The emetic tartar, if given with patience, and combined with bleeding, produces depression and nausea enough, and occasionally, we suspect, even more than enough. In a case of dislocation of the humerus, bleeding to twenty ounces, and an ounce of the liquor antimonii tartarizati produced the most deadly faintness we ever remember to have witnessed. The patient subsequently died of phlebitis; but, whether the excessive nausea had any thing to do with the supervening inflammation of the vein that was opened, we cannot pretend to affirm.

II. LARGE LACERATED WOUND OF THE PERINEUM, SCROTUM, AND URETHRA.

[Reported by J. R. BEDWELL.]

A man, twenty-seven years of age, was brought to the Infirmary, October 8, 1827, in consequence of part of a house having fallen on him. A lacerated and gaping wound extended from the tuber of the ischium by the anus, along the perineum, and through part of the scrotum, exposing the bulb of the urethra. Considerable bleeding had occurred, but an oozing took place on his admission. The lids of the wound were brought together by five or six sutures, a compress of lint and wet rags applied, and over them all a T bandage. Thirty drops of laudanum were also given in an ounce of mint water, and the patient ordered to be kept low. Next day no unfavourable symptoms had appeared, but the urine passed freely from the wound about the bulb of the urethra, in which there was evidently a large laceration. He took some castor oil that day, and was going on well on the 10th, when an attempt was made to introduce a flexible catheter into the bladder, but it could not be passed beyond the wound. Slight sloughs formed over the exposed part of the urethra, and were detached without any severe constitutional symptoms. On the 20th the patient made some water by the natural passage, and Nov. 10th, the external wound was healing fast, and the whole of the urine was voided the right way. A stricture formed about the rent in the urethra, which required the use of the bougie, but at the time of the report, the patient was nearly well, and about to be discharged from the Infirmary.

"Mr. Fletcher remarked that this was a case of torn up Perineum and Urethra, cured by the simplest means. The dresser had carefully stitched up the wound, probably without knowing of the laceration of the Uretha. Nature, with her adhesive process, did all, as she does in Lithotomy, where the Urethra is sometimes greatly injured. Art was here required only to enlarge the point of the urethra, which was contracted from the injury. Gentlemen should understand that these cases of ruptured Urethra, from external violence, are very different from those which happen from disease.'"

This is certainly a very different case from that in which the urethra bursts behind the stricture, and occasions extravasation of urine. Suppose, however, that the urethra is broken by external violence, the skin and integuments being sound. The difference, then, would not be so great, indeed the cases would be similar, as far as the immediate effects were concerned. In both, the urine would get loose from its natural channel-in both, it would be infiltrated into the surrounding cellular membrane-in both, suppuration and sloughing of that membrane would occur, unless the surgeon made free scarifications. It is not the mere mode in which the urethra is opened that constitutes the important item in the case, but the circumstance of the integuments being broken or unbroken. If they are wounded the urine escapes, and is not ejected into the cellular tissue, because the violence which ruptured the urethra, also scarified the external parts.

III. DIFFICULT CASE OF LITHOTOMY.

[Reported by R. FLETCHER.]

Every one at present has his difficult case of lithotomy, though, fortunately, every one has not the curse of a LAMBERT to report it for him. The subject of the present case was a man, ætat. 50, admitted with the usual symptoms of stone, accompanied with such excessive irritability of the bladder, that Mr. Fletcher did not think it right to encou rage him with very much hope from the operation, which, however, was performed at his own request. After cutting into the bladder, two large stones were discovered, which required the incision

in the viscus to be enlarged, and required nearly half an hour to accomplish their extraction, although they had previously been broken. During the operation, the transversalis perinei bled nearly a quart, and the patient, in consequence, became so low and cold, that brandy was required to support him. Early next morning, he was seized with vomiting of high-coloured green matter, and rejected every thing administered in the way of medicine. Enemata were given without effect; the pulse was 120, and feeble-the tongue furred and white. In the evening he was so depressed as to feel convinced that he must die, and suffered, at the same time, from pain and tenderness in the hypogastrium. Leeches were ordered, but not applied till next morning, when a croton-oil pill was given, and thrown up. The pulse was now uncommonly quick and feeble," and the tongue brown. In the afternoon the tongue was imperceptible, and brandy was given, in small and frequent doses, with the happiest effect. The pulse rose-he had stools in the course of the night, and has since been doing well. Mr. Fletcher considers that the brandy saved him, by maintaining the powers of life till the bowels acted. That the brandy saved the patient we have no doubt whatever; but whether the action of the bowels was of that importance Mr. F. would seem, by his remark, to imply, we are not so secure. From eases we have seen, we are led to suspect, that after excessive sanguineous evacuations or hæmorrhages, the bowels will be torpid, merely through the depression of the vis vitæ, consequent on the loss of blood. However that may be, Mr. Fletcher deserves great credit for the able manner in which he conducted so desperate a case to a fortunate conclusion.

