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glands and other parts about the mouth by means of the branches of the superior cervical ganglion, which accompany all the branches of the external carotid artery in nearly the same manner as those of the semilunar ganglion do the arteries distributed on the abdominal viscera."

From the preceding extracts and statements our readers will form some idea of Mr. Swan's hypothesis of the action of mercury.

AN ESSAY ON THE TONGUE IN FUNCTIONAL DERANGEMENT OF THE STOMACH AND BOWELS, AND ON THE APPROPRIATE TREATMENT; ALSO THE TONGUE'S ASPECT IN ORGANIC DISEASE of the Lungs AND HEART. By Edward Williams, M.D., Senior Physician to the Essex and Colchester Hospital. Second Edition, 8vo. pp. 236. Simpkin & Co. and Renshaw. London, 1847.

THE following extract from the Author's Preface gives, if we mistake not, the very pith and kernel of his elaborate researches.

"It was after much reflection that we began arranging the materials for the Essay, nor was it without considerable labour in selecting from the case-books those instances in which the tongue's aspect was described, and by the avoiding those in which the tongue's appearance might have been influenced by medicaments, that we were enabled to shape our proceedings; however, in all labour there is profit,' and the tongue presented itself under two principal aspects, namely, when the papillæ were developed, and when they were not observable.

"In pursuing the subject, by arranging the cases in a tabular form, it became apparent that when the papillæ, especially the filiform and tuberose, were prominent or florid, that the gastric symptoms were the most prevalent, and this circumstance led to the examining the symptoms attending a development of the different orders of the papillæ. A careful analysis of these cases established the inference, that the stomach was specially affected when the filiform or tuberose papilla were developed; hence the tongue of gastric functional derangement.'

"A like review of the remaining cases led to the conclusion, that disturbance of the intestinal canal was accompanied with certain appearances of the tongue, the papillæ not being observable, and thus originated the 'tongue's aspect in functional derangement of the intestines.'"-P. vi.

Even if we had space to epare, it would have been utterly impossible to give the reader any thing like a correct idea of the contents of Dr. Williams' volume. The details communicated are surprisingly minute, and none but a most zealous and pains-taking observer could have had the patience to record and compare such a host of particulars. Those who feel an interest in all the curious niceties of symptomatology and diagnosis in reference to an individual organ of the body, cannot but be gratified with our author's work.

ON INDIGESTION AND CERTAIN BILIOUS DISORDERS CONJOINED WITH IT; TO WHICH ARE ADDED SHORT NOTES ON DIET. By G. C. Child, M.D., Physician to the Westminster Dispensary. Octavo, pp. 219. London: Churchill, 1847.

THE author has evidently expended much care and labour in the preparation of his work. Although not containing any thing with which every medical man of

1847.]

Child on Indigestion, &c.

551

any experience is not perfectly conversant, its contents certainly evince on the whole, an attentive observation of the phenomena of Dyspepsia, and a sound judgment in their discrimination and treatment. Dr. Child attempts, on several occasions, to reduce the study of the symptoms of this protean disease to a standard of greater accuracy and exactitude than has been done before, by frequent reference to the statistical data furnished by 200 cases of which he has kept a minute register. It is, however, very questionable whether any good can ever result from such elaborate divisions and sub-divisions as are found in the following passage on the subject of the "various pains observed in indigestion:"

"All the terms may be arranged in six groups.

I. Weight about the pit of the stomach, or front of the chest-and as more or less synonymous with this, may be regarded,

Distention.

Tightness.
Oppression.
Pressure.

Stoppage; the lodging of food, as if it would pass no further than the epigastrium.

II. Aching. Gnawing.

A dull, wearing, or 'dead' pain.

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A dragging or heavy' pain.

III. Sensation of heat (fer chaud of French writers).

Burning or hot pain.

Acridity.
Rawness, &c.

IV. A sensation like cramp.

Spasms (often applied by patients to sharp pain).

As if the stomach were fixed or nailed to, or drawn up against, the spine; as if it were turned into bone; as if a bone were in it.

A ball, bullet, or something hard at the epigastrium, or under the

sternum.

A knot in the same place.

A drawing pain, forcing the patient to stoop, or 'bending him double.'

A severe dragging, twisting, or tearing pain.

As if a cord were drawn tightly round the waist.

V. Sharp pains.

Spasms (used also to denote cramp).

Acute, quick, or darting pain.

Plunging, twinging, or pinching.

Like pins and needles (often an anomalous pain).

VI. Anomalous pains form a less numerous class than one might expect, and are chiefly observed in the nervous, hysterical, and hypochondriacal. They are insufficient of themselves to characterize dyspepsia, and hence are always associated with some of the other pains above mentioned.

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Beating, fluttering, hammering, pulsation.

A moving' in the stomach; nerves working.'

Tumbling, trickling.

A sensation of cold at the pit of the stomach.

