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far from the object to favour the closingof the wound, you may put in a pea ortwo, a ball of silver or ivory, or the issuemay be refreshed by a dressing, for a fewhours, with the antimonial ointment.When the original sore has nearly healed,all dressing may be dispensed with, so thatthe thinner part of the discharge evapora.ting, a crust may be formed. The forma-tion of an adherent crust may be ensured byrubbing the surface very lightly with thenitrate of silver. In all cases, and monso when there has been much swellingand varix, support must be given, lonafter the healing of the surface, by bandag(or laced stocking’.

I need not tell you that the healing of every sore is much promoted by attentionto the digestive organs, by putting them into a proper state to digest or assimilatethe food, which must be supplied in properquantity and of good quality.On some future occasion I shall turn

your attention to those sores which spreadby sloughing and rapid ulcerative absorp-tion-the acute and chronic phagedenaand their appropriate treatment. At ournext meeting I shall make some remarkson the treatment of calculous diseases,with reference to the case of Shaw, who,you are aware, is rapidly recovering fromthe operation performed the other day.

M. LISFRANC

ON

WHITE TUMOURS OF THE JOINTS.

(Concluded from page 176.)

Ttii principle last mentioned (that ofattending minutely to the state of the

viscera, before locally treating a white

swelling) having been laid down, anothergeneral question, on which practitionersare not agreed, presents itself, viz., shouldthe patient keep the limb in a state of per-fect tranquillity, or may he be permittedto walk ? In my opinion rest is indis-

pensably necessary. Do we not knowthat white swelling, even when cured, isliable to return under the influence of ex-cessive exercise, and though the contrarymay occur, yet those are exceptional caseswhich cannot weaken the force of the

general rule.When iodine was first employed in the

treatment of white swelling, it was pre-tended that the new medicine renderedevery other precaution useless, and that

the patient might continue to walk asusual. We experimented this method, and! accidents were in consequence developed,evidently under the influence of exercise.But without advising the patient to walkabout, may we not at least communicatesome gentle motion to the limb, in caseswhere anchylosis is to be apprehended?The answer to this is easy, and its principlereadily conceived. When neither pain norinflammation exists, moderate motionbrings no inconvenience. Should a slightdegree of inflammation exist, the surgeonmust be content to communicate, once aday, some gentle movement to the injuredlimb; but when any attempt at motiongives rise to excessive pain &c., we mustrefrain altogether ; the patient can hopefor nothing better than anchylosis. Thisleads me to speak of the conduct whichthe surgeon should pursue when the im-

possibility of avoiding anchylosis has beenonce foreseen, for when the latter accidentis complete and irremediable, it is at leastadvisable that the fixed position of the

limb should bring with it the smallest in-convenience possible; and if the anchylosiswere false, the injured limb is the more

readily restored, and the less it deviatesfrom its natural position. When thetumour occupies the elbow-joint, the fore-arm should be demiflexed. On the con-

trary, when the lower extremity is affected,the leg should be kept perfectly straight;indeed it might be even advantageous tofix the whole lower extremity with a pro-per apparatus. You must not imaginethat this continued state of extension is

very painful, for we have often employed itwithout any inconvenience.

If the practice we have alluded to weremore generally employed, you would notsee so many patients, after having beencured, compelled to drag after them alimb in a state of demifiexion, which is notonly useless, but even an inconvenience,from the various shocks to which it is ex-

posed. In the same way, if the limb werefixed in a splint in cases of coxalgia, weshould avoid that enormous shortening ofthe extremity which it is so difficult to

remedy. Finally, a precaution of greatntilitv to enable us to observe with exac-titude the effects of the treatment, is to

surround the tumour with three dark linestraced by means of the nitrate of silver;one above, the other below, and a thirdembracing its great circumference. Thesize of the limb may be taken along eachof these three lines with a piece of ribbon,and this manœuvre repeated every ten orfifteen days indicates precisely any varia-tion in the magnitude of the tumour.The preliminaries being thus arranged,

