covered with any of the ointments which I have already mentioned to you. However, 1 should remark that the composition of the ointment does not seem to have any effect whatever. I have tried them all, and afterwards common cerate, and found the latter to answer as well. Dilatation then is the chief element of cure in such cases, and I believe that considerable success would attend its use if we could induce our patients to resist the pain which it, in the first instance, always occasions.

Incision of the sphincter ani was proposed by Boyer, and recommended by him as the best, indeed the only mode of treating fissure of the anus; his practice has been followed by most of our surgeons up to the present day. Boyer regards this method as infallible, yet several practitioners mention cases in which it has failed. He was naturally led to advocate this mode of practice, because he believed that contraction of the sphincter ani was the chief cause of fissure.

The preparatory steps of this operation are exactly the same as those for fistula in ano. The lower intestines are to be emptied by means of a lavement, or some mild purgative, in order to ensure quietude for some time after the operation. The instruments employed are a straight, probe-pointed bistoury; a common bistoury; a large tent; a T bandage, and all the minor accessories. The patient is placed on the edge of a bed, with the head low, the under limb extended, the upper one flexed, and the buttocks kept widely apart by assistants. The surgeon now introduces the index finger of his left hand into the rectum, guides along it the flat side of his probe-pointed bistoury, and divides the sphincter. Should the fissure occupy the median line in front, he must not cut upwards, for fear of injuring the urethra or vagina. Boyer thought it sufficient to divide the sphincter at any point, without caring where the fissure may be; but I am of opinion that you will do well to pass the blade of the knife through the fissure at the same time that you divide the muscle. When this has been accomplished, you continue the incision upwards and downwards for an inch or two, so as to cut through the whole thickness of the sphincter. A single incision is usually sufficient; but if there be several fissures, or if excessive contraction of the sphincter be present, then we must make a second incision on the opposite side of the anus. When the edges of the fissure are rounded off, hard, and thickened, we seize them with a forceps, and remove the hardened portions either with the knife or scissors.

The dressing is very simple. A tent of lint covered with cerate is placed between the lips of the wound, but its upper extremity must reach about an inch beyond the superior angle of the incision. The space between the buttocks is then filled with lint, and the whole supported with a T bandage. The tent must be supplied every day until cicatrization takes place. I have said nothing of the occurrence of hemorrhage, for it is almost impossible that any such accident should happen; but were it to arrive, you must have recourse to the usual means of arresting it, with which you are all familiar.

Such, gentlemen, are the methods of treatment generally employed for the cure of fissure of the anus; cauterization, dilatation, incision. The latter treatment is successful in a vast majority of cases; but as some modern practitioners have insisted on the point, that constriction of the anus is the effect, not the cause of fissure, their opinions have produced some new ideas relative to the treatment of this affection. Upon the principles of these gentlemen, I have practised excision of the fissure instead of dividing the sphincter muscle. This operation had been highly spoken of by Mothe and Guérin; I had mentioned it myself in 1832, and some of my operations were published in 1836. The following is the method which I adopted. The patient is placed in the same position as for incision of the sphincter; the point of the border of the anus occupied by the fissure is then seized with a hook, and a couple of strokes of the bistoury on the right and left complete the excision of the fissured part. Sometimes I employed the scissors to remove it, but always avoided cutting the muscular tissue underneath. The operation is soon over, and unattended with pain; I have performed it eight or ten times at least, and have almost always succeeded

in curing the patient. In one or two failures I was unable to find out whether the want of success depended on my not having cut out all the diseased structure, or on some other cause. I believe that when the complaint is of long standing, we should divide the sphincter, and at the same time remove the ulceration; that is to say, combine incision and excision together. I shall do this in the case we are about to operate on. The disease here has existed for several years; the ulcer is large, with a grayish, lardaceous base; and it is very probable that simple incision of the muscle would fail to effect a cure. You may ask me, perhaps, why I employ excision, and do not remain content with division of the muscle, a mode of treatment which has been sanctioned by experience. My reasons are the following. Division of the sphincter is an easy and quick operation, and attended almost certainly with success; but it compels us to cut through the deeper-seated tissues beyond the muscle. The wound which results always suppurates for some time, and may occasion dangerous accidents. The inflammation and formation of matter may extend to the pelvis, and compromise the patient's life. I have seen two cases in which the patients died after a division of the sphincter for fissure of the anus. The operation of excision is entirely free from this danger, because the cellular tissue beyond the sphincter is not touched. The resulting inflammation is very slight, and the wound requires to be dressed for three or four days only. Finally, it is an operation much more simple than division, and one which we should always prefer in recent cases; but when the disease is of long standing, and the contraction of the sphincter violent, we should combine the two operations, so as to ensure success in the most obstinate cases.—Provincial Med. and Surg. Journal, April 3, 1841.

