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the withdrawal of the first. Thus the aperture of the sac is at once hit off. One precaution is necessary to be attended to, if a gum catheter be used. After the stylet is withdrawn, the tube is liable to be compressed by the edge of the swathe, and the exit of the fluid impeded. The difficulty is overcome simply by removing the edge of the swathe from the orifice. It is preferable that the catheter should be furnished with two apertures.

We fancy the trocar and canula will have the best of it.

DREADNOUGHT HOSPITAL SHIP.

CONDITION OF AN ELBOW NEARLY THREE YEARS AFTER EXCISION OF THE JOINT.

Facts like the following, which shew the ultimate results of remedies are valuable, and, unfortunately, no less valuable than rare.

A man had the upper extremities of the ulna and the radius, and the lower extremity of the radius excised by Mr. Busk, the able surgeon of the Dreadnought, in November, 1837. About a year after the operation, the patient went to sea, and did his duty on board ship.

"He presented himself to me on the 6th of this month, when I had an opportunity of fully examining the condition of the limb. Before removing his clothes it required close observation to detect any difference between the limbs, and he stated that no one on board the vessel of which he had been mate for nearly twelve months was aware that he had any thing the matter with his arm. On baring the arms, however, there was considerable difference in their size, although the muscles of the right had much increased since I had seen him last. The affected arm was altogether smaller than the other, but was not otherwise at all deformed. The shape of the elbow was so little altered that any one not aware of the fact would hardly have been able to convince himself that the articulation had been removed. The arm could not be flexed to more than a right angle, but could be perfectly extended. There was no lateral motion. The motions of supination and pronation of the hand were perfect. He had no pain, and found only that the right arm was not as strong as the left. He had become very stout, and appeared to enjoy the most robust health."*

HOTEL DIEU.

BARBAROUS OPERATION FOR FISTULA, BY M. Roux.

Dr. J. C. Hall, in a sensible paper on Fistula Ani, gives this account of M. Roux's operation for fistula. It is worthy the times of the Grand Monarque. He, (M. Roux, not the Grand Monarque,) introduces a long piece of boxwood into the rectum, having its concavity towards the fistula. A silver director is then introduced along the fistulous track, and its end made to come in contact with the wooden gorget in the bowel. A long, strong, narrow sharp-pointed knife is then introduced along it, till it comes in contact with the piece of boxwood. The director is then withdrawn, and by keeping the point of the knife fixed upon the gorget, and withdrawing both together, all the parts between the fistula and the rectum are divided. This part of the operation completed, the

* Med. Gaz. July 24, 1840.

bistoury is exchanged for a scalpel, and all the hardened base is carefully dissected out. A thick long probe is then procured, having a button at one end; this is covered with charpie, smeared over with some yellow-looking ointment, and the wound crammed full of it to the bottom.*

GLASGOW ROYAL INFIRMARY AND LOCK HOSPITAL.

DANGERS FROM THE EXHIBITION OF THE IODIDE OF POTASSIUM.

Dr. Lawrie, physician to the above Institutions, relates several cases with the view of pointing out the dangerous consequences that may follow the use of the iodide of potassium. The cases we need not quote-the conclusions we may.

"It would appear," says he, "that the hydriodate of potash and iodide of starch are dangerous and uncertain remedies. I am, in my own mind, quite satisfied that they were the causes of death in cases 3d and 5th. Their uncertainty, in a remedial point of view, is even more to be lamented than their danger. If they were unsafe in large doses, and safe in small, or if the disease for which they are exhibited, or the constitution of our patient, had any definite influence on their poisonous effect, they might be used with comparative impunity. As yet, however, I know of no criterion by which we can judge beforehand of their probable effect; that the quantity exhibited is no guide, I am very certain. Case 3d had only taken one grain of the solid iodine twice daily for five days, when he died, while many of Dr. A. Buchanan's patients take seventytwo grains of iodine daily, in the same form, without any bad effects, for days and weeks together. Case 5th took five grains twice daily for a week, when she died; while Wm. M'Symont, æt. 50, Ward 7, with gangrene of the penis, took 3j. daily for eleven days, with apparently great benefit to his disease, and not one of its injurious effects. I have given it in double this dose, and known half an ounce given daily with impunity. I very much regret this danger and uncertainty. I consider hydriodate of potash as by far the best of our recent remedies, and have prescribed it more frequently than any other medicine. In future, however, I shall be more cautious in its employment. Every patient for whom it is prescribed should be frequently seen by his medical attendant, and should be warned to omit it whenever any of its constitutional effects appear. Case 5th teaches us to omit it when the papular eruption is profuse, and not to resume it. Swelling of the neck, hoarseness, and dyspnoea (cases 3d and 5th,) are most dangerous symptoms. For them I believe there is no remedy but tracheotomy, early performed, and on it I would place great reliance. Case 5th teaches us that delay is fatal; and I would not in any future case allow the state of the bronchial mucous membrane to deter me from its performance. If the above observations are correct, it would further appear that these iodides exert their poisonous influence on the mucous membranes of the air passages, not as direct irritants, but indirectly through the circulation, in the form of acute inflammation. I have never seen them act as irritants to the gastro-intestinal mucous membranes, nor have I ever seen them produce emaciation, atrophy of the mammæ and testicle, hectic, and those other symptoms described by various writers under the name lodinia."+