the surgeon should commence by attack-

215

ing inflammation where it exists. This employ excitants. In twenty-two inonthsis what constitutes for us white swelling the cure was complete.in the acute stage. It is a matter of some ’, Hitherto we have supposed the surgeonconsequence to study the character of to have been called to a case of whitethis inflammation ; it is generally of long’ swelling which has presented manifest

standing, and exists in tissues already symptoms of inflammation ; but if these

altered ; hence we cannot expect to re- symptoms are absent from the very begin-solve it as readily as a healthy phlegmon- ning, should we trust to appearances, andous inflammation. Besides, the consti- have recourse to excitants, the treatmenttution of the patient, generally weakened proper in the chronic stage ? We have al-

by the effects of pain or a constitutional ready seen tlz;.t the inflammation may bevice, does not permit us to employ san- latent, and then excitants would certainlyguineous emissions to any great extent; do a great deal of mischief: ic is morewe must spare the patient’s strength, if prudent to commence with one or two ap-we wish to preserve the power of re- plications of leeches, in order to avoid allcurring again and again to these means. chance of accident. Even when the acuteWhen che patient is robust, and the in- stage, combated vigorously, no longer ex-lamination severe, we may commence by hibits any symptom, we must not be tooan application of fifty leeches. Under hasty in our employment of excitants :

any other circumstances we do not apply these might bring back the inflammationmore than thirty, and often not above in tissues already too much under its in-fifteen. They should not be put immedi- fluence; hence we should rather give theately on the tumour, lest the irritation of patient a little rest, and allow him an in-the bite should be propagated to the in- terval of eight or ten days, when a courseterior, and thus hasten its degeneration; of treatment quite different from the for-they must be applied all round, at one or mer may be commenced.two inches from one another, and after The means which have been proposedthis first application the result must be for the purpose of dissipating the chronicstudied with care. Sometimes the inflam- eugorgement that constitutes the whitemation begins to decrease on the instant, swelling, are very numerous. We shalland as long as this favourable circumstance now examine the most efficacious, studycontinues it is not to be disturbed. In the manner in which each acts, and pointother cases the inflammation remains out how each should be employed, or, in -

stationary, or becomes more acute, and other words, explain the indications byhere it will be proper to prescribe about which our practice has been guided. Wetwenty leeches two days after the first set. would place in the first rank local blood-We admit only one exception to this letting moderately employed. Like all

general rule, viz., when the patient is other agents in medicine, this remedy actsweak, the pulse small and depressed; differently according to the manner inin such case we give the patient time to which it may be employed. Thus, in or-recover his strength, and we confine our- der to determine congestion towards theselves to the use of local baths and cata- uterus, and bring on the menstrual dis-plasms. The former remedy has often the charge, we apply advantageously a smalleffect of increasing the volume of the number of leeches, or employ a smalltumour, but this augmentation of size is bleeding from the foot: while, to combatonly momentary, and hence little alarm- congestion of the peritoneum, we bleeding. After local blood-letting we prescribe largely from the system, and apply a con-narcotics, applied along the inner surface siderable number of leeches. Everybodyof the limb ; the regimen must be strict, knows that a few leeches often determineindeed it is right for the patient to live a erysipelas, which very seldom takes placegood deal at the expense of his own flesh. when they are employed in numbers.

Experience also proves that according tdSuch is the course of treatment we have the number of leeches applied to a white

been in the habit of constantly employing swelling, in the acute stage, we can gene-with various success. Sometimes every rally augment or diminish the pain as it £

vestige of inilammation was dissipated in were at will. When the inflammationfive or six weeks ; but more than once we exists in a chronic form, we prescribe fromhave seen it break out with increased four to ten leeches, according to the pa-force at the very moment we thought it dent’s strength, with the essential preextinguished, require a new series of treat- caution of arresting the hemorrhage fromment, and persist for three or even six the bites at the end of half an hour, inmonths : finally, in one case we had to order to render the congestion more sure.combat the acute stage during fourteen The result of such applications is various : -.months; and it was only at the expiration sometimes no effect is produced for theof this long period that we were able to first few da s; but we must wait four i