ward symptoms arise to thwart the objects of the surgeon, or even endanger the patient's existence. Hæmorrhage, either externally, or into the tunica vaginalis, is not very unfrequent, and tetanus has, in several instances, followed the operation. M. Dupuytren, who, from his situation of "chef des travaux anatomiques," has dissected a considerable number of hydroceles, believes that these accidents depend on a variation in the anatomical relations of the hydrocele, a variation of which the surgeon should be aware. The following case is adduced in illustration of the Baron's remarks.

Case. Auguste ***, ætatis 13, of delicate constitution, was admitted into the Hôtel Dieu, with a hydrocele of six months' standing in the left side. The whole circumference of the hydrocele might be grasped without pain, but the instant the upper part was touched, the patient experienced the sensation of the testicle having been meddled with. On using the lighted taper, the testicle was found to be lodged in this part; and, "from the extremity of one of its diameters," the cord passed in front of the scrotum to gain the inguinal canal. In short, the testicle occupied the summit of the hy drocele, and the spermatic cord was situated along its anterior part. Under these circumstances, M. Dupuytren performed the operation at the middle and external part of the scrotum, in order to avoid the lesion of the organs alluded to above.

M. Dupuytren believes that, had the usual operation been resorted to here, and the testicle and cord been wounded, as they must, it is not improbable that serious mischief might have followed. At all events, he recommends, and we think very justly, that prior to thrusting in the trocar, the position of the testicle and spermatie chord should be carefully ascertained.

XXXVIII.

HOTEL DIEU.

1. VARIETIES OF HYDROCELE-MODIFICATIONS OF THE USUAL OPERATION.

The operation of injection for hydrocele is certainly, in the great majority of cases, extremely easy and safe in its performance, as well as successful in its results. Cases, however, occasionally occur, where unto

II. SUICIDAL AMPUTATION OF THE PENIS AND WOUNDS OF THE HEART.

A considerable number of cases of voluntary mutilation of the genital organs would seem to be occurring in Paris. Out of many such detailed in the Clinique we select the following, as interesting in more than one point of view.

Case. A stout dark-complexioned man, about forty years of age, reduced to distress, by misfortunes and misconduct, was determined to destroy himself, and had been on the point of throwing himself into the Seine, when, for some misdemeanour, he was put in prison. Believing that he could never re-enter society, he cut off the penis close to the pubes, and, although the knife was extremely bad, amputated the organ in a very scientific and surgeon-like manner. The hæmorrhage was not very great, but, as soon as the circumstance was discovered, he was taken to the Hôtel Dieu, where ligatures were applied on the arteries of the dorsum penis, of the corpora cavernosa, and the bulb; a sound introduced into the urethra; and the wound simply dressed. The patient at this time was tranquil, but a strict surveillance over his motions was practised, as the calm, it was thought, might be delusive. For some days no untoward symp. toms occurred, but then there supervened a violent delirium, for which he was bled from the foot, had opiate injections, and gentle purges. The delirium continued, symptoms of depression came on, the urine became loaded with muco-purulent matter, the pulse was in general slow, the extremities cold. The patient died at length in a sub-apoplectic condition three weeks after the infliction of the wound.

Sectio Cadaveris. The membranes of the brain were gorged with blood and "serosity," the brain much injected, and its substance very firm. On raising the sternum, a large ecchymosis was found on the pericardium, and the cavity of this serous membrane was half filled with liquid blood. On looking for the source from which this effusion could have come, several small wounds, plugged by a black but fibrinous clot, were discovered on the anterior surface of the ventricles. In the centre of the ecchymosis before described, on the upper and anterior portion of the pericardium, two penetrating narrow wounds were found, and these parts were covered by false membranes. Examination of the anterior wall of the thorax, disclosed between the cartilages of the second and third rib on the left side, a small, nearly round, and cicatrized wound. Beneath the skin, between the intercostal musoles, and beneath the pleura, was a large ecchymosis. The opening in the pleura was marked by a reddish brown spot, surrounded by false membranes. The lung was not wounded, but the wounds in the heart were

five or six in number, and principally seated in the right ventricle. The substance of the heart itself was pale and easily torn. The whole of the mucous membrane of the stomach and intestines was chronically inflamed, and several old ulcerations were found in the neighbourhood of the ileo-cæcal valve. The mucous membrane of the bladder also bore marks of chronic inflammation, and the urine contained in the viscus was purulent.

