673

riding over the lower to the extent of the shortening. He isunable to walk, except with a crutch, and cannot bear theslightest weight upon the limb. A consultation having beenheld, it was decided the limb should be removed by amputa-tion, the original injury being in such close contact with theknee-joint as to preclude the possibility of any other opera-tion.March 17th.-Having been put under the influence of chloro-

form, Mr. Holtremoved the limb by making a nap fromthe calf ofthe leg, cutting through the ligamentous union, and dispensingwith the use of the saw. Some little delay was occasioned,after the leg was removed, by hemorrhage from a small vesselrunning between the ununited portions. This, however, beingsecured, the edges were approximated and retained by threesutures, strapping and a bandage being applied over the whole......Five P.M.: Some little oozing has taken place, the bowelshaving been open, and necessarily disturbed the limb.—Half-past ten P.M.: No further oozing; remains perfectly tranquiland quiet. Desired he might have a morphine draught, in theevent of his not feeling an inclination to sleep by twelve.18th.-Nine A.M.: Passed a quiet night, sleeping for some

hours tranquilly; reaction commencing; pulse 136; skin hot;complains of slight thirst; countenance cheerful.-Two P.M.:Pulse not so frequent; skin rather hot; tongue clean andmoist; does not complain of pain.-Ten P.M.: Progressingfavourably; pulse 120; tongue clean and moist; skin comforu-ably warm; has had some hours’ sleep. To repeat the morphinedraught, if necessary. i19th.-Passed a quiet night; pulse 110; skin warm; tongue

clean and moist; countenance cheerful; no pain or starting ofstump. Desired he might have beef-tea, one pint.-Eight P.M.:In every respect progressing favourably.20th.-One P.M.: Passed a good night; pulse 120,and rather

feeble; tongue moist; skin rather hot; bowels not open; doesnot complain of thirst. The straps on either side were re-moved, but there had not been any attempt at union. Apoultice was applied over the stump; and Mr. Holt desiredhim to have beef-tea, double strength, and four ounces ofwme.-Eight P.3i.: No further symptoms requiring report.21st.-One P.M.: Pulse remains 120, but has more power;

stump not doing anything; no attempt at suppuration; upon reomoving the centre strap, a dark, suspicious-looking spot pre-sented itself; the edges of the wound sloughy, emitting air of afeaw character; countenance, however, remains cheerful. Mr.Holt ordered mutton-chop, egg, beef-tea and wine to be in-creased.-Eight P.M. : The man being considerably worse, Mr.Holt was sent for, and found the thigh enormously distendedat the upper portion; pulse almost imperceptible; skin cold andclammy. Upon inquiry, the sister stated he appeared to getworse all of a sudden, the limb appearing to be blown up withair. Fearing there might be secondary haemorrhage, thestump was opened, and carefully examined, without any bloodbeing detected. Desired to take brandy and ammonia everyhalf-hour.22nd.-Pulse gradually got weaker, and he died at half-past

twelve.

Post-mortem examination.-Upon cutting into the thigh, asense of crepitation was communicated to the knife, verysimilar to that of cutting through a healthy lung. The mus-cular and areolar tissues were much distended with air of afretid character, and there was a small quantity of serum in-filtrated in the surrounding structures. The femoral arterypresented a healthy appearance, its lower portion, however,being embraced by the ligamentous substance which formedthe bond of union between the fractured extremities of thefemur.

Remarks.-Mr. Holt said, that he was induced to performthe operation in the manner described, (being similar to thatmentioned by Mr. Syme and Mr. Fergusson,) to allow as longa stump as possible; and by dividing the ligamentous con-nexion, (instead of removing the limb by cutting through thefemur, above the original fracture,) the upper rounded extre-mity of bone was left, thus affording a better chance of speedyunion. The fatal termination of this case was to be attributedto gangrene, extending with great rapidity. The patient, un-fortunately, was unable to bear the shock caused by the re-Jnoval of so large a portion of the body in a healthy condition.The constitution made an effort at the production of suppura-tion, but failed, no secretion of a healthy character being ap-parent, at any time, on the face of the stump; and gangrene,having once supervened, proceeded with rapid strides to afatal termination, there not being a sufficient amount ofvitality left to rally under the stimuli administered.

Reviews.

On Stricture of the Urethra, and Fistula in Perinaeo. By JAMESSvME, F.R.S.E. Edinburgh: Sutherland & Knox. London:Simpkin, Marshall, & Co. Octavo, pp. 72.

