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"But suppose the gluteal and sacral regions afford no marks of local disease, you may, perhaps, discover indications of mischief, as the fingers approach either groin, and here, or just below Poupart's ligament, you may encounter, first, the crepitation; next, the boggy' feel; and then you may perceive the dusky discoloration before alluded to. The history belonging to such cases as this will differ materially from that which I have related, as connected with the former example. You may be told that an elastic swelling of long standing, and which occasionally disappeared altogether, has latterly become permanent and firmer in consistence than before. That vomiting, and constipation, and pain, have suddenly appeared, and existed for a few days, and that, with or without medical aid, the bowels have become free, and the vomiting has ceased, while the swelling continued to enlarge and to acquire a red and congested hue. Now, what is this case? It is most probably a knuckle of intestine adherent to the mouth of a hernial sac, and having a perforation or sloughy opening, through which feculent matter has escaped into the sac, and failing to be bounded by plastic inflammation, or from sloughing of the whole sac itself, has been injected with its fetid gases into the cellular tissue. An illustration of this form occurred in Joseph's Ward, about two years ago, and created a considerable degree of interest at the time.

"Having traced the lesion to the neighborhood of the groin, you are not to conclude hastily that a hernial tumor is its source; and if the right inguinal region be the locality, there is more occasion for reserve on this point. The history may suggest another and very different organic change as the source of the emphysema. You may learn that a firm and painful swelling has been felt in the abdomen, at the lower part of its right side, and just inside of the hipbone. That constipation, or great irregularity of bowels, had been complained of, and had been succeeded by sickness or vomiting, with chills or rigors, and of fever more or less strongly marked. That the integuments about the groin had become red and painful, and that extension of the limb occasioned considerable suffering. You may, in fine, have the history of phlegmonous tumor in the right iliac fossa, or ileo-cæcal abscess. On examination, you may detect, in addition to the boggy swelling, a gurgling which is transmitted, by pressure, upwards in the direction of the ascending colon. In this, as in the former cases, the lesion evidently consists in the escape of the gaseous contents of the intestine into the areolar tissue.

"It is surprising how rapidly the cellular web becomes injected by this poisonous element. A few hours may suffice to develop a swelling extending all over the front of the abdomen.

"The crepitation which is so characteristic of emphysema is, as I have said, not always to be detected in the most prominent portions of the swelling. This would appear to arise from the over-distension of the cellular plates, which very soon lose their vitality, and fall into a sloughy state. In one case I had an opportunity of inspecting the parts which had been destroyed by contact with the deleterious agent; and when incisions are made into such parts, the nature of the change is equally apparent.

"The extent to which the abdominal parietes may be occupied by this peculiar swelling will not be the same in all cases, and will depend on its duration. If you are not consulted for twelve or eighteen hours after its commencement, the swelling may then have engaged the entire area of the abdominal surface, and have assumed the smooth, tense, hemispherical prominence alluded to. At an earlier period of its progress it will occupy a less extensive surface, and one-half, perhaps, of the abdomen will exhibit this peculiar swollen condition. I have also seen it present a distinct swelling at each side of the external margins of the recti muscles, the connection between those two portions being established by a transverse projection across the hypogastric region. In the case where the swelling occupies the whole anterior surface, the appearance of the abdomen might, to a hasty view, suggest the idea of a cavity tense with liquid effusion. "The practised observer will, however, even here, remark that the umbilicus is depressed and buried in the middle of the swelling, and he will contrast this appearance with that which is displayed in dropsy. In the one case the umbilicus is sunken and concealed; in the other case the umbilicus projects, and may be even distended by the liquid within.

"It is, notwithstanding, by the careful exercise of the finger, that the diagnosis is to be established. It is to the diagnosis alone that I now wish to direct your attention. The treatment, as well as a history of its results, will form the subject of another inquiry.