On making inquiries it was found that, after having mutilated himself in prison, not only the knife with which he had committed the act, but also a long needle made use of in the business he followed, (a saddler,) had been taken from his person. This must have been the instrument with which he had made the wounds in the heart, as, after his reception in the Hôtel Dieu, nothing of the kind could have come within his reach, and indeed the idea was confirmed by the state of the cicatrix externally. The wounds thus inflicted were in fact little more than a species of acupuncturation, which will readily account for the trifling hæmorrhage and almost total absence of symptoms indicative of their existence during life. The pulse, as was stated in the history of the case, was slow, the action of the heart was apparently undisturbed, there was no dyspnoea, nor any syncope. Whether, in the event of the patient's having lived, these wounds in the muscular substance of the heart, would have caused any serious symptoms is more than any one can absolutely determine. For our own parts, we should feel great difficulty in conceiving that the pericardium could remain half filled with blood, without producing, sooner or later, some disturbance in the system.

III. ANEURISM OF THE BRACHIAL ARTERY AFTER BLEEDING-OPERATION OF TYING THE VESSEL ABOVE-M. DUPUYTREN EM

BARRASSED.

To a man whose learning is only of the schools, or who having very little of any description, sits down in his closet or his garret to criticise or calumniate those who are unfortunate enough to be his brethren, nothing would seem easier than

the operation of securing the brachial artery. In the dissecting-room, frequently. indeed to a dexterous surgeon on the living body, a touch or two of the knife is almost sufficient to expose the vessel, and the rest is sufficiently simple. Occasionally, however, and no one beforehand can foresee the difficulties, occasionally, we say, even the operation of tying the brachial artery is tedious, difficult, and unfortunate, in the hands of the best and most dexterous operator. The following case will illustrate the truth of our remarks.

Case. Jean Auguste, ætatis 32, a hawker, of strong constitution, was bled from the arm, and received a wound in the brachial artery during this operation. The hæmorrhage which ensued was stopped by pressure, but returned at the end of some hours, and produced a considerable extravasation of blood in the fore-arın. This, which constituted a diffused aneurism, at the end of some time, by the partial absorption of the blood, and conversion of the surrounding cellular membrane into a species of sac, formed a circumscribed one, and six weeks after the accident, when the patient was received in the Hôtel Dieu, the tumour was no larger than a hen's egg. On examining it with care, the pulsations were found to be obscure, and ceased altogether on forcible extension of the arm, as well as on compressing the brachial artery above. From these phenomena it was thought, indeed it was clear, that the opening from the artery into the sac was either very small or oblique, and also that the latter received its blood from only one source.

pulsated so plainly, that the doubts which had previously existed were dispelled.

The reporter observes, that the amphitheatre of the Hôtel Dieu is so constructed, that, in order to allow the spectators to see the operation, M. Dupuytren was obliged to stand behind the limb, which was necessarily extended horizontally, instead of being laid in an easy supine position. These circumstances were much against the surgeon, and no doubt added to the difficulties met with. In the evening the limb was of its natural temperature, and next morning the pulse was felt in the radial artery. An erysipelatous blush had attacked the wound, accompanied with fever, and, after some time, the cutaneous inflammation extended to the fore-arm. These untoward symptoms, however, disappeared under the administration of diluents, &c. and on the 4th day, the pulsations in the radial artery were felt no more-the tumour was stillthe limb of its natural warmth, and entirely free from pain. The circulation became re-established, though slowly, below the ligature, but several attacks of erysipelas succeeded on the arm and fore-arm, and were repelled by the application of a blister to the centre of the inflamed part. Gastric symptoms also arose, and required two bleedings from the arm, and some alteratives. The aneurismal tumour quickly softened, the cicatrix of the lancetwound gave way, three or four ounces of black, liquid, inodorous blood issued from it, an abscess followed, but, finally, the patient recovered completely, and at the time of closing the report, was daily expected to leave the hospital.