WHEN we saw the announcement of a work on Stricture ofthe Urethra, by such a distinguished surgeon as ProfessorSyme, we expected to find the results of his views and expe-rience, on the pathology and treatment of so important a sub-ject, recorded in a somewhat extensive volume. We weretherefore somewhat disappointed on first seeing this thin

octavo, with seventy-two pages of somewhat large print.Mr. Syme has not been fortunate, hitherto, in his endeavours

to induce his professional brethren to adopt his peculiar planof treatment, even in that part of the-kingdom where he isacknowledged as the head of surgery, and where his influenceshould not be without weight; consequently, he has made thisother effort to obtain the general adoption of his practice.

, The present work chiefly consists of the author’s views onone particular mode of treating stricture, with a collection ofcases so treated, and terminates with a few remarks on Fistulain Perinseo. Mr. Syme sets out with the enunciation of a,truth which is but too evident—that strictures of the urethraare frequently most troublesome and refractory, and " that themeans of treatment which have hitherto been employed mustbe either uncertain in their operation, or only temporary intheir beneficial effect." Hence, Mr. Syme has proposed whathe considers" a simple and easy mode of obtaining success"-namely, the division of the stricture through the perinaeum,differing, however, from the operation ordinarily put in force.Certainly, it is quite true that occasionally surgeons will meetwith certain forms of stricture which cannot be overcome byordinary -treatment, and which require the use of a cutting in-strument, but" where a catheter, however small, can be intro-duced through a stricture, there the surgeon will have goodreason to expect a cure if he be patient and skilful." We.were forcibly reminded of this remark by a celebrated sur-geon, on finding Mr. Syme state that the first step is to passan instrument through the stricture and cut down to it behindthe obstruction. To see the use of the knife thus freely advo-.cated in cases where a catheter could be passed through thestricture excited in us strong feelings of surprise. Yet

every surgeon of extensive experience will meet with stric-tures where instruments may be passed again and again with-out benefit, in consequence of their disposition to contract,and it is in such instances that Mr. Syme recommends hisparticular plan of treatment.He has accurately and clearly described the nature and

symptoms of these obstinate cases, and referred the difficultyin treatment to their true sources. He says-I do not here allude so much to the mere tightness of

contraction, and the difficulty consequently experienced inpassing a small instrument through the stricture, as to theunyielding disposition manifested by the constricted canal,and its tendency to contract, perhaps even more closely thanbefore, after being partially or completely dilated."In such a case, to use the author’s words,-" The patient, in vain expectation of relief, is apt to require

in succession the assistance of many different practitioners,each of whom, supposing that the previous want of successhas depended upon deficiency of skill or care, ptoceeds to arepetition of the dilating process, destined to afford only asimilar disappointment, or the more serious consequencesalready mentioned as not unusual under such circumstances."-p. 13.

In these unpromising and refractory cases, the author putsin force the following operation:--" A grooved director,slightly curved, and small enough to pass readily through thestricture," being introduced, he makes with a small bistoury anincision through the perinaeum in the middle line, cuts uponthe groove of the director, on the bladder side of the stricture,

674

and divides it forwards. This operation can be done, accord- ing to the author’s statement, in less than a minute. Elevensuccessful cases are related, and he states " of all the cases inwhich I have divided the stricture, only one has been followed I

by any unpleasant result :’ I" So far, this is good, but the serious question remains to be I,asked-was there a necessity to resort to the use of the knifein all these cases, and in more which the Professor says he ’’,could bring forward 1 Bearing in mind that the first thing inthe operation practised by the author, is to pass an instru-ment through the stricture, we cannot but consider that manysuch cases which would be condemned to the knife, might befinally overcome by a patient and skilful use of the catheter;for instance, we refer the reader to Case vii. ’,"A sergeant, in one of the Queen’s regi.ments serving in

Scinde, twenty-six years of age, who had returned home with z,a detachment, was recommended to my care on account of a I,stricture of the urethra at the bulb, under which he had ’Ilaboured for three years. Finding that the contraction wasvery tight, and learning that the patient was desirous of re- i

pairing to his depot without delay, I proposed division ofthe stricture, and performed it on the 4th of April; the Icatheter was removed on the 6th, and by the end of the week z,the whole of the urine passed by the urethra. A full-sized bougie was passed twice or thrice afterwards with the intervalof a few days, and the patient then proceeded to his duty at amilitary station in England, where, I am informed, he hascontinued perfectly well."-p. 32.