A sinking, emptiness, or numbness at the same place.

"Table showing the comparative frequency of the different kinds of pain above

mentioned in 200 well-marked cases of indigestion:

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Such labour is almost like that of one seeking to describe the thousand forms of clouds in a summer sky, or the ever-varied hues upon a pigeon's breast. The "Short Notes on Diet," were surely not intended for the instruction of medical men; if designed for other readers, they should not have found a place in a work addressed to the profession.

LECTURES AND OBSERVATIONS ON CLINICAL SURGERY. By Andrew Ellis. Small 8vo. pp. 275.

Dublin, 1847.

ALTHOUGH the perusal of Mr. Ellis' little work impresses us with the belief that his Lectures must prove highly useful to those to whom they are addressed, yet they seem to us to scarcely contain sufficient of novelty or original observation to call for publication. The author manifests a disposition, however, to independently examine the foundations of received opinions, in spite of the prescriptive authority of great names by which these may be supported, which, tempered as it yet is by rendering of due deference to these, is well deserving of imitation and approval. We proceed to select a few passages from some of the Lectures.

Treatment of Wounds of the Brachial Artery.-After describing the various results of injury to this vessel, Mr. Ellis proceeds to give an account of their management, some portion of which is as follows:

"Let us begin the consideration of this subject by asking what a surgeon ought to do, supposing he had reason to believe, from the history of the case and ocular evidence, that the brachial artery had been wounded? Under such circumstances, if the case were mine, I would proceed as follows:-In the first instance I would procure a long roller, and as much lint or sponge as would be sufficient to make a compress; the hæmorrhage being restrained, in the mean time, by an assistant; who either with, or without the aid of a tourniquet made efficient pressure on the brachial artery above the wound; I would proceed to apply the bandage from the fingers (the fingers themselves being included) up to the bend of the arm: I would then place the compress over the wound, and with repeated figure of 8 turns of the bandage, make moderate pressure, with the hope that such a wound might heal without the supervention of any aneurismal affection whatever. I would then have the patient placed in bed, with his arm moderately extended on a pillow, and give directions that the bandage and compress should be kept constantly wet with a cold evaporating lotion. I would likewise adopt, in a rigid manner, the antiphlogistic plan of treatment, and moderate the heart's action by the cautious administration of small doses of tartar-emetic and digitalis. I have stated that I would keep the limb in the extended_position; the reason why I consider this the best position is the following:-We are to suppose the wound in the artery is in the longitudinal direction, that is to say, that its greatest diameter corresponds with the long axis of the wounded vessel; this being the case, it is obvious that, by keeping the arm in the extended position, the extremities of the wound must be drawn far asunder; and in this way its lips or sides brought close to each other, and placed in a position favourable to union by adhesion. If the patient could bear this state of things for five or six days, I would then cautiously remove the bandage; but would not disturb the compress. I would now apply a new roller with a moderate degree of tightness, and direct a continuation of the antiphlogistic plan of treatment, with some mitigation, for at least a week longer. By this time the wound in the artery will, in all probability have healed, and the liability to aneurism passed away. I have

1847.]

Ellis' Lectures on Clinical Surgery.

553

known two cases treated in this way with complete success; one by the late Mr. T. Roney, and the other by the late Mr. Todd, both gentlemen of high professional attainments and of well-merited distinction."-P. 63.

This proceeding must, however, be discontinued if great pain and tension of the limb take place. Pressure having been thus tried in vain, and a diffused softish swelling attended with a "sort of undulatory pulsation" existing, we must open the tumour, remove the extravasated blood, and tie the artery above and below its wounded portion. In the case of circumscribed brachial aneurism the cure may be accomplished by compression or by the application of one ligature above the aneurismal tumour. The bandage already described should be applied with moderate tightness, great pressure not only being painful and sometimes dangerous by bursting the imperfectly formed sac, and converting the circumscribed into a diffused aneurism, but also in no-wise conducive to a cure. In the first volume of the Dublin Journal is an account of three cases treated by Dr. Cusack by means of compression applied over the tumour, Valsalva's treatment being coincidently employed. In two, the cure was accomplished without causing the obliteration of the arteries engaged. In the third, the sac gave way, and the case was then treated by ligature. According to Scarpa's investigations the cure of these aneurisms is generally effected without obliteration of the artery or healing of the original wound in its parietes-the cured aneurisms he examined appearing to have degenerated into small tumours, consisting of the fibrin of the blood which had externally established a connexion with the circumjacent cellular membrane, and internally with the aperture of the artery. "In one of the cases the inner part of the aneurismal opening was closed by a calcareous deposit." Compression tried in vain, we must cut down and apply a ligature to the vessel without disturbing the aneurism.

