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closes up to its margin, and thus do away with the necessity of amputation by the surgeon : the absorbents set to work, at the line between the dead and living bone, and in from four to eight weeks, the work is complete, and the skin soon closes over it."
"If while a stump is swollen, inflamed, and suppurating freely, the surgeon cuts down to remove a projecting end of bone, he adds to the inflammation, causes more or less hemorrhage, shocks the system, makes the condition of the stump altogether worse, and gains no time in the final result, even if the case does well. One of the greatest objections to the operation is the danger of extending the necrosis, by exposing a fresh surface of bone to unhealthy pus of the stump. This must necessarily be the most common result ; the projecting bone to be removed dies because it is exposed to air and pus, and the surface exposed by the second operation is likely to be followed by similar results from the same causes.”
Contusion of bone is, says Dr. Nott, very often followed by serious results. Many cases have come under his observation where the ball has entered, grazed the bone, and passed out, the wound healing rapidly. But in a few months, sometimes weeks-periostitis showed itself, which, going from bad to worse, ended in necrosis and exfoliation of a portion of bone over the sight of the contusion. The climate of the Southern States is according to our author peculiarly favourable to recovery from wounds. He says: “I feel assured that no experience of the old world can compare in success with that of the surgeons of the Southern States, not from any peculiar skill on their part, but from the superiority of the climate." Altogether we consider Dr. Nott's little work a valuable addition to our surgical literature. As here in Canada, we cannot tell the moment that many of us might be called to the field, it becomes our bounden duty to be thoroughly posted in that class of cases—that would certainly come under our observation, and on them Dr. Nott has thrown much light.
Descriptive Catalogue of Fluid and Solid Extracts in Vacuo, also Concen
trated and officinal Pills, prepared by HENRY THAYER & Co. Cam
bridgeport, Mass., 1866. We have received from Messrs. Henry Thayer & Co., a handsome book of over two hundred pages, being a descriptive catalogue of the fluid extracts and other preparations made by this well-known firm. Within a few years many practitioners have discarded many old infusions, and used in their place fluid extracts of the same article. Some profess to have met with disappointment from their use-complaining that the es.
tracts are not of a uniform strength. So long as the required strength can be guaranteed by a respectable firm, for ourselves we would prefer to use the fluid extract in many cases. Being concentrated, a smaller dose is required, a desideratum not to be overlooked. In their preface they say, “Except when prepared from officinal formulae, we manufacture a plain extract of the plant, believing that physicians will prefer to form combinations according to their own judgment. In strength each fluid pound of extract contains the strength of a pound of raw material.” So far as we are aware, the extracts prepared by Messrs. Thayer & Co. are not much used in Montreal, but we have no doubt that if they prepare them of a uniform strength, and advertise them, they may obtain a share of medical patronage.
Successful Removnl of the Uterus and both Ovaries by Abdominal
Section; the tumour fibro-cystic and weighing thirty-seven pounds.
By HORATIO R. SRORRER, M.D., Boston. We have had this small pamphlet in our possession for some time. It gives the details of a case of great interest, and its success will cause many to consider whether the assertion of the unjustifiableness of the operation is correct. Extirpation of the uterus has been principally performed by American surgeons, and including Dr. Storrer's there are now sis successful cases on record against eighteen fatal ones. was originally published in the Boston Medical and Surgical Journal.
HOW SHALL WE TREAT CHOLERA ? Notes on the Pathology and Treatment of Cholera. By GEORGE JOHNSON, M.D.,
F.R.C.P., Physician to King's College Hospital; Professor of Medicine in
King's College; etc. The question which I have placed at the head of this communication, is one which, at the present time, is of the highest interest and importance; and it is one to which probably many of us will soon be called upon to give a practical answer. Dr. Handfield Jones has discussed the subject at some length in the last number of the JOURNAL; and he invites others to give the results of their experience, particularly with reference to these two questions—Is it right to suppress choleraic diarrhæa at once and decidedly by any means in our power ? or is it a better and a more successful practice to encourage the evacuations by eliminants? The whole tendency of Dr. Jones' remarks is in the direction of an affirmative answer to the first of these questions, and of course of a negative to the second. Now, the ultimate appeal for the decision of all questions of this kind must be to facts and to experience; but the difficulty of obtaining trustworthy facts and the results of unbiassed es. perience is much greater than is commonly imagined. The facts are often seen through the distorting medium of a theory, and the jndgment is in consequence perverted. To illustrate this by an example: two practitioners (MM. Briquet and Mignot, Traité Critique et Analytique du Cholera Morbus, 1850, p. 514) who believe that the worst symptoms of cholera are the result of the drain of fluid from the blood, treated 200 cases of diarrhoea in the hospital, under the most favourable cireumstances, by repeated large doses of laudanum, and twenty-six of the patients so treated passed into the stage of collapse. Now, while it is assumed that the arrest of the disease in the 174 cases was a salutary result of the treatment, it is also assumed that the transition from the stage of choleraic diarrhea to collapse in the other cases was a consequence of the laudanum having failed to arrest the gastro-intestinal discharges. Buta totally different and possibly a more correct interpretation may be given of these phenomena. It is at least conceivable, though it is obviously incapable of proof, that, if these 200 patients had been kept in bed and had taken only copious draughts of cold water or any other simple diluent, not one would have passed into collapse, and all might have recovered more speedily than they did while taking large doses of laudanum. It is an indisputable fact, that a large portion of cases of choleraic diarrhoea will terminate in recovery under the use of the simplest possible remedies which are wholly free from astringent properties. Thus the late Mr. Wakefield, who was surgeon to the Middlesex House of Correction during the last epidemic of cholera in 1854, stated in a letter to the Times, that he had treated upwards of 150 cases of choleraic diarrhoea amongst the prisoners by thirty grains of sesquicarbonate of soda in a wineglassful strong mint tea. The dose was repeated every half hour. No fatal case occurred. “The disease was arrested with a rapidity that was quite magical,” and he had rarely occasion to administer the dose more than three times before the sickness and diarrhea were arrested. While under treatment, the patient was confined to a diet of beef-tea, cocoa, or arrow root; nothing solid, not even bread, being allowed while the diarrhea continued. Now, this plan of treatment, which was remarkably well suited for allowing full play to the curative efforts of nature, can scarcely
be supposed to have had any direct remedial effect, and it was certainly not an astringent treatment; yet the results were in the highest degree satisfactory, and form a striking contrast with the results of the opiate treatment in MM. Briquet and Mignot's cases. I am aware that too much reliance must not be placed on a comparison of the results of treatment in cases occurring at different times and in different countries; but there are many facts and considerations which point to the same conclusion as the comparison which we have just now instituted.
