Periscope.-Fistula in Ano treated by Ligature.

233

mation to a rule, by which the elevation of extensive causes; and such they may be, leaving the nature and regions may be computed to have taken place at pre-quality of the subterranean forces untouched-nothing vious periods. After mentioning the instance of the rise written, nor said, nor, it may be, supposed, concerning of the Chilian Coast in 1822, he adds, "In an inquiry them. Either the force was not there equally directed on this point, it becomes of consequence to learn some upon the interior of the extended mass, or if it were, particulars respecting the levels. Taking a particular did the mass oppose an equal resistance. Dr. Rae beach, it is generally observed, that the level continues properly remarks with regard to this, that in the present very the same along a considerable number of miles. A state of our knowledge, it is premature to pass an opinion, second and third beach, are also observed to be exactly or nearly in words to that effect. It may be said, howparallel to the first. These facts would seem to indicate quiet elevating movements, uniform over a large tract. to the immediate causes, and leaves the whole inquiry, ever, that the opinion then announced, has no reference It must, however, be remarked that the raised beaches at one part of a coast, rarely coincide with those at anrespecting them, open to investigation. I consider this other part, forty or fifty miles off. We might suppose gical science, and that there are no phenomena which the inquiry to be one of the greatest possible moment in geolothis to indicate a limit in that extent of the uniformity of extended territory of Canada presents, nearly so deserving the elevating cause. But, whatever doubt may rest observation and study. upon this minor point, enough has been ascertained to settle the main one, that we have in these platforms indubitable monuments of the last rise of the land from the sea, and the concluding great event of the geological history."

SURGERY.

FISTULA IN ANO TREATED BY LIGATURE.
LUKE, Esq.

By

fistula in ano by ligature kept moderately tight, by means
The following cases are illustrations of the treatment of
of a small screw tourniquet, thus gradually dividing by ul-
ceration those parts usually div.ded by the knife.
The advantages of this method of treatment over the
treatment by the knife are,-1st, The shorter period which
usually elapses before the final care; 2nd, The less pain
The absence of all cause of dread of the knife, and the
which is usually experienced during the treatment; 3rd,
consequent inducement which it offers to the timid to an
in the deeper forms of stula which communicate with the
all danger from bleeding-an advantage of great importance
rectum at a considerable distance from the anus.
treatment is conducted in the following manner :-An eyed
ary way through the fistula into the rectum, from whence
probe, armed with dentists silk, is introduced in the ordin-
the silk, together with the detached extremity of the probe,
introduced into the rectum upon the forefinger of the opera-
is withdrawn through the anus by means of a spring catch

The

Whatever credit the conclusions of geologists may generally be thought worthy of, it must be admitted that they act fairly, if they fairly exhibit the grounds that sustain them. You have the facts, judge of the conclusions who will. It is true, that in natural science, many facts advanced as such, may, upon attentive sifting and careful examination, be found to have no title to that character, they are then only stubborn things, when they are found to be true things, and the finding them to be so or not, to-effective curative treatment; and lastly, the avoidance of gether with the multiplication of them by the industrious observation of the student, constitutes the chief value of the inductive philosophy; and if the additional facts which the author, whose views upon this subject I have transcribed, are to be depended upon, and that under the limitation that has been assigned to the most remarkable of them, I hold the question as to the formation of the parallel lines by the waters of the ocean, and consequent negation of any inland fresh-water sea as their cause, to be a conclusion as valid as the nature of the evidence, which in such cases is necessarily but of greater or less probability, permits us to attain.

tor.

