you will conform to the second rule, that is, to remove the whole tumour and nothing more."

Dangers of Operations.

Dr. Stevens enumerates as the dangers to be immediately apprehended and guarded against-hæmorrhage-the introduction of air into the veins-and exhaustion.

Hæmorrhage.-On venous hæmorrhage we need say nothing.

"Arterial hæmorrhage may be diminished by tearing the vessels from the tumour. I have seen some surgeons tear the tumour itself out: this cannot always be done except to a limited extent, because a large number of parts are thus put upon the stretch at once. The better way is to hold the tumour, and tear off its investments, one portion at a time, with the fingers or with a strong pair of forceps: this method is also less painful than the former. Sometimes a vessel will retreat behind the ramus of the lower jaw, or into the axilla, and give rise to a troublesome bleeding. As these are usually the last attachments to be divided, it may be prudent to tie them before this division is made. I would also advise you always to divide and to secure the trunks of arteries, before dissecting among their branches. If you neglect this rule, you may cut and tie the

same vessel half a dozen times, as I have often seen done. This is the reason some surgeons are constantly encountering tumours of extraordinary vascularity; this vascularity being, in fact, simply owing to their wandering away from the sac of the tumour, and dividing the vessels at each successive cut nearer and nearer to the heart."

An important means of diminishing hæmorrhage, in the removal of large tumours, is to subject them, for some hours previous to the operation, to the influence of cold applications.

Introduction of Air into the Veins.

"I have met with this occurrence only once in my practice, and that was in this Hospital about ten years since. I was in the act of removing the last of several of the deeper.chain of lymphatic glands of the neck, which had become enlarged so as to interfere with the functions of deglutition and respiration, and was cautiously using the knife about half an inch on the outer side of the internal jugular vein. After a slight escape of venous blood, I heard a noise like that produced by drawing up with a syringe the last drop of water in a vessel. I immediately placed my finger over the spot from which the blood had issued, not being able to discover any orifice; and looking the patient in the face, asked him how he felt, he answered, 'very well.' Marks of consternation were visible around me, and many suggestions were made which I did not heed, but calling for an eyed probe, I directed a ligature to be passed through it. I applied to the internal jugular vein two ligatures,-one above, the other below the wound, directing them to be successively tightened. I then removed my finger, and proceeded with the operation. No bad consequences followed the application of the ligatures. The wounded vein appeared to be a branch of the internal jugular, but I did not think it safe to pass a ligature directly round the divided vessel, not liking to run the hazard of removing the pressure of my finger."

Dr. Stevens objects naturally to operating on a female about her menstrual period. He recommends the operator to have the instruments he wants within his own reach. He likes, in great operations, to have the assistance of a judicious medical practitioner, a personal friend, if possible, of the patient, to console, to watch, to support him.

"An adult, with ordinary powers of endurance, will, generally, sustain an operation of the average severity, during protracted suffering of one hour's duration, rarely much more than this. A clammy skin, with coldness of the extremities, and a soft, thready pulse, indicate alarming exhaustion of the vital powers. But an experienced surgeon will judge most accurately from the expression of the countenance, from the eye and mouth especially the former partially loses its lustre, the latter becomes relaxed, until, finally, the eyes are turned upward, and the jaw falls, indicating an almost hopeless condition. The voice, also, is an index of the degree to which the vital powers are sunk; its tones become more and more feeble, until, at length, the patient can only speak in a low whisper, like one in a collapsed stage of cholera, and finally ceases to articulate at all. On the first approach of this state of things, I would advise you to give your patient a few minutes' respite. I give you the above indications, as being the only ones that occur to me as capable of being conveyed by language; your own observation will hereafter enable you to determine their real value. It is also important for you to know that a patient will endure a long operation much better by being allowed two or three short intervals in which to rally during the progress of an operation, it being more easy to prevent him from sinking, than to raise him from extreme prostration."

Finally Dr Stevens counsels the surgeon never to undertake an operation against his own judgment, nor if possible assist at one.

DR. LAW ON DISEASE OF THE BRAIN, DEPENDENT ON DISEASE OF THE HEART.*

M. Legallois first drew attention to the fact, a striking and, practically, an important one, that hypertrophy of the heart disposes to apoplexy. Legallois

* Dublin Journal, May, 1840.

has been followed by others, and the doctrine has for some time been firmly established. The object of Dr. Law, is to extend the proposition, and to lead us to believe that disease of the brain may not only be occasioned by too great but also by too little an impetus or quantity of blood, the result of cardiac disease.

He lays down the following propositions, which he supports with several cases and with much ability. For the facts and arguments we refer to our esteemed con'emporary. The propositions themselves are sufficiently intelligible in their naked form. They are as follows:

1st. The pathology of the brain is in many instances intimately connected with, and dependent upon, pathology of the heart.

2nd. To limit the pathological relation existing between these two important organs to apoplexy, the result of hypertrophy of the left ventricle of the heart, is to narrow it much within its true limits.

3rd. Ramollissement of the brain occurs in connexion with diseases of the heart, whose effect is either directly or indirectly to diminish the flow of blood to the head.

4th. This cerebral lesion may be connected with either disease of the aortic or mitral valve.

5th. Hypertrophy of the left ventricle of the heart, in order to produce apoplexy, must depend upon some impediment to the circulation, placed at a greater distance from the heart than the origin of the vessels which convey the blood to the brain.

6th. When ramollissement of the brain occurs, in connexion with an imperfect or patulous condition of aortic valves, the close analogy that we trace between the physical signs and constitutional symptoms of this lesion and hæmorrhage, as well as the results of treatment, render it very improbable that the disease of the brain is the result of too much blood driven to it, and with undue force.

7th. When ramollissement of the brain occurs, in connexion with disease of the mitral valve, the state of the pulse, which, as a diagnostic mark of this lesion, is habitually small, precludes the idea that the cerebral lesion is produced under the usual conditions of inflammation.

8th. While ramollissement of the brain occurs as a result of inflammation, hyperemia, &c., it occurs also under diametrically opposite circumstances.

9th. To confound such opposite modifications of disease, and to apply to them the same treatment, must necessarily lead to the most mischievous practical results.

10th. The circumstances under which we have seen ramollissement of the brain to take place, seem to identify it with gangrene, or death of a part consequent upon a diminution of its due supply of blood.

HOSPITALS OF MALTA.

One

There are four hospitals in Malta, one naval, one military, and two civil. of the last is in Valetta, and the other in Citta Vecchia or Notabilé, near the centre of the island. There is a civil hospital, also, in Gozo. At Floriana, adjoining Valetta, there is an asylum for the insane, and the town last mentioned is furnished with a public dispensary. The civil hospital in Valetta is as well furnished and as neatly kept as most of the institutions of the kind in England and France.

A University was established in the island, by the Jesuits, in the year 1592. It has included a medical department ever since its commencement. The Medical Faculty is composed of five Professors. The chairs are, 1st. Anatomy and Surgery; 2d. Physiology and Pathology, including Theory and Practice; 3d.