’

We see in this case nothing but a tight stricture, and withthe exception of the patient’s wish to obtain a speedy cure,we certainly cannot imagine the necessity there was to re-sort to an operation by the knife. We cannot divest ourselvesof the feeling that the catheter, if used skilfully and patiently,will prove more effectual than Mr. Syme is willing to allow,and will supersede the use of the knife, which should be andmay be avoided in the majority of instances. Still, however,the operation recommended is, according to the author’s

showing, a safe, simple, and effectual remedy, and we cannotbut look upon it as a considerable improvement in surgery.The author next goes on to consider the various methods

which have been, and are to this day employed by the mostexperienced and able surgeons for the cure of stricture. Ofcaustic he thus speaks :-- With regard to the use of caustic for the cure of stricture,it must be obvious that all which has been said as to the in-jurious effects and dangerous consequences of introducing themost simple dilating instruments into the urethra, will applywith tenfold force to the employment of bougies armed’with escharotic substances, or any other apparatus constructedfor the conveyance of such irritating agents. But, indepen-dently of this objection, I do not hesitate to express my per-suasion, that a real organic stricture cannot be removed bycaustic, since, even admitting that the agent could be accu-rately applied, the destructive effect of the nitrate of silver isso limited, as to be quite inadequate for the purpose, whilethat of potass is so diffused, that in the event of destroying thestricture, it must cause a worse one, through the unavoidableloss of substance attending its operation, and the consequentcontraction in healing. On the whole, it seems more reason-able to conclude, that in the cases of alleged cure by causticthere was no real stricture in existence, than to suppose thatso improbable, or rather impossible, an achievement had beenaccomplished."-p. 53.. This is severe, and some will think unjust, criticism. It is

alleged, as ? well known, that caustic has been employed forthe cure of stricture with great success by respectable andtrustworthy surgeons. We happen to have on our table thewell-known work of a most respectable and excellent surgeon,(Mr. Wade,) and in that small volume are clearly and faith-fully recorded the results of many years’ experience of theuse of the potassa fusa, and those results are as satisfactory asany that Mr. Syme can adduce. Moreover, we happen topossess a document from the pen of the author of that book,in which are the following expressions:—" I give you my word,that I have never done harm by my mode of using the potassa

fusa, which you will see is not applied so as to cause a slough,the great mischief produced by the nitrate of silver :’ "You

may depend upon the statement made by me concerning theeffects of the potassa fusa, a statement which is rather underthan above its value in the treatment of stricture :’There can be no doubt that caustics were used too indis-

criminately by the late Sir Everard Home, and that, subse-quently, they have been much abused by surgeons; conse-quently, this mode of treatment has fallen into disrepute; yetMr. Syme has, however, gone further, probably, than he oughtto have done, in condemning both it and its advocates.Another mode of treatment which the author has thought

fit to criticize in severe terms, is that of the old plan of cut-ting into the urethra through the perinseum, on the point of acatheter.

"The last, and certainly most objectionable of all themethods which have been mentioned above, as in use for thetreatment of stricture, is, cutting into the perinaeum in searchof the obstructed canal, without any further guide than thepoint of a catheter, introduced, not through, but merely downto the contracted part."—p. 56.

Moreover, we are told, further on, that this operation " hasbeen resorted to as the refuge of awkwardness, or failure, inthe introduction of instruments."-(p. 57.) According to this,we must suppose that Mr. Syme is never baffled in the use ofa catheter, that no stricture is impermeable to an instrumentin his skilful hands, consequently, he never finds it necessaryto resort to the old perinseal operation; yet the end and aimof his book are to recommend a perinseal incision in thosecases where he has failed in curing his patients with thecatheter; and, doubtless, those who use his method will notbe accused of resorting to it "as the refuge of awkwardness."We should like to know what Mr. Syme would do in those

desperate cases where, from long neglect and other causes, aconsiderable length of the urethra has become converted intoa tough, gristly mass, when the tissues of the scrotum and peri-nasum are immensely thickened, and riddled with nstulse, andwhere, with the most patient attempts, no instrument can bepassed into the bladder. Would his own operation sufficehere ? We fear not. Professor Syme, no doubt, would be ableto overcome the obstruction by the catheter, but we areashamed to confess that the " hospital surgeon in London"is sometimes baffled, and is obliged to resort to the perinæalsection; nevertheless, he has the consolation of knowing thathe is performing a humane and justifiable operation, althoughhe may have the sad misfortune to feel, that by so acting heis liable to the charge of resorting to it "as the refuse of hisawkwardness."In his remarks upon fistula in perlnceo, we find nothing of