The parts to be divided are thus enclosed between the two extremities of the ligature, to which a small fistulaholes provided for the purpose, and knotting them so as to tourniquet is subsequently attached by passing them through prevent their being withdrawn. A screw is then applied, by the turning of which the requisite amount of tension is kept up. When the fistula does not communicate with the Speaking of the Canadian Lakes and Valleys of the St. rectum, a perforation is made in its walls by the eyed Lawrence as phenomena, whose cause might be explain-dinarily used. probe, the extremity of which is made sharper than that ored, in harmony with the hypothesis of a gradual, though ure, and the attachment of the tourniquet, is conducted in In other respects, the passing of the ligairregular elevation of the continent, reference was made the same manner as when there is both an external and inby me to the insufficiency of the water-scooping theory; the ligature is accomplished with great facility, and with ternal opening. It should be observed, that the passage of and the formation of the Lakes was attributed to un- little if any more pain than attends the ordinary examinaknown causes which excepted their internal or lower that the tension of the ligature is never so great as to cause tion of a fistula with a common probe. Care is also taken superfices from the operation of the elevating force or more than slight uneasiness at the part, and at its first apforces. As to the cause of these exceptions, nothing plication is usually left loose, to allow for swelling of the was alledged; represented as intercapedines, no closer ap caused by its pressure. enclosed part arising from the slight inflammation which is proach was made to a hypothetical assumption of the days, ulceration of the enclosed part commences, and the After the lapse of three or four

tourniquet becomes loosened, indicating the necessity of manner, and he declares that the whole of the pain was not the ligature being made tighter. This is done every three or four days, by making two or three turns of the screw with a watch-key fixed on a handle. While the process of ulceration is proceeding, a process of granulation is filling up the cavity behind the ligature, and on this account it is not desirable that the ulcerative process should proceed very rapidly, lest the latter should not proceed pari passu, and a cavity be left unclosed. When a case has proceeded favourably, it usually happens that it may be reported as cured within one or two, or at most a few days after the complete division of the enclosed parts and consequent falling off of the tourniquet. During the treatment, it is desirable that causes tending to produce inflammation should be avoided, but in many cases the confinement of the patient is unnecessary, and moderate exercise may be used. Should inflammation, however, supervene, much pain is experienced by the greater tension given thereby to the ligature, the obvious remedy for which is the loosening the ligature by reversing the screw of the tourniquet.

Periscope. On the Diagnosis and Treatment of Fractures.

235

a cure was effected without the use of instruments or of medicine, both of which combined would only alleviate and not cure.

[For the support of the rectum in these cases, we have found an instrument made by Mr. Eagland of Leeds, of the greatest service and efficacy. It consists of a circular spring to go round the loins something like the common truss. To the posterior part of this is fixed another spring, which is brought down as far as the anus and terminated by an ivory ball, and fixed in front like a suspensory bandage by two side straps. This ivory ball, which is oval in shape, keeps up the gut very effectually, in the same way as a prolapsed uterus or a hernia is kept up.]—Lancet, Dec. 7, 1844, p. 326.

membrane pressing down on the anus, which impede the evacuation of the fæces, introduction of instruments, and the injection of enemata. This morbid condition of mucous membrane, the author attributes to a neglected state of the bowels, and repeated great distension of the rectum by fæces, which causes the mucous membrane, when the bowel is empty, to hang in loose folds. This disease, if neglected or mismanaged, gives rise to prolapsus ani, an irritable and painful state of the sphincter, and an intro susception of the upper and undilated portion of the intestine, into the lower and dilated part. The treatment recommended for the simple relaxed rectum is, the avoidance of all aperient medicines, and the injection of a pint of cold water into the bowel every night previous to going to bed, the removal of the prolapsus, and the application of belladonna ointment to In cases of constipation from relaxation, aloes in combithe irritable sphincter. In the case of intro-susception of nation with sulphate of quinine was a favourite prescription the rectum, in addition to the use of the cold water injection, of Dr. Abercrombie, and often succeeds remarkably well, the exhibition of some mild aperient, taking care that especially in persons advanced in life. whilst a costive and hardened state of the faces is pre- In cases of great dilatation, might not injections of nivented, purging is avoided, and a course of the hyd. cum trate of silver be of service, administered as recommended creta, with hyoscyamus or conium, or the iodide of potash by Trousseau in the diarrhoea of children? (See Northern and sarsaparilla. Journal of Medicine, vol. i. p. 347 ) It has a great effect [Dr. James Johnson disagrees with Dr. Hunt with res-in producing contraction of the calibre of the vagina. pect to the use of mild aperients. He considers them to be essential to the successful treatment of the affection. He says-]

In cases of constipation, it is essential to effect a cure that the colon as well as the rectum should be acted upon. Fæces often collect above the rectum, and cannot be reached by small injections of cold water. These injections are, moreover, not so harmless as people seem to imagine; at all events, he has seen them productive of violent tormina and great pain; in some instances, producing faintness. He would, in this class of cases, administer some mild aperient, which would act on the colon, and soften the fæces in that tube-such, for instance, as the tartrate of potash or the confection of senna.