216

five days before we pass any definitivejudgment, and then return to the charge.In some cases the tumour diminishes andsoftens on the day following the detrac-tion of blood; in others, on the contrary,it augments half an inch or even more incircumference. This latter phenomenon,on the nature of which the patient mustbe tranquillized, is in general favourable,and shows an energetic modification inthe vitality of the tumour. The tume-faction commonly subsides in twenty-fouror forty-eight hours, and it continues di-

minishing progressively for eight or ten

days together. It is also a favourablecircumstance when the leeches producean erysipelatous blush on the surface ofthe skin, which does not last for anylength of time, and aids considerably theresolution. In some patients a slightoedema may come on, which, however,soon goes off, or is easily dissipated bycompression. In other cases, finally, wehave seen a very intense erysipelas de-

velop itself: here the wished-for effect isexceeded, and we must combat this newinflammation by thirty or forty leechesmore. We have said that when theleeches do not produce any change afterfour or five days, we proceed to a freshapplication : but we must not obstinatelyemploy this remedy without good results;and if, after several trials, it fails, we mustthen turn to another. When, on the con-trary, the amendment is clear, we mustrepeat the abstraction of blood: but hereagain there is a rule to be followed : thus,so long as the affection goes on well, wemust not trouble the progress of resolu-tion by any unseasonable stimulants. Wewait until things become stationary; andwhen one or two days have passed overwithout any progress being made, it istime to have recourse to new applications.The first abstractions of blood are gene-rally followed by highly advantageous re-sults ; but this means becomes worn out,and at length produces no effect what-ever : we then choose another remedy,which is in turn worn out, and may after-wards return to the leeches, whose appli-cation is now accompanied with itswonted good effects. We should, however,point out some cases in which leeches mayproduce unfavourable results. We shouldabstain from applying them to females

during the menstrual discharge, or evensix or eight days before and a day after.In patients disposed to apoplexy, or at-tacked with some affection of the thoracicviscera, blood-letting is not proper whenthe tumour is situate on the upper ex-

tremity : it is equally contra-indicated inwhite swelling of the lower extremitywhen the female is pregnant, or when she

is affected with sub-inflammation of theuterus.The most powerful resolvent next to

sanguineous emissions is, without doubt,compression. Its good effects are so in-

contestable, that many practitioners adviseit indifferently in all cases of white swell-ing. It cannot be denied that they havebeen successful, particularly in chroniccases; but when the disease is acute, com-pression, like any other excitant, may giverise to a good deal of injury. We havemade the trial in this hospital, and beencompelled to abandon it. This, gentle-men, is easily conceived, for when com-pression becomes painful, even in thechronic stage, what must he its effect onapart still labouring under inflammation?Compression is not so efficacious whenthe tumour is hard; but when, under theinfluence of other means, softening oncebegins, when the subcutaneous cellulartissue appears merely infiltrated and cede-matous, then its beautiful effects are bestwitnessed. But to produce all the ad-

vantage of which it is capable, we shouldknow how to manage it well, and hence itmay be useful to speak a few words onthe method of applying it. Like everyother therapeutic agent, compressionought to be dosed (pardon the expres-

sion), if we would not depress or miss theobject for which it is employed. To giveyou an analogy which every one will

understand, the ophthalmic ointment ofDesault often aggravates the inflammationof the edge of the eyelid, which, on thecontrary, it appeases when mixed with

three parts of cerate. In the same way, com-pression, moderately employed, answersvery well in a case where a strongercompression would spoil everything, andvice versa. We distinguish five degrees,or, to employ the word that best expressesour idea, five doses of compression. Thefeeblest is represented by a simplebandage. In the second we add cones ofagaric, two inches high, as a mean bywhich the tumour is covered, and whichare maintained by circles of the bandage. Ifthe tumours be moveable, as we sometimessee them on the sides of a joint, we surroundthe base of the tumour with a ring, moreor less thick, of agaric, maintained by abandage, and then apply in the centre thecone of agaric destined to act directly onthe tumour.

The third dose is given with graduatedcompresses, which are harder than the; agaric, and compress more firmly. A de-. gree above this is obtained with splints,or pieces of metal enveloped in linen.