That treatment of choleraic diarrhea is obviously the best, which most speedily and completely puts a stop to the purging without subsequent ill effects. In the treatment of this disease, we must never lose sight of an important principle which, with reference to another class of diseases, has been forcibly impressed upon us by one of the great living masters of our profession.
Dr. Latham says:
« There is a lesson which we are apt to learn slowly, but which all of us come to learn at last. It is this: that while present pain and present peril call loudest for relief and rescue, still in relieving and rescuing the ultimate well-being of the patient must not be disregarded altogether. To compare great things with small, it is not only in the art of war, that an imprudent victory has been the beginning of many disasters." (Lectures on Diseases of the Heart, vol. i, p. 236.) For several years, I was in the habit of treating summer diarrhea,
Ι and during the epidemic of 1849 choleraic diarrhoea, by opium and astringents; and it was the frequent failure of this method that led me to search for some better theory of cholera than that which suggested this unsuccessful practice.
My observation of the effect of opium in cases of choleraic diarrhea is briefly this. When the diarrhea is abruptly checked by the opium, the patient sometimes passes at once into a state of collapse; while, in other cases, the diarrhea, having been arrested for a time, returns as soon as the effect of the opiate has passed off. In other cases, again, the diarrhæa continues, in spite of repeated doses of opium, for a period sometimes of several days; the patient meanwhile having a hot skin, a quick pulse, a coated tongue, headache, and other febrile symptoms.
On the other hand, I found, during the last epidemio of cholera, that when choleraic diarrhoea was treated by emetics, mild laxatives (castor oil), and cold water, the disease subsided much more speedily, and not one case, out of a large number so treated, passed into the stage of collapse. They all quickly recovered; although I am now convinced that in several instances much more castor oil was given than was necessary or desirable.
This is a true account of the results of the two opposite modes of treating choleraic diarrhæa, as I have observed them. And, moreover I maintain that these results are in strict accordance with the most rational theory of cholera.
What is the most probable explanation of choleraic diarrhea ? It seems likely that a poison enters the blood, either through the lungs or through the gastro-intestinal canal; and that this poison excites certain zymotic changes in the blood, in consequence of which some blood-constituents undergo morbid alterations which render them not only useless but noxious. These morbidly changed blood-constituents are then excreted by the mucous membrane of the stomach and intestines, and are ultimately ejected by vomiting and purging. It appears then that there are three distinct and well defined stages: 1, zymotic blood-changes, consequent on the imbibition of a poison or ferment; 2, vascular excretion of morbidly altered blood-constituents; and 3, intestinal elimination of the morbid excreta. Now, if this be the true explanation of choleraic diarrhoea, what is the probable effect of opium upon each stage of the disease? Is there the slightest reason to suppose that opium has the power to prevent or to check the zymotic changes in the blood; I know of none; and I believe that there is no evidence that opium has any such influence. But, from the known power of opium to check excretion, we should infer that it would probably prevent or retard the escape the altered blood-constituents by the mucous membrane of the stomach and bowels; and then, if it be true, as we believe, that the immediate cause of choleraic collapse is an arrest of the circulation through the lungs, induced by morbidly altered blood, we can understand that the astringent action of opium upon the gastro-intestinal mucous membrane may be quickly followed by collapse. And here again facts and theory agree in a remarkable manner.
Yet, once more, what is the effect of opium when a quantity of morbid secretion has been poured into the intestinal canal ? Obviously it must retard the escape of these offensive matters, and so prolong the disease. What says Sydenham upon this point ? "By checking the
" disease at its onset, I should wear out the patient by an intestine war, and I should just confine the enemy to his seat in the bowels, should impede the natural evacuations, and detain those humours which were seeking for an outlet.” And, again, with reference to the use of astringents, he says: “They keep the enemy to his quarters, and they change him from a visitor to a denizen. Besides this, the disease is prolonged, and there is danger in the delay. Vicious humours creep into the blood; ill conditioned fever is excited; and the patient suffers not only a severe