In the habitual constipation which so often produces this affection, Dr. Graves, after objecting strongly to the use of mercurial purgatives, recommends the following combination:—

B Electuarii sennæ ii.; pulv. supertart. potass. 3 ss.; Carb. ferri 3.; Syrupi Zingib. q. s.-Ft. electuarium.

The dose must be regulated by its effects, but in general a small tea-spoonful in the middle of the day and at bedtime will be sufficient.

Dr. Graves says, that the value of carbonate of iron as a tonic aperient has not been appreciated.-Northern Journal of Medicine, Jan. 1845, p. 185.

ON THE DIAGNOSIS AND TREATMENT OF

FRACTURES.

STANLEY, Esq., of St. Bartholemew's Hospital, London. In certain cases wherein the occurrence of fracture is not

These medicines produce no irritation or unavailing efforts to evacuate the rectum : on the contrary, they soften the fæces above, and soothe rather than irritate. In the second class of cases mentioned, in which there was intro- By susception of the rectum, he has found Ward's paste corrugate the folds, and give tone to the heart. In this class of plainly indicated by the mobility or distortion of the part, cases, when the bowels have protruded, and have not been or by the existence of crepitus, there is one strongly precarefully returned, it was liable to become inflamed, and sumptive sign of it, the attention to which has often helped be productive of great suffering. When persons so afflict-us in doubtful cases, especially in the instances of fracture ed walked about or sat down, this was liable to occur. The of the lower end of the tibia and fibula, also of the head of most efficacious mechanical contrivance with which he was the tibia; this sign is, an acute tenderness of the periosacquainted for the support of the rectum in situ, was the teu manifested in handling the part, combined with deepapplication of two silk handkerchiefs, one of which was to seated ædema from serous effusion into the cellular tissue be passed round the waist, and one end of another tied be-around the periosteum. An experienced hand and eye will hind, and the other end in front-a piece of soft sponge, readily distinguish these circumstances characteristic of covered with linen, being placed in the middle, so as to ex-fracture, from the general swelling and tenderness of the ert gentle pressure on the extremity of the bowel. This soft parts, the result of simple contusion. A man at the was simple, and easy of application. All instruments for present time in the hospital was admitted shortly after he the purpose he had found inefficient. had slipped down in the street; there was no distortion of the Mr. Bransby Cooper agreed with Dr. Johnson in refer- leg, and no yielding or crepitus could be any where detected; ence to the expediency of applying remedies that would act but such was the acuteness of the pain occasioned by pressure on the colon in the first class of cases described by Dr. of the lower part of the tibia, with the evidence, besides, Hunt. He considered, however, that the application of of the deep edematous swelling over this part of the bone, handkerchiefs in cases of prolapsus recti, as recommended that the fracture of it was suspected; and accordingly the by Dr. Johnson, was far inferior as a remedial agent to the limb was confined in splints. Ten days afterwards, an plan mentioned in the paper-namely, that of evacuating oblique ridge on the lower and front part of the tibia shewed the bowels at night, just before retiring to bed. In dis-that the bone was broken, and that the diagnostic sign of eases of the rectum, this rule was one of the greatest impor- the fracture had been of some value in determining the tance. If the bowels were evacuated in the morning, the treatment. Crepitus is frequently but a doubtful sign of patient either moved about, or remained in the sitting pos-fracture, especially in the injuries of bones near their artiture, by which irritation was kept up, and there was no op-cular ends; here it may be caused by an alteration of the portunity of keeping the rectum in situ. When evacuated synovia within the sheaths of the su rounding tendons, or just before bed-time, the patient remained in the recumbent within the contiguous joint; and, in injuries of the hip or position for many hours, and the affected bowel was, during shoulder, when the disp aced head of the femur or humerus the whole of that time, in the pelvis. By this simple planlies in contact with a surface of bone beyond the articular

236

Periscope. On the Diagnosis and Treatment of Fractures.