We prescribe the iodide a good deal, and we cannot say that we ever saw much mischief from it. Slight salivation, and some irritation of the gastro-in

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testinal mucous membrane we have seen-nothing more. But then we give it with caution-in moderate doses-not when there are, or have just been pyrexia or inflammatory symptoms—and we stop it when it disagrees.

PENNSYLVANIA HOSPITAL.

STATISTICAL ACCOUNT OF THE CASES OF AMPUTATION PERFORMED AT THE PENNSYLVANIA HOSPITAL, FROM JANUARY 1, 1838, to JANUARY 1, 1840.

The application of statistics to the great operations, is likely to be very serviceable. With what horror have we regarded lithotomy? It has been looked on as the most painful and fatal of operations. Yet it is not near so fatal as amputation, nor, perhaps, as most of the great operations.

Dr. Norris, one of the surgeons to the Pennsylvania Hospital, has published an account of the result of amputations performed in the institution. He alludes to a similar account published by Mr. Phillips, in the Medical Gazette. The number of cases collected by him is 640, embracing all cases, acute, chronic, and the results of violence which occurred in the practice of the persons by whom the returns were furnished within the period of four years. "Of these cases, 490 are reported cured, and 150 died, either in consequence of the operation or the progress of the disease, to rescue the patient from which, recourse was had to the operation."

Dr. Norris observes :

"The necessity of extending any observations that may be made through a term of years, is strikingly shown by an inspection of the tables which I have made; in some years the mortality after these operations being very small, while in others, though a similar class of cases have come under notice, and been subjected in every way to similar influences and treatment, the mortality has been large. From the first of January, 1830, to the first of January, 1832, but one death took place out of eleven amputations made during that period, while from the first of January, 1832, to the first of January, 1834, one-half of those amputated died (seven out of fourteen), and in the next succeeding two years the mortality became still greater, eight out of fifteen terminating fatally. From 1836 to 1838, the mortality then strikingly decreased, the loss being only one-third (five out of fifteen) and by the accompanying table it will be seen that, from the first of January, 1838, to the first of January, 1840, there has been but a single death out of twenty-four amputations, seventeen successive operations having had a favourable termination. To assert that death after amputation is rare with us, would be warranted by the experience of the past two years, though undoubtedly it would be as far from giving a true idea of the danger of the operation, or of our average success, as to aver our ordinary results to be such as were had between the years 1834 and 1836."

For reasons which seem satisfactory, but which we need not state, Dr. Norris concludes that the success at the Pennsylvania Hospital represents sufficiently that in the other large hospitals of America. All those amputations performed within twenty-four hours after admission, are included under the head of immediate, the patient in such cases having been brought to the house soon after the receipt of his injury. With one exception, the common circular operation was performed, and the stumps were all dressed so as to procure union by the first intention. The ordinary mode of dressing, is first to bring the flaps together by means of three or four long strips of adhesive plaster, and after covering the lips of the wound with lint spread with cerate, to apply a small cushion of charpie over the extremity of the stump, and to secure the whole

with a bandage moderately tight. The first dressing was generally made on the third or fourth day, and repeated daily afterwards till cicatrization was complete.

Dr. Norris furnishes a table of the amputations performed in the hospital from January 1, 1838, to January 1, 1840. That table we need not introduce, but content ourselves with citing the results of the amputations in question, added to those of the eight previous years.

Of eighty amputations on 79 patients, performed during a term of ten years at the Pennsylvania Hospital, thirty-five were primary, of which twenty-four were cured and eleven died, four of the deaths occurring within the twenty-four hours immediately following it.