Finally, the fifth and last degree is malaxa-tion, which consists in kneading the tu-

; mour strongly until we have developed

217

some pain, and then compressing it with

cones of agaric. The next day, if the irri-tation persists, it is a proof that the vi-tality of the tissues has been awakened,and in most cases a notable diminution

supervenes : we now have the ameliora-tion go on tranquilly, and have again re-course to malaxation, when it comes to astop.As you may readily conceive, it is a

matter of the highest importance to de-termine the exact degree of compressionthat should be employed. In general it isproper to commence with the lowest de-

gree ; we may afterwards augment it ac-

cording to the effect produced. This pre-caution is peculiarly essential where wehave to treat a joint recently attacked byinflammation, and where we fear to re-

produce it. If, on the contrary, we haveto combat one of those swellings hard aswood, which are met with most commonlyabout the wrist-joint as a consequence ofexternal violence, we may commence withthe fourth or fifth degree in the first in-stance. We have seen a tumour at leasttwo inches in thickness, occupying thewhole external side of the knee-joint, dis-sipated by malaxation; the other degreesof pressure, after having produced sometrifling benefit, had remained altogetherinefficacious. Whatever degree of pres-sure we may think fit to employ, it is ne-cessary in all cases to roll a bandage fi-omthe point of the extremity up to the tu-mour, in order to avoid the infiltrationwhich it would not otherwise fail to pro-duce. The compression must not onlybear upon the engorged points, but, on anaverage, should extend two inches aboveand below them; the vessels passing tothe tumour are thus compressed, and theafflux of fluids is diminished. Finally, thecompression should be renewed everytwenty-four hours, both because this lapseof time is sufficient for the relaxation ofthe bandage, especially when the tumourdiminishes, and also to give the part somerepose, which feels more sensibly the ef-fects of the remedy if suspended daily forabout half an hour. The action of pres.sure, like other agents, wears out, and atthe end of a certain time it produces noeffects; we must then have recourse toother means. If, however, we are fortu-nate enough to have cured the tumour bypressure alone, we must still continue itsuse for some time, gradually diminishingthe force until we arrive at the simple cir-cular bandage. The medicinal agent, pro-perly so called, will furnish matter for asecond lecture.

ON ABSORPTION.

By T. G. HAKE, M.D., Physician to the

Dispensary, Brighton.

(Concluded from page 110.)

f IT must be evident to every mind whichhas been trained to reflection, that theaction of all foreign bodies on the livingtissues is the same in principle, althoughdifferent in degree and kind, in proportionas those bodies differ among themselves.The primary effects of irritating poisonsare evidently local, since they manifestthemselves in no other form than that of

pain and the sensation of burning, whilethe local secretions are modified or dried

up. After this a reaction sets in, of theinflammatory kind ; the nerves, as in thecase of narcotic poisoning, hold but a di-minished empire over the muscular sys-tem ; hence the latter is convulsed ; thusthere is vomiting, hiccough, troubledrespiration, and either permanent or

spasmodic contraction of the features,&c. But the attempts made at local de-composition are so powerful, that the fatalmetastasis of the impression brings thepowers of life to the lowest ebb; the skinis pale, the extremities are cold, and thereare cold sweats; there are sometimes eveneruptions, while extreme prostration andanguish add their characteristics to thedisease. These and other symptoms re-spond to the local action of irritants onthe prima via, are the measure of thataction, and its only curative means, whileat the same time they keep the system in

a a state which prevents the whole actionof the poison from falling on the part towhich it has been applied, and which, bythus dividing the mischief, postpones thedestruction of the individual tissue.While the action of septic poisons re-

sembles in many respects that of narcotics,of which a detail has been given, the nar-coto-acrid are as nearly as possible madeup of the two classes whose names theyhave received. For practical uses arrange-ments are convenient, but what drug isthere which is purely narcotic or irritant?Each class is allied to the rest by stronglymarked features, and it is probable thatalthough the series of known actions doesnot form a chain, each link of which is anincreased state of its former, the gaps haveonly to be filled up by further observation,experiment, and reasoning.The state named asphyxia is alwavs

produced by a defect of oxygen, in what-ever the cause may be found; but thegeneral symptoms which accompany that