30. Case of Dislocation of the Cervical Vertebræ cured. By Dr. SCHUK, of Vienna.-A man, 24 years of age, whilst engaged at his work on the 5th of December, 1838, twisted his head suddenly round, in consequence of one of his companions roaring into his ear, when he instantly felt something give way in his neck, and found it impossible to move his head. Next morning, when he applied for assistance, his face was swollen, his head turned to the right, and bent down towards the shoulder. His neck was slightly arched on the left side, but hollowed out on the right. He complained of pain, which was augmented on pressure over the seat of the third, fourth, and fifth cervical vertebræ, and he was unable to move the head in any direction; every attempt to do so gave pain. The direction of the spinous processes of these vertebræ could not be accurately ascertained. He complained of weakness of the right arm, and could only raise it with great effort. The other functions of the body appeared to be natural. It was thus apparent that partial dislocation of some of the cervical vertebræ existed, and some attempts were made to reduce it by drawing the head directly upwards, the trunk of the body being held fixed; these, however, failed, but they gave no pain.

On the 7th of December, the weakness and numbness of the right arm were greater. New efforts were therefore made to effect the reduction of the dislocation. The patient was laid in the horizontal posture, the shoulders were held fixed by means of folded sheets, whilst a towel was passed under the chin, in order to allow of a greater force being used for the extension; an assistant supported the occiput with both his hands. Extension was then made and gradually augmented, till the patient and assistant felt a snap as of two bones meeting. The extension was then gently relaxed, when it was found that the head was restored to its normal position, and the power of moving it was restored. The weakness of the limb, however, remained, and was even worse next day. On the 9th, he complained of vertigo and starting during his sleep, and his pulse was quick. For this he was bled to a considerable extent, which induced fainting and convulsions. He passed, however, a good night, and next day his pulse was nearly natural, the vertigo was gone, and he had partially regained the use of the right arm. He left the hospital cured on the 13th.-Ed. Med. and Surg. Journ., from Medizinische Jahrbuch des Osterreichischen Staates, vol. xxx, 1840.

31. On the Auscultatory Phenomena in externally situated Aneurisms, and on the difference between an independent and a communicated pulsation in Tumours. By DR. SCHUK, of Vienna. When the stethoscope is placed over an aneurismal sac, or over a diffused aneurism, one perceives a very loud uninterrupted bellowssound increasing with each pulsation. It is the more marked the more powerful the action of the heart is; the nearer the aneurism is to the heart, the rougher the wall of the artery turned towards the blood is, and the easier the blood contained in the aneurismal cavity can be put into eddying and vibratory motions by the wave of blood passing through it. The last circumstance explains why, in enormously large aneurisms with but few layers of coagulum, as well as in those of which the sac contains scarcely anything but layers of coagulated lymph, the bellows-sound is proportionally weak. In the first of these cases the quantity of fluid is too great for all its parts to be put into strong vibration by the current of blood; and, in the second, the quantity of fluid put in motion is small, and the layers of lymph, laid one over the other, hinder, in some measure, the conduction of the sound.

When the blowing is remarkably loud, it is observable that the note of the murmur is not equally high throughout; but that at the beginning of the diastole of the artery it appears higher, and thence decreases remarkably till the next diastole.

This murmur extends for a considerable distance both towards the heart and even somewhat further towards the distal portion of the artery, and becomes weaker as it is examined at a greater distance from the aneurism.

The causes of the murmur are, first, the friction of the current of blood on the rough walls of the aneurism, or the fibrine, or on the edges of the orifice of communication between the artery and the aneurismal pouch; second, the vibration or eddying motion of the fluid blood contained in the aneurism, excited by the current of blood passing through it.