Twenty were secondary, of which thirteen were cured and seven died.

Twenty-five were for the cure of chronic affections, of which twenty were cured and four died.

Thirty-two of the amputations were of the upper extremity, of which twentyseven were cured and five died.

Forty-seven were of the lower extremity, of which thirty-one were cured and sixteen died.

Seven were amputations at the joints, of which four were cured and three died.

22

13 of the 79 operated on, were under 20 years of age, of whom 12 were cured, and 1 died. 26 were between 20 and 30, were between 30 and 40, were between 40 and 50, were upwards of 50,

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of whom 19 were cured, and 7 died. of whom 15 were cured, and 7 died. of whom 9 were cured, and 7 died. of whom 2 were cured.

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1. That amputation with us is to be regarded as an operation attended with much danger to the life of the individual, the mortality after it being one in 3.

2. That the chances of success after it are much greater in persons who have been for some time suffering from chronic diseases, than in those who have it done while in robust health, the mortality in the former class of cases being one in 6, while in the latter it is one in 3.

3. That immediate amputations after injuries are less fatal than secondary operations, the mortality after the former being one in 3, while in the latter it is one in 2,

4. That amputation of the lower extremity is much more fatal than that of the superior member, the mortality after the former being one in 21%, while in the last mentioned class of cases it is only one in 6%, and

5. That the danger increases with the age of the individual operated on.— Amer. Journ. of Med. Sciences, May, 1840.

One double.

The great amputations only, it will be recollected, are alluded to. No death has followed any of the amputations of fingers, or toes, which have been made in the hospital during the ten years past.

REPORT OF SURGICAL CASES TREATED DURING THE MONTHS OF JULY, AuGUST, SEPTEMBER, AND OCTOBER, 1839. By G. W. NORRIS, M.D. one of the Surgeons to the Hospital.*

FROM this Report we shall extract the more interesting cases.

I. UN-UNITED Fracture.

1. Un-united Fracture of the Bones of the Fore-Arm of four weeks standing. Treatment by perfect rest and pressure-Cure.-Henry Baldwin, a healthy boy, ætat. 12, was admitted July 31st. His mother stated that his accident had been produced by a fall four weeks previously, and that his arm had been attended to by a physician in the country. Upon examination the fracture was found to be near the middle of the fore-arm; neither of the bones had united, considerable deformity existed, from bending of the bones outwards, and the integument was slightly ulcerated over the projecting ulna. The fore-arm was secured to a splint extending from the elbow beyond the fingers, and as much pressure was made over the projecting fragments, as the patient was able to bear. At first the bandage was removed, and the pressure re-applied daily, and, after a short time, every second or third day. By the 20th of August, perfect union had taken place, and the limb had become much straighter. Pressure and the splint, however, were continued till the 4th of September, and on the 28th he was discharged perfectly well, and with a very slight deformity at the part.

2. Un-united Fracture of the Femur of seven months standing-Treatment by rest and compression.—Michael Ward, ætat. 50, and enjoying good general health, was admitted September 14th, with an un-united fracture of the femur. He states that he received his accident in the middle of last February, by the fall of a bank of earth upon the limb. His left femur was broken obliquely in its lower third, together with both bones of the leg of the same side a short distance below the knee. After a treatment of seven or eight weeks, with long splints (probably Desault's) he was suffered to get up and move about, the union of the bones of the leg being firm, though somewhat deformed, while the thigh was much deformed and un-united. In August he set out from Ohio for Philadelphia, and performed one-half the distance on foot, with the aid of crutches. On admission, the left limb was found to be two and a half inches shorter than that of the opposite side. The lower part of the thigh was enlarged, owing to a great mass of callus which had been thrown out around the seat of fracture, and was much bent outwards, the lower fragment being drawn to the outer side of the limb. When placed in the erect position, he was unable to bear any weight upon the limb, and upon attempting to do so the motion of the lower upon the upper fragment, was very evident both to the patient and observer. Strong extension had no effect in bringing down the limb to its natural length, and all that was proposed by the treatment was to produce union of the fragments, and, if possible, a diminution of the deformity, by rest and pressure, without attempting to remedy the shortening. For this purpose a roller was applied from the toes upwards, after which strong pressure was made over the projecting portions of bone by means of a bandage secured to a well padded long splint placed upon the inner side of the limb. This apparatus was continued until October 14th, the bandage being tightened every

No. LXVI.

* Amer. Journ. of Med. Sciences.
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