"Abdominal cutaneous emphysema is, no doubt, a rare accident in those diseases, in the course of which it is liable to occur. Malignant disease of the rectum may pass through all its stages without perforation of the intestine ; and when perforation takes place, it is, in the majority of instances, limited by plastic deposit, and thus the fetid abscess is conducted to the surface by routes which vary in different cases. The contents of the sloughing hernia may reach the surface in a similar way, and an artificial anus be the result. The ileocæcal abscess may, in like manner, be uncomplicated with this lesion. The resonance and the gurgling which I have, on a former occasion, described as characteristic of some forms of this abscess, are entirely different from the diffused and huge emphysematous swelling to which I now refer.

"But rare as it undoubtedly is, it has been frequently witnessed in this hospital, and you should be prepared to recognize it when suddenly presented to your notice."

ART. 104.-Ligature of the External Iliac for Femoral Aneurism.

By Dr. WOOD.

(New York Journal of Medicine, May, 1857.)

In this paper Dr. Wood relates a case in which he performed this operation, and he brings together the cases in which the operation had been already performed, with a view of exhibiting the chances of secondary hemorrhage.

In Dr. Wood's case the pulsation in the posterior tibial artery was absent until the seventh day after the operation.

On the thirteenth, the ligature from the external iliac was removed.

On the eighteenth, secondary hemorrhage supervened; five days after the ligature came away.

Pressure by the hand was kept up twelve days-from the eighteenth to the thirtieth day-after the operation. The shot, bandage, and compress were then substituted.

On the twenty-eighth day after the operation, and tenth after the hemorrhage, pulsation of the external iliac artery entirely disappeared. On the thirty-eighth, part of the shot were removed; the remainder, with a compress and bandage, applied as before.

On the sixty-fifth day after the operation, and forty-seventh after the hemorrhage, all the dressings were removed, and the patient discharged cured.

The following collection of cases exhibits the dangers of secondary hemorrhage, complicating ligature of the external iliac :

Cases of secondary hemorrhage after ligature of the external iliac :

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Summary.-Number of cases, 14; recovered, 4; died, 10.

ART. 105.-On the Use of Tincture of Aconite as a Preventive of Rigor after passing a catheter into the urethra. By Mr. LONG, Surgeon to the Liverpool Royal Infirmary.

(Liverpool Med.-Chir. Review, Jan., 1858.)

"I had recently under my care at the infirmary," says Mr. Long, "at the same time, three cases of irritable and almost impermeable stricture of the urethra; in all of which it was impossible to make any progress by dilatation, in consequence of the severe rigors which ensued after each attempt to pass the catheter. Finding that the ordinary appliances did not prevent the occurrence of the rigors, and that the introduction of the instrument could not be attempted oftener than three or four times in a fortnight, in consequence of the severe local and constitutional irritation which followed its use, I adopted the following plan: I gave two minims of Fleming's tincture of aconite, in an ounce of water, immediately after the introduction of the instrument. The result was as follows: In one case the tincture was given without any omission, after every introduction of the instrument: no rigors occurred, and the treatment progressed without any interruption to a successful termination. In the second, the same result occurred. On one occasion the tincture was omitted, as an experiment, and a rigor occurred, followed by its usual consequences. The tincture was resumed, and no rigor again occurred, though the instrument was allowed to remain in the stricture for half an hour or longer. This case also did well, but the man left the infirmary before the dilatation was fully completed.

"In the third case, which was the most severe, no rigor occurred whilst the tincture was given, and the case was progressing favorably. The aconite was, as in the second case, omitted, for the sake of experiment, and two introductions of the instrument were effected without the recurrence of rigor. On the third occasion, however, so severe a rigor, and such untoward local and constitutional symptoms experienced, that up to the present moment no further use of the instrument could be attempted. I conclude that in the above cases, the tincture of aconite, by its direct sedative power, exerted a powerful influence in preventing the occurrence of rigors, and that in similar cases it may become a valuable addition to the means usually employed."

ART. 106.-On the Treatment of Excessive Involuntary Seminal Emissions. By Mr. SOLLY, F. R. S., Surgeon to St. Thomas's Hospital.