cavity, in moving the limb a grating sensation may then But we have now learned by experience that in the event be communicated to the fingers, so closely allied to that of of a fracture failing to unite within the usual period, methods fracture, as to be with difficulty distinguishable from it. In are to be adopted far more gentle, and, what is more importhe shoulder, for instance, when the head of the humerus tant, far more likely to be successful, than any one of the seThese methods are, exeris driven between the subscapularis muscle and the scapu- verer proceedings just indicated. la, the movements of the arm will communicate to the cise of the limb for the advantage of the action of the muscles hand of the surgeon a grating sensation not distinguishable surrounding the broken bone, maintenance of firm pressure from the crepitus of fracture. As it concerns the diagnosis against the portions of bone, that they may be kept steadily of fracture, it must be borne in mind, that by the operation in contact, and if possible by their periosteal surfaces. of the force which has broken a bone, its ends may get so Influence of the action of the muscles around the slowly firmly impacted together, as not to be separable without vio- uniting fracture. Of this there can be no doubt; it is evilence; hence it has happened that a man with both bones of denced to us in the many instances of fracture of the tibia not his leg broken has been able to bear considerable weight on firmly united within the ordinary period, wherein the pathe limb. I had a patient whose tibia and fibula were bro- tient has been desired to move about on crutches, not bearing ken about their middle, by the kick of a horse; yet he con- weight on the limb, but swinging it about freely, and in a trived, with the help of a stick, to walk from Highgate to short time the uniting medium, which was flexible, is found the hospital, a distance of between four and five miles. Un-to be perfectly firm. I lately had in the hospital a woman, der circumstances of doubt, assistance in the diagnosis may aged 32, with a fracture of the femur, at the junction of its be obtained by ascertaining in what manner the accident oc- upper and middle third; it was treated strictly by confinecurred; and here it is to be recollected, that a shock impart- ment on the back with the application of a long splint to the ed to the distant part of a limb may cause the fracture of the outer side of the limb. At the expiration of two months, the shaft of the femur or tibia. A man had just raised a sheep-ends of the bone were ascertained to be freely moveable. The hurdle from the ground, and was holding it in his hands, thigh was then kept firmly encased in leather splints through when a gust of wind turned him round with the hurdle; the the next two months, at the expiration of which the ends of great toe of his left foot coming against a stone, he immedi- the bone were found to be still freely moveable; it was now ately felt and heard his leg break; his wife, and another man determined again to apply the leather splints in a manner to standing by, also heard the crack. He was directly brought maintain firm pressure against the ends of the bone, and beto the hospital, and the tibia was found broken in two places, sides, to encase the thigh in the splints composed of layers of transversely through its middle, and obliquely through linen cemented together by the mixture of white of egg and' its lower third. Also, on occasions when it would not be ex-flour, and around these to apply the starched roller. The pected, an inordinate or spasmodic action of the muscles sur- limb being thus secured, the patient was desired to move rounding a bone may cause its fracture. A coachman, in about freely on crutches. Almost from the commencement descending from his seat, felt a sudden twist in his limb; and from that instant he was unable to bear weight on it; he contrived to reach the ground on his other leg without falling, and was directly brought to the hospital, when there was ascertained to be a fracture of the shaft of the femur, just below the trochanters.

of this plan, the woman began to express a consciousness of firmness in the limb of which she had not before been sensible. After another six weeks, the bone had become so firm that she could bear weight upon it, and she left the hospital' walking perfectly well. I could draw no other conclusion from this case than that the firm union of the fracture was

Influence of pressure upon the ununited fracture.-The application to the limb of stiff leather splints, or other apparatus calculated to maintain firm pressure against the bone, is undoubtedly a most important part of the treatment of ununited fractures, and the merit of first establishing it belongs to Mr. Amesbury. It should not be the object to maintain the fractured ends of the bone in contact, but rather that the two portions of the bone should overlap, to allow of their periosteal surfaces being firmly pressed together, for as the tissue of periosteum is more readily disposed to the deposit of osseus matter than the tissue of bone, accordingly by the actual and firm contact of the periosteal surfaces the advantage is obtained of a better chance of the union of the fracture, which well compensates for the shortening of the limb consequent on the overlapping of the two portions of the bone.