importance. As in his views regarding the formation of fkfistula in ano, he has totally differed from Sir BenjaminBrodie; in like manner he comes to an exactly opposite con-clusion to that celebrated surgeon, respecting the origin of aperinseal fistula. Sir Benjamin Brodie believes that ulcerationof the urethra takes place behind the stricture, as the firststep in its formation, whilst Professor Syme considers thatmatter is first formed externally to the urethra, and that thelining membrane of this canal subsequently gives way. Webelieve the Professor to be, in the main, correct in these views;yet we do not think that a fistula is always formed in thismanner; we have lately had under our observation two casesin which there was every reason to believe that ulcerationand giving way of the urethra were antecedent to the forma-tion of matter and fistula.No mention is made of the utility and even necessity of the

free perinaeal incision in certain cases of perlnasal fistulm, at-tended with a cartilaginous induration of the urethra. It is

only in these cases, with very few exceptions, that we havehitherto considered the use of the knife absolutely requisite,and it is here, as we have before said, that is seen the wonder-ful benefit of laying the diseased parts freely open, so as to

675

allow an exit for matter and urine, and subsequently, by ajudicious use of the catheter, permit the re-establishment ofthe divided urethra. The mode in which he has spoken ofthis operation, and the absence of any reference as to its

utility in cases of complicated perinaeal nstulae, would induceus to believe that the Professor has not had an opportunityof meeting with those very desperate cases of perinaeal fistulæwhich have every now and then fallen under our notice inLondon.In concluding our notice of Mr. Syme’s work, we feel called

upon to state that the operation he has recommended mayprove to be a valuable contribution to surgery, inasmuch as itis a simple and, according to his statement, an effectual one.Nevertheless we are,by no means sure that it will be foundnecessary to resort to the knife so frequently as he indicates.It should always be the aim of the surgeon to avoid the use of i

the knife if possible, for nothing tends to bring surgery intodiscredit more than unnecessary operations. We do not be-long to those, however, who wish to decry operative surgery;it is too much the fashion now-a-days to do so, and we stronglysuspect that those who do it are unable, either from timidityor ignorance, to use a knife properly. We are of opinion thatthe majority of strictures of the urethra may be effectuallycured by the catheter alone; yet our own experience, and thatof others, tells us, that it is necessary sometimes to resort tomore severe measures, and therefore we would recommendall surgeons to make themselves acquainted with the particularmode of treatment advocated by Professor Syme.

REPLY OF "THE LANCET" REVIEWER OF THELIFE AND WRITINGS OF DR. JOSEPH CLARKE,TO DR. SIMPSON’S CRITICISMS.

WE have again carefully read this work, and once more re-commend it, in the strongest terms, to all our readers engagedin the practice of midwifery. The character of the scientific,truthful, and successful Dr. Joseph Clarke, forms, indeed, amost striking contrast to that of the noisy, chattering jack-daws, now strutting upon the obstetric stage of this country." How seldom would most practitioners be found to use in-struments," says Dr. Collins, " if the successful course pursuedby Doctor Clarke were universally aimed at. Is it not worthyof our best consideration, with the invaluable statement beforeus, that in an extent of practice in the upper ranks of life,perhaps unexampled, there was not one single instance of deathresulting from laborious and protracted labour. This is a practicalfact, which ought to be carefully recollected, and seriouslyweighed, by most of our continental brethren, who use instru-ments in every fifth, tenth, fifteenth, twentieth, or thirtiethlabour under their care, with the object of expediting delivery :as also by some of our own countrymen, whose unsound doc-trines, inculcating interference to promote hasty delivery, the unquestionable truths here recorded clearly demonstrate to beunjustifiable and most uncalled for. Should not this inexpres-sibly important record for ever silence those who venture topublish crude and fanciful opinions, unsupported by any datafrom their own experience affording similarly happy results.It affords me infinite satisfaction to supply this truthful registryof facts, for the universal and serious consideration of theprofession. These truths speak in language the most convinc-ing, and must, when studied, leave an indelible impression."*These most important observations were directed chiefly

against the mischievous and absurd opinions recently promul-gated with such assiduity by a northern professor, on tearingaway the placenta, instead of turning the child, in cases ofplacental presentation; on turning, as an alternative for cra-niotomy, and the long forceps, in cases of distortion of the pel-vis ; and on the unnatural practice of inducing asphyxia, andstupefaction, by ether and chloroform, in cases of perfectlynatural labour, to destroy that pain which is essentially neces-sary to the safe completion of the process of delivery.