(Lancet, Feb. 6, 1858.)

"It is now," says Mr. Solly, "some years since Lallemand first recommended the use of this caustic to correct the distressing drain on the system which results from these discharges. I am convinced the great value of this plan has not received that attention from the profession which it deserves, while the quacks have availed themselves of it, abused it, and converted, by its indiscriminate and intemperate use, a valuable remedy into a curse.

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"Every now and then I see patients from the country who tell me that their medical attendants decline to use it; and I know that some of the heads of the profession are opposed to it. As, however, during the last three years, I have found it almost invariably successful, I think it right to make this statement. Most of these cases are the consequence of evil habits engendered at school. Much has lately been written, and much is being honestly attempted, in order to abate the frightful evils of prostitution; but bad as are the evils which arise from that source, they are nothing in comparison with those arising from masturbation—a crime which is ignored by the public, the profession, and by too many of the scholastic order. It is a dreadful social evil, and the punishment which follows in its train, unlike the marked and self-evident retribution from illicit intercourse, proceeds so slowly that its victims are bound hand and foot before the medical man is called in to prescribe for its consequences. Epilepsy and insanity are amongst the most prominent of its effects. But I must not now be led away into particulars, though I do conjure the profession not to ignore the existence of disease as the result of masturbation, and thus

drive its votaries into the hands of quacks. They are amenable to treatment, and the surgeon will be rewarded for his trouble.

"As a rule, I first pass a steel sound, and after the urethra becomes less irritable and sensitive, I apply the caustic; in the use of which I make no claim for originality. I employ the caustic-holding catheter of Lallemand, and having passed in over the veru montanum into the bladder, I draw it back again; and on reaching the veru montanum, unsheath the nitrate of silver over the opening of the ejaculatory tubes, quickly sheath it again, and withdraw it from the penis. Its application in this way does not produce much pain, not usually so much as the first introduction of the steel sound; for, in all these cases, the urethra is exquisitely sensitive, and the veru montanum swollen.

"In those cases where the nocturnal emissions simply occur too frequently, and the evil habit which induced them has been abandoned without the occurrence of epilepsy or mental derangement, perseverance in the use of this caustic, applied once or twice a week, according to the irritability of the patient, and continued according to the subsidence of the seminal emissions, from one to two months, with such tonics as the sulphate of iron, quinine, and zinc, will, as far as my own experience goes, effect a cure. This assertion applies even to cases where the testicles have shrunk to little more than the thickness of a penny-piece, and the varicose veins of the cord resemble a bag of

worms.

"On a subject like this I must not detail individual cases; but I do assert, most positively, that the above description is no exaggeration of the physical changes which take place in the organs of generation, and that such cases are not incurable."

ART. 107. On the Causes of Death after Lithotomy. By Mr. BRYANT, Assistant-Surgeon to Guy's Hospital. (Guy's Hospital Reports, Third Series, vol. iii., 1857.)

This paper is based upon 176 cases of lithotomy taken from the clinical records of Guy's Hospital, and upon 40 post-mortem examinations, of which 25, or 14.20 per cent., occurred in the 176 cases already mentioned. The conclusions are

1. That lithotomy is at least twice as fatal during the first five years of life as it is during the second.

2. That during puberty, or between 11 and 20 years of age (the third period), it is more fatal than during any other period.

3. That after 20 and up to 40 years of age it is comparatively of small fatality.

4. That 30 per cent. of the fatal cases are during the first 20 years of life. 5. That 10 per cent. are during the second 20 years of life.

6. That 60 per cent. are above 40 years of age.

7. That 14.20 per cent. of the cases operated upon prove fatal.

8. That hemorrhage is the cause of death in the proportion of 15 per cent. 9. That 12.5 per cent. of the fatal cases died from exhaustion, or simple sinking; and that these are generally above the middle period of life.

10. That pyelitis or inflammation of the kidney is the cause of death in 15

per cent.