In a varicose aneurism the auscultatory signs are heard in the most striking manner. I had not long since two opportunities of observing this condition; in both it resulted from unfortunate venesection at the bend of the elbow. In these cases the murmur, by its intensity, becomes a whizzing sound, and the equality of the strength, as well as of the note of the sound at the different movements of the motion of the blood, is very remarkable. These phenomena are already distinct at a period of the disease when, from its short duration, but little dilatation of the wounded vein has taken place, and they are, therefore, of essential use in facilitating and supporting the diagnosis. The loudest sound is heard at that part at which the purring can be most distinctly felt with the finger; that is, where the arterial current excites the vibrations of the venous blood. With the distance from this part, the sound gradually decreases in loudness, and at last merges into a bellows-sound, which is audible only during the diastole of of the artery, and which is recognized on whatever part of the limb the stethoscope is placed, as well at the shoulder-joint as at the dorsal and palmar surfaces of the hand.

The phenomena just mentioned are of themselves, and for their own sakes, interesting, and they increase the probability of the diagnosis of aneurisms of all kinds. But their practical value appears especially evident in reference to the fact, that by their means one may distinguish an independently pulsating tumour, i. e., an aneurism, from one to which pulsation is only communicated. In all works on surgery we constantly meet with expressions of regret that it is in many cases so difficult to determine whether a tumour which has the symptoms of both a visible and a sensible pulsation is an aneurism, or whether the motion is only communicated to a morbid growth by the artery running under it. If the tumour can be pushed aside, and if, when its position is changed, the pulsation ceases because the artery now no longer runs under it, one may be quite sure there is no aneurism. But this cannot always be done, and in such a case, doubt, as to nature of the disease, must sometimes exist in the mind even of an experienced surgeon.

If by pressing it with the finger we lessen the calibre of an artery, for instance the external iliac, to a certain extent, and sufficiently for the finger to perceive the sensation of purring, we may hear a blowing sound at the moment of the pul

sation, along the whole course of the femoral artery down to the knee, but which, though evident and easily recognized, is yet far weaker than in an aneurism. It bears the greatest resemblance to what is called the placental murmur in pregnant woman, only it is for the most part of short continuance, and limited to the moment of the arterial diastole. The phenomena that are thus artificially produced not unfrequently occur naturally in consequence of the pressure of tumors or morbid products on the arteries. If the pressure is too considerable, or too slight, no blowing is produced; in the former circumstance, because the arterial walls are brought into contact, and the circulation is prevented at that part; in the latter, because the slight pressure is not sufficient to give rise to such an obstruction of the blood as to produce a murmur of the increased friction between the blood and the arterial wall. Large thyroid glands, comprising, in some measure, the carotid, afford the most frequent opportunities of testing the truth of these observations. The blowing becomes in the same proportion weaker, and at last entirely ceases as the gland gradually diminishes in size under the use of remedies. This short consideration of the matter, therefore, warrants the following conclusion;-a tumor which pulsates synchronously with the adjacent artery may be considered to be an aneurism when the murmur heard with the stethoscope is loud, uninterrupted, loudest and often highest in its note at the commencement of the diastole of the artery, and gradually from that point of time decreasing in intensity; but the pulsation is only one communicated from a subjacent artery when the murmur is either altogether absent, or, if present, is heard only at the moment of the pulsation.-Lond. Med. Gaz. Dec. 1840, from Med. Jahrb. des Orsterreitchischen Stautes, B. xxi. S. 3.

32. On Pneumonia in connection with, or as a consequence of, Surgical Operations and Injuries. In the London Medical Gazette for February last, there are some interesting remarks on this subject, by Mr. J. E. ERICHSEN. From a table which he gives of 41 deaths, occurring from various injuries and diseases in the surgical wards of University College Hospital (in which an account of the state of the lungs was kept), these viscera were found in twenty-three cases to be in the first or second stages of pneumonia. Of the remaining eighteen cases, the lungs, with the exception of a few cases in which scattered tubercles were found, were healthy in ten; and of the eight cases in which there was disease of the lungs, but no pneumonia, bronchitis was found in four; oedema of the inferior posterior part of both lungs in one; vomicæ from tubercles in another; and of the remaining two, the lungs were emphysematous in one case; and gorged with fluid blood, the patient only living six hours, in the other.

Of the twenty-three instances in which pneumonia was found, that disease had advanced to hepatization in eleven cases; the remaining twelve being in a state of congestive pneumonia in the first stage of the disease.