In our review of the life and writings of Dr. Joseph Clarke,we quoted the following passage from one of the admirableletters above referred 0to You state, that in a printed

* See particularly Dr. Collins’ Letters to Professor Simpson, of Edinburgh,Provincial Medical and Seergical Journal of England, Oct. 18th. 1848 ; alsothe Britich Record, Dec. 1848.

Report of the Edinburgh Maternity Hospital, then lying beforeyou, one in every 134 mothers died, (puerperal fever included;)one in every 368, (puerperal fever not included.) See MonthlyJournal for November, 1848. What do we find in the Reportreferred to ? î This simple fact: that of 374 patients deliveredin two years, in the Maternity Hospital, under your care,seven mothers died, or one in 532. All the other deliverieswere out-patients ! So much for that Report. I have, how-ever, accidentally found another, from the same institutionunder your care, in the June number of the same Journal for1847, p. 934, made by you to the Medico-Chirurgical Societyof Edinburgh, to which no reference is made. It is extremelybrief-namely, ‘ Report of the Instrumental Deliveries in theSt. John-street Maternity Hospital, by Professor Simpson.The deliveries in two years amounted to 1400: one out ofevery twenty-one mothers died! The forceps were used threetimes; the crotchet, once.’ This exactly amounts to the mor-tality which I reported under Dr. Hamilton, which occurreda quarter of a century ago; so that there is not a shade ofimprovement-nay, it is, in reality, nearly double Professor’Hamilton’s frightful mortality, as his patients were deliveredin the hospital; whereas a very large proportion of the 140amust have been out-patients, (although no distinction is made,)in whom, I have clearly shown, the mortality is one-half."

In the June number of the Monthly Journal of MedicalScience, at p. 934, it was stated, in the report of Dr. Simpson’spaper communicated to the Edinburgh Medico-ChirurgicalSociety, that " one out of every twenty-one mothers died." Inthe same report it was stated that the total number of cases was1400, both of which statements were erroneous. But from themonth of June, 1847, till the month of January, 1849, these,errors stood without any acknowledgment or correction fromDr. Simpson, or his friends the editors, and but for Dr. Collins’sletter, in all human probability they would have remainedwithout contradiction to the present moment. The eyes of’these individuals were, however, opened by Dr. Collins on the25th November, 1848, and then, after two months, the editors,(who are both now defunct,) in a foot-note of small type, as ifashamed of the whole ailair, and to avoid detection, acknow-ledged the errors they had committed, without any expression-of regret, only begging, in a deprecating tone," that for thesake of our peace of mind, if not of his own, Dr. Collins willfor the future abstain from using the errors of our printers andreporters as a ground for throwing doubts upon the authentic.and detailed statements of Professor Simpson, or any one elsewith whom he may happen to be engaged in professional con-troversy:’ After this the Professor appears to have consideredhimself wholly relieved from all responsibility, and then, likethe French at Waterloo, calling out, " Sauve quipeut!" retreats,.exclaiming, " But I need scarcely add that I am most assuredlynot responsible for the mistakes and absurdities of that orany other report of the meeting at the Medico-ChirurgicalSociety. Nothing, I think, could be conceived more ridiculousthan that the author of a statistical paper, read before any,society, was answerable for the blunders of any unauthorizedreporter of it." He does not venture to state that this egre-gious statistical blunder had escaped his notice from the monthof June, 1847, till January, 1849. It is hardly possible to be-lieve that he was not fully acquainted with these errors soonafter they were committed, or to refrain from suspecting thatwithout the help of Dr. Collins, they would never have beenacknowledged. Is this the first occasion on which he hasallowed enormous statistical blunders, perpetrated by himself,where he was responsible for the accuracy of the figures, toremain long without any correction, and which were first cor-rected by others ? We are not ashamed to plead guilty ofbeing ignorant, in some degree, of all the contents, especiallythose deposited in this peculiar form at the bottom of thatauthorized receptacle for the effusions of the Edinburgh pro-fessors. We would now, however, request our critic to state,whether he has, by himself or his subordinates, committed any-other conscious statistical blunders which have not yet beenacknowledged? If aware of any such, let him at once confessthe fault, and let him thus make a clean breast, that thescience of obstetric statistics may not any longer be mystified.by the repetition of similar proceedings.December, 1849.

TEE-TOTALISM.—A prize of one hundred guineas has justbeen awarded to Dr. W. B. Carpenter, for a prize essay on" The Abstinence from Spirituous Drinks in Health andDisease." The judges were Dr. W. A. Guy, Dr. Leith Roupell, and Dr. John Forbes.