Under these circumstances, the operation of securing the artery in the middle of the arm was performed by M. Dupuytren. It was cut down upon, exposed at the inner border of the biceps, and separated from the median nerve in the course of a very few minutes; but now, from the pain, or the cold, or other causes that "we know not of," the heart began to beat but feebly, the pulsations in the artery ceased, it could not be distinguished from the nerve, the surgeon was embarrassed, and, finally, upwards of half an hour elapsed before this apparently simple operation was completed. The patient by this time had rallied, and the artery VOL. X. No. 20.

71

M. Dupuytren saw this softening of the contents of the sac in a case of axillary aneurism, after the application of a ligature on the subclavian. In that instance he opened the sac by an incision. In a case of aneurism of the femoral artery, we witnessed this circumstance after the operation of tying the vessel, and the patient sank under the irritation excited by the dissolution and putrescence of the contents of the sac M. Dupuytren attributed the softening of the blood, &c. to the erysipelas which occurred in both his patients, but in that to which we have alluded, no erysipelatous inflammation, we believe, took place.

XXXIX.

MEDICAL REFORM.

While the cause of medical reform has been nearly ruined in this country, and all rational reformers disgusted and deterred by the conduct and character of certain brawling demagogues, our Gallic brethren are pursuing a wiser course, and are already almost certain of success. It appears that many petitions on the subject of MEDICAL REFORM had reached the legislature, and been referred to the ROYAL ACADEMY OF MEDICINE; and that a General CONVOCATION of medical men has been called in consequence. This 66 AsSEMBLEE GENERALE DES MEDECINS DE PARIS," took place in the "HÔTEL du DEPARTEMENT de la SEINE," on the 17th December last, when there were present one thousand and ninety-three physicians, surgeons, and "practiciens assimilés aux Docteurs." residing in Paris. The president was M. Desgenettes, the vice president was M. Bally, and the secretary was M. Gendrin. This convocation of all regular practitioners, without exception, was for the purpose of electing fifteen of the most talented and distinguished among them as a COMMITTEE for receiving all communications and suggestions--and for drawing up a memorial to government, on the important subjects of medical education, practice, and police. The committee includes Desgenettes, Broussais, Rostan, Husson, Magendie, Louyer-Villermay, Bally, Bouillaud, and many others of distinction. M. Desgenettes, after alluding to the message of the Minister of the Interior to the Royal Academy of Medicine, observes that, "however enlightened this body may be, yet the physicians and other medical practitioners of Paris and the Provinces, should have a voice in the proposed ameliorations." "The object was no less than that of fixing legally the basis of medical education, and the conditions of qualification-to erect tribunals of discipline, and a medical police.' s'agit de fixer légalement les bases de l'enseignement et les conditions des receptions; enfin, de Créer des Chambres de discipline et une police médicale." "We believe,"

says the address, "that all medical practitioners, equal in rights, as they are, in the eyes of the public, whose confidence they possess, ought to be equally consulted on such an important occasion." "Let us confess, gentlemen," says M. Desgenettes, "that our profession stands in need of speedy reform-for the noblest of arts is, with too many, become the vilest of trades." "Car le plus noble des arts, est, entre les mains de plusieurs, le plus vil des métiers."

In the report which the secretary read to this immense assemblage, of the preparatory steps which had been taken by the commission appointed for that purpose, he observes, "the healing art will not render to society all the advantages which society has a right to expect, till the exercise of it is regulated by institutions which shall guarantee not only the proper education but the subsequent probity of its professors." Convinced of the necessity of this, the government, whose solicitude has been awakened by the numerous complaints from all parts of the kingdom, wishes to concentrate all the documents which may tend to form the basis of a law destined to put an end to the innumerable abuses which have crept into the practice of medicine." The report goes on to state, that the existing corporate bodies of France have not been able to effect the most salutary regulations, and that if the investigation be confided solely to these bodies, the evils will never be remedied The following passage we shall not translate :-it is couched in very strong language.

"La nécessité de réformer, si générale. ment sentie, ne les entraînera-t-elle pas à conseiller des mesures qui pourraient, dans leur application, restreindre des droits acquis, mettre en péril l'indépendance de la profession, l'égalité de tous les hommes qui ont des droits égaux? corps privilégiés eux-mêmes, ne se laisseront-ils pas entraîner à donner leur assentiment à l'établissement de priviléges et de corporations qui, créés sous le prétext du bien général, au profit de quelques uns, pesarient sur le plus grand nombre ?"

It is hardly necessary to remark, that