11. That pelvic cellulitis is the cause of death in 15 per cent.

12. That this pelvic cellulitis is not generally the result of a too extensive incision through the prostate, but as the result of continuity of a structure which has become inflamed from the necessary injury inflicted upon it by the operation, or by the presence of a calculus.

13. That the combined influence of pyelitis and pelvic cellulitis prove fatal in 15 per cent.

14. That 12.5 per cent. die from pyæmia.

15. That pelvic cellulitis, the result of accidental causes during the operation, may prove fatal in 7.5 per cent.

16 That disease of the kidney is found in at least 30 per cent. of the fatal

cases.

17. That pelvic cellulitis is found at least in 37 per cent. of the fatal cases, either alone or associated with other disease.

18. That peritonitis, as the result of lithotomy and cause of death, is never found unassociated with other complications, such as pelvic cellulitis or perforation of the bladder.

19. That acute cystitis may alone prove the cause of death.

20. That chloroform, independent of its own special risks, does not seem to have any influence upon the fatality of lithotomy.

ART. 108.-On Lithotritic Instruments in cases of Enlarged Prostate.
By Mr. COULSON, Surgeon to St. Mary's Hospital.

(Lancet, Jan. 30, 1858.)

In the following remarks Mr. Coulson proposes to explain the necessity which exists for employing a peculiar lithotrite in patients who have stone and enlargement of the prostate. It is now more than three years since this necessity was impressed upon him. He had a case of vesical calculus in a stout man, seventy years of age, whose prostate was enlarged; although the ordinary lithotrite was introduced without difficulty, he found it impossible to seize the stone, in consequence of the lithotrite being too short. The operation was deferred until a new instrument was made. Since the period just mentioned, four similar cases have occurred in his practice. In each case the patient labored under enlargement of the prostate, and in each he would have been unable to terminate the operation without the use of the instrument which he describes in this paper.

"The changes in the genito urinary organs produced by enlargement of the prostate, and requiring the use of peculiar lithotritic instruments, may be explained in a few words. Many men who have passed the middle period of life labor under some enlargement of the prostate; and such a condition of the gland seriously interferes with the functions of the bladder; but for my present purpose it will suffice to consider the effects produced on the urethra and floor of the bladder by any considerable swelling of the prostate. A consideration of these effects will at once show in what manner the modified instruments that I employ in such cases are, of necessity, required. A constant effect of prostatic enlargement is elongation of the urethra. This lengthening of the canal may be connected with several conditions of the enlarged gland; it is, however, mainly confined to the prostatic portion of the urethra, and occurs in one of two ways. As the enlargement pushes up the neck of the bladder under the arch of the pubes, it necessarily draws up and elongates the vesical end of the urethra; or, while the gland is slowly enlarging from before backwards, that portion of the urethra which traverses it must necessarily follow the abnormal development of the prostate, and become elongated. In his recent work on the 'Prostate,' Mr. Thompson observes, that in some preparations which he examined, the urethra measured three inches from the orifice of the bladder to the membranous portion, instead of an inch and a half, which is the normal length.' In all cases of this kind, more especially when the middle lobe is chiefly affected, the orifice of the bladder is thrown backwards in proportion to the development of the enlarged lobe; and hence the point of any instrument used is apt to catch against the superior wall of the canal before it enters the bladder. This is an obstacle which the surgeon is very likely to meet with; and I may add, the shorter the instrument he employs, the more likely is the obstacle to occur. "The effects of the morbid growth on the cavity of the bladder also require some notice. These effects, so far as regards my present subject, will depend on the degree of prostatic enlargement, and on the lobe principally affected. When the enlargement is chiefly confined to the middle lobe of the prostate, which encroaches on the floor of the bladder, the capacity of that viscus at its lower part is proportionably diminished. I have seen a considerable part of the bladder occupied by the enlarged prostate; and, in extreme cases, preparations of which are preserved in our museums, the morbidly developed gland

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