"Gentlemen, we have now arrived at the consideration of the best method of treating the arterio-venous or varicose aneurism. It is a well-established rule in surgery that we should never operate in a case of this kind unless when compelled to do so by urgent circumstances. For example, suppose pressure had been fairly tried without advantage, that the tumour is increasing in size, that it is painful and the limb swollen; when this state of things is established, the necessity for surgical interference is but too obvious. The operation which promises most advantage under such circumstances is that of tying the artery above the aneurismal tumour, as in the case I have just mentioned; leaving the tumour itself to the action of the absorbents. Judging from the literature of this subject, the operation should be undertaken with the utmost caution and circumspection, inasmuch as the records of surgery furnish but few cases in which it was not followed by untoward circumstances. I have myself witnessed but one case of this form of aneurism, in which the artery was tied. The case I allude to was treated by the late Mr. Hewson in the Meath Hospital. For some days after the operation the case appeared unpromising, the tumour having retained its former size and pulsation. On the third day after the operation, Mr. Hewson applied a compress of lint over the tumour, and retained it in this position by strips of adhesive plaster, which were drawn obliquely over it; but in such a manner as not to completely encircle the limb, so as to impede the return of venous blood. In the course of three or four days, the compress was cautiously removed for the purpose of ascer taining the state of the tumour, which was most satisfactory. The swelling was not one-half the size it had been previous to the application of the compress; it had acquired a solid feel particularly at its circumference, and the pulsation had become exceedingly obscure. The compress was again applied as before; the ligature came away in eight or nine days, and the patient left the hospital in five or six weeks perfectly cured.

"In cases of aneurismal varix the surgeon should never interfere beyond recommending the patient to wear a bandage constantly on the limb to prevent over-distension of the veins."-P. 73.

Rules for the Employment of the Trephine.-Mr. Ellis, after exhibiting the evils which resulted from the practice inculcated by Mr. Potts and his followers, states the limited number of circumstances under which the improvements of modern practice render this operation justifiable. 1. As it is a dangerous ope ration, it must not be undertaken unless it cannot render the patient's condition worse, or indeed unless it is likely to improve it. 2. It should be at once resorted to in the case of compound fracture, with depression, and bad constitu tional symptoms. 3. It should be performed in a case of compound fracture, with depressed bone, and a foreign body, even although the constitutional symptoms be not urgent; for, in such a case, fatal inflammation may be afterwards set up, or the patient may become the subject of epilepsy or other diseased state of the brain. 4. Compound fracture with great depression, although there is no foreign body present, and the constitutional symptoms are slight, presents another case, but as eminent surgeons are here at issue, Mr. Ellis would not recommend interference in the case of children, unless the bone be depressed a full inch. We remember in the days of our pupillage, at St. Bartholmew's, nothing excited the deprecatory remarks of that formidable critical body, the Dressers, more than the apparent timidity which more than one of the surgeons manifested in meddling with this case of the category. Events, however, generally proved the correctness of their practice, and that in cases which were long watched after they had quitted the hospital. 5. In the case of contused wound of the scalp, especially if situated over the parietal bone, attended with fracture, without visible depression, but with bad constitutional symptoms, if reaction cannot be brought about by the usual means, rather than let the patient die without the chance, the trephine should be used in the possibility of the pressure being caused by the depression of the inner table, or the effusion of blood upon the dura mater. 6. In contused wound of the scalp, without visible fracture, but with very urgent constitutional symptoms, the same reasoning is employed by Mr. Ellis. 7. The same in violent contusion of the scalp, with bad constitutional symptoms. 8. In the case of recurring insensibility after temporary recovery from the effects of a blow on the head, the operation is always indicated, the compression arising from effused blood." 9. It is so likewise when the history and symptoms lead to the belief that matter has formed between the dura mater and skull, although it is seldom of service, in consequence of the deeper-seated portions of the organ being simultaneously affected. 10. The presence of a sinus must never prevent the operation, providing the cause of compression is there located.

It will be seen that Mr. Ellis admits of a greater extension of this operation than is generally now done. Much may be said, drawn from the desperate nature of these cases, in favour of such practice; but we believe that the instances of success are not sufficiently numerous to offer much encouragement.

Rupture of the Bladder.-"In the first place, it may, perhaps, appear somewhat strange to you, that the bladder should have given way, in both instances, in that part which is covered by peritoneum. Now you are not to consider this in the light of an accidental circumstance; in every case I am acquainted with, in which the bladder gave way, in consequence of falls or blows on the abdomen, the rupture took place in the peritoneal region of the organ. In support of this statement, I beg to refer you to two very important cases of this description, which have been published in the second volume of the Dublin Hospital Reports,' by Dr. CUSACK; and also, to the ninth volume of the Dublin Journal of Medical Science,' in which you will find the particulars of some interesting cases, detailed by my distinguished colleague, Dr. HARRISON. The only explanation I would venture to suggest, is the anatomical fact, that the superior and posterior regions are weaker than the other parts of the bladder; inasmuch as they do not receive any support from the reflections of the pelvic fascia

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