That the depressing circumstances which attend confinement in a hospital, together with the recumbent position, have some effect in predisposing to this disease, is shown by the fact, that of the 18 cases in which no pneumonia was found, 11 died before the 3d day after admission, viz. 4 on the 1st day, 2 on the 2d day, and 5 on the 3d day. Of the remaining 7, 1 died on the 5th day, another on the 14th, and 4 at periods varying from one month to two months and a half. Of these last 4, one died of phthisis after amputation of the leg, and two of the others were not confined to a recumbent position until a very short time before death; one, in fact, with sloughing ulcer of the neck, and sloughing ulcer over the trochanter, died in her chair.

On the other hand, of the 23 cases in which pneumonia was found, only one died before the 3d day, and that was an old bed-ridden woman, moribund on admission; 4 died on the 4th day, 2 on the 5th day, 6 between the 8th and 14th days, and 9 between the 16th day and 6th week. In all the cases in which the congestive pneumonia was found, the patient was, from the nature of his injury or disease, required to be kept in the recumbent position; and this, no doubt, together with other causes already mentioned, must have disposed him, Mr. E. thinks, to the occurrence of the disease, by giving rise to congestion of the lungs.

"Inflammation of the lungs, occurring in a person already suffering from a severe injury or a capital operation, is of course a complication greatly to be dreaded, and one which, it has been shown, is much more frequent than is usually believed. It is a complication against which it is necessary to guard as strictly as possible, both on account of it being of a very dangerous nature, and of it assuming very frequently a latent character; that is to say, the rational symptoms are in a great measure, or altogether wanting, and the presence of the disease can only be ascertained with certainty by a carefully conducted physical examination of the chest, which, as it is the posterior part of the lung that is almost constantly affected, it is extremely difficult to institute in the great majority of surgical cases; as it must be obvious to every one that it would be extremely injurious to place a patient suffering from a severe injury, or one who has lately undergone a capital operation, in such a position as would enable us to examine the posterior part of his chest with care. When this can be done, however, we find the same physical signs that occur in typhoid pneumonia, namely, dulness on percussion, with sibilous or bronchial respiration. The crepitation is not so well marked in this as it is in the more active forms of the disease. Sometimes it is entirely absent, and when present it only exists for a short time, and is, as Dr. Hudson observes to be the case in typhoid pneumonia, quickly lost by the accumulation of blood in the surrounding vessels compressing the air cells. As the latency of this disease is usually increased by the low condition of the patient, or by the existence of some severe injury which may chiefly attract the surgeon's attention, it behoves him to watch with the utmost care any appearance, however slight, of the supervention of a chest affection. He must not wait for the marked symptoms of active acute pneumonia to show themselves; but if the respiration be at all hurried and short, if there be any dyspnoea, lividity of the lips, or occasional slight cough, although there be no expectoration, no pain, and little or no pyrexia, he should immediately be on his guard, and, if possible, examine the chest with his ear, to ascertain if there be any of the well-marked and easily recognized signs of pneumonia present; and, if so, have recourse to as active a mode of treatment as the circumstances of the case will warrant.

"The knowledge of this tendency in severe injuries and operations to give rise to pneumonia, should always make us cautious in using the knife whilst there is any disposition in the patient to disease of the lungs, and should teach us the necessity, after operating, of guarding most carefully against those circumstances which are, in health even, exciting causes of inflammation of these organs, and which will act with increased vigour on a constitution already lowered by irritation. On this account it would be prudent to defer operations during very severe weather, or during the prevalence of an epidemic pneumonia.”

33. Operation for the cure of Stammering.-The greatest novelties in surgery, which the Foreign Journals for the last three months present us, are the operations for the cure of stammering. Of these we shall give a full account, not that we believe that they will accomplish all that is claimed for them, but in the performance of our duty to keep our readers informed of what is doing.

Operation of Dieffenbach."The idea lately suggested itself to me," says the celebrated Berlin Professor, "that an incision carried completely through the root of the tongue might possibly be useful," in relieving stuttering which had resisted other means of cure, "by producing an alteration in the condition of the nervous influences, allaying spasm of the chordee vocales, &c.," and on this slender possibility, based on a most vague notion, it is not worthy of being termed a theory, he proceeded at once boldly to divide completely the root of the tongue.

Three modes of operating are described by Dieffenbach as tried by him to accomplish this object. "1st. The transverse horizontal division of the root of the tongue. 2d. The subcutaneous transverse division, in which the mucous covering of the tongue is left inviolate. 3d. The horizontal division, with excision of a wedge-shaped portion."