Adjustment of fractures. For this object, in many instan- mainly attributable to the adoption of the proceedings having ces, nothing more is required than that the limb should be for their object the free action of the surrounding muscles. placed in an easy posture; directly this is done, the ends of Since in this case, the firmness of union had not commenced the bone adjust themselves perfectly well. And I have at the expiration of four months from the occurrence of the learned by experience, that when one fair effort, by the ex-fracture, it almosts warrants the conclusion that no period is tension of the limb and manipulation of the broken bone, has two late for the commencement of that stage of the reparafailed to effect the adjustment of its ends, there is but little tive process of fracture upon which the firmness of union deprobability of success from a repetition of the same proceedings, pends. to which the obvious objections are, the severe pain they occasion, and the injury they do to the surrounding soft parts. When one well-directed effort by extension of the limb and manipulation of the broken bone has failed to effect its adjustment, we must trust to the chance of its adjusting itself; and if it does not do so, we may assume the existence of one or other of the following obstacles to adjustment, over which extension of the limb, or other proceeding we may adopt, can have but little influence-that the displaced ends of the bone have become firmly impacted together; or that the bone has been broken in two places, and the middle piece displaced, upon which the extension of the limb has no effect; or that a displaced tendon or muscle has got between the ends of the bone; or that one end of the bone has been driven into, and has become firmly impacted in the substance of an adjacent muscle; or that the muscles on one side of the limb having been lacerated, the muscles on the opposite side, their antaOn the Use of the Immoveable Apparatus.-The treatgonists, acting inordinately upon the broken bone, have dis-ment of fractures by the immoveable apparatus, as it is termplaced it. ed, has been of late especially adopted by Dr. Scutin, Chief Surgeon of the Hospital at Brussels. The object aimed at by this treatment is to avoid the inconvenience of confinement, by enclosing the limb in an apparatus sufficiently strong to prevent the separation of the fractured surfaces, and of sufficient lightness to allow the limb to be moved about with ease. Varieties of apparatus have been recommended for this object; that which I employ in the hospital consists of

[Fractures which are slow of union are happily much more common than fractures which will not unite. Until a few years back, if it were ascertained that a fracture at the end of the usual period had not united, splints were applied, and the patient had still to keep in bed, and if the bones remained ununited after a few weeks more, the fracture was declared incurable.)

Periscope. On the opertion of Tracheotomy.

the splints, composed of layers of linen, cemented together by a mixture of egg and flour, and of the starched roller. The excellence of the splints thus contracted is, that with the firmness of the case they form, they are so exactly moulded to the inequalities of the limbs, that when confined to it by the turns of the roller, not the least movement of the limb within the splints can occur; and this is obviously essential to the quietness of the ends of the bone. Curiously enough this turns out to be the revival of a practice adopted in bygone times. Cheselden, in his Anatomy, states "that a professed bone-setter living in Westminister communicated to him the following method of treating fractures; this way was, after putting the limb in a proper posture, to wrap it up in rags, dipped in white of eggs, mixed with wheat flour; this drying, grew stiff, and kept the limb in good position;" and in his observations appended to Le Drain's Surgery, Cheselden observes, "there is no bandage equal to this for a fractured leg. I always use it, leaving that part upon the tibia very thin, that if it grows lose by the abatement of swelling, I then cut out a piece and bind it closer. Upon a journey, I once set the cubical bones of a gentleman's arm that was broken, and making use of this bandage, he, the next two days, made long journeys without any inconvenience, and at the end of forty days took it off, and was perfectly well."

237

the forceps the mucous membrane of the urethra, and with a pair of scissors makes four slight incisions, so as to forin four equal flaps; then using a fine needle carrying a silk ligature, he unites each flap to the skin by a suture. The wound unites by the first intention; adhesion being formed between the skin and mucous membrane which become continuous, a condition analogous to what is observed at the other natural outlets of the body. The cicatrix then contracting, instead of operating prejudicially, as in the old methods, tends, on the contrary, constantly to open the urethra, whilst a perfect covering is provided for the ends of the corpora cavernosa. In the spring of 1843, I had the satisfaction of seeing this ingenious operation performed by M. Ricord, at the Hôpital du Midi; when I saw the patient, eight days afterwards, the sutures had been removed, union had taken place between the skin and mucous membrane, and the urine had freely passed without the intervention of a catheter. I saw this patient again when he was about to leave the hospital, at which time the cicatrix was complete, the orifice of the urethra patent; there was an excellent stump, and in short, the operation appeared to be perfectly successful. M. Ricord has performed the operation in other cases, and, he reports, with the same happy results. I have performed the operation many times on the subject, and have found no difficulty in the execution of it. Another inconvenience mentioned by Mr. Hancock, the difficulty of directing the stream of urine, is one which be comes troublesome in proportion to the shortness of the stump. It may be obviated by the contrivance recommended by Ambrose Pare. The patient must provide himself with a funnel-shaped canula, made of box, ivory, or metal, the base of which, being applied over the stump, and resting on the pubes, the other end will serve to carry the urine clear of the person.-Lancet, March 8, 1845, p. 266.

There are objections to the indiscriminate use of the immoveable apparatus, and especially to its application upon a fractured limb immediately after the receipt of the injury; still, however, under certain circumstances, it is a most valuable addition to our plan for the management of fractures. Upon the subsidence of the inflammation and swelling immediately consequent on a fracture, the limb may in general with safety be enclosed in such splints as I have described, and which, when properly applied, will prevent any motion between the ends of the bone, and with a fracture of the femur as of the tibia, by the application of these splints, the patient will be enabled to move about on crutches, and even bear weight on the limb long before the fracture is firmly united. In several cases of fracture of the tibia I have by means of this apparatus been enabled to discharge By ROBERT LISTON, F.R.S., Senior Surgeon to University the patient within little more than a fortnight from the occurrence of the accident, when, for particular reasons, it has been an object of importance to leave the hospital at this early period, instead of remaining here the usual time

of five or six weeks.

In another class of cases the greatest benefit has been derived from the use of the immoveable apparatus. I allude to fractures of the thigh and leg in aged persons, in whom, from their not bearing confinement well, the stomach has become deranged, with failure of appetite, and obvious decline of the vital powers; directly these changes are noticed, the injured limb is enclosed in the immoveable apparatus, whereby the patient is enabled at once to get up and move about on crutches, and the unfavourable symptoms have immediately disappeared. I feel certain that by adopting this line of conduct, the lives of some old people have been saved who otherwise would have sunk.-Medical Gazette, Nov. 29, 1844, p. 273.

ON AMPUTATION OF THE PENIS.

By ROBERT BARNES, M.B., L.

[Mr. Barnes publishes an account of the mode in which M. Ricord avails himself of the process of contraction after amputation of the penis to keep the urethra open.

The principle of most surgeons in this operation is to counteract contraction.]

M. Ricord's principle is to avail himself of this process of contraction, and turn it to account in preserving the orifice of the urethra patent. The proceeding is this-having performed the amputation, with the, precaution of preserving sufficient skin, and no more, to sheathe the corpora cavernosa, and secured the vessels the surgeon seizes with

ON THE OPERATION OF TRACHEOTOMY.

College Hospital.

(Condensed from the Lancet, Nov. 1844.)

The trachea requires to be opened for the extraction of foreign bodies. In this case no time is to be lost, as fatal symptoms may arise at a moment's notice. If the foreign body is loose, it will sometimes fall out by itself as soon as the opening into the trachea is made. At other times, they will not come away for a day or two after the operation. If it be situated above the opening, it may sometimes be disentangled and extracted by a bent probe. It is usually, however, found below; in this case, after having ascertained its exact situation by the probe, it must be extracted by the forceps.

Tracheotomy is also necessary on account of acute disease. Sometimes, in cases of scalded glottis, the symptoms become so alarming as to render the operation indispensable. It is occasionally also required, in consequence of wounds in the neck, where suffocation is threatened in consequence of extravasation into the tissues. Edema of the glottis is another affection which sometimes imperatively calls for the operation. In all these cases, we must not wait until death is imminent before we open the trachea, but do sa while the lungs and head are as yet unaffected. In some cases of ulceration of the larynx, an opening is made in order to enable the patient to breathe more freely, and to give the ulcers time to heal. The latter indication may be promoted, by touching the diseased part with a solution of lunar caustic.

In acute laryngitis, if the disease be confined to the larynx, it may be necessary to open the trachea. In croup no benefit will ensue from the operation, because the trachea, and even the ramifications of the bronchi, are involved in the disease. We are not justified in having recourse to