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be of a logical cast, so that he may not mistake analogies for proofs, or draw too hasty conclusions, such as inferring, for example, from the phenomena observed in frogs, the certainty of similar facts in man.

From the time of J. L. Petit, surgery and medicine have been based upon normal and pathological anatomy. This is an error. Normal anatomy is truly a great aid, for it teaches you the position of the nerves and blood-vessels, and of all the internal organs. It is essential for the mechanical part of surgery or operative medicine. But has not surgery just as much need of cutlery and pharmacy ? and should we therefore not accord them as important a position as anatomy? The true basis of surgery is Physiology ; but not the physiology which has been up to the present time almost exclusively taught you, and which has been termed the “ Romance of Medicine.” Of what use in practice is such physiological knowledge? How are your therapeutical procedures inAuenced by knowing that it is the heart which propels the blood, the lungs which respire, the liver which secretes the bile, or the kidneys the urine? Even the discovery of the circulation has not advanced the treatinent of disease a step. Before Harvey's time Botal bled coup sur coup, and while recognizing what there is of beautiful in this discovery (for the truth is always beautiful), we may almost say that, from that epoch, therapeutics, as regards blood-letting, have pursued a retrograde course. In fact, experience seems to have led the ancients to bleed from a variety of veins; and upon what grounds is this practice abandoned ?

True medical and surgical physiology, that which employs itself in discovering the manner in which Nature repairs the breaches made in the human body, dates from JOHN HUNTER. He in fact first investigated the manner in which she comports herself in the healthy man for the resistance to causes of disturbance or ruin. Physiology, so understood, forms the basis of the rational part of surgery. It will direct us to the study in its origin, its causes, its progress, and its consequences, of that great phenomenon, inflammation. It will shew us how to direct or repress, or to excite it, as the case may be. Reflect upon the import of this change of basis-physiology in the place of anatomy-and you perceive in it consists an entire revolution in the art of surgery.

There is something else besides his organs which appertains to man. The organs exist in the dead body. There is besides in the living body a power whose nature is unknown, a power which circulates the blood, generates motion and thought, and which offers resistance when an external agent deranges that order which constitutes health. It has been differently regarded; some considering it as dependent upon physical or chemical laws, others as mechanical. But can we in this way explain even the most ordinary fact?

You cut your finger; the blood flows, and then stops after the formation of a clot. Oh! it is the heart, it is said, a hydraulic machine which propels the blood until the obstacle produced by chemical decomposition closes the vessels. In nearly the same manner may the red circle surrounding the wound be explained. Exosmosis then suffices ; just as endosmosis explains its disappearance. But why do not these phenomena thus come to pass in every case? Why do they occur at one period rather than another? Why do we not see them on the dead body, while it differs not as regards its chemical relations from the living man? It is because vital force exists no longer. What is this vital force, then? No one knows. We admit it just as we do attraction and chemical affinity. But what matters its nature? Sufficient for us to know its action. This knowledge is however of the highest import; for it is only by studying the phenomena by which it reveals itself, by penetrating the laws which govern it, that we can learn how to direct it. Let us examine well then how it acts in order to resist external agents; but, above all, let us study it in man, and preserve ourselves from the too common error, the abuse of experiments upon animals. These are useful only when they are made upon the nearest approaching species, or upon such as regards the point in question are identical." We could not, for example, describe inflammation in

1847]
Duties of a Surgeon.

255 man according to the phenomena observed in the dog, in which there is hardly any suppuration, or the rabbit, in which it exists not at all. Let us then investigate the mode of action of the vital force, and first let us observe it under the most simple circumstances. We have received a cut; the blood flows, then stops; the capillaries are injected, and inflammation is established. If we leave Nature alone, and trust to the vital force, we observe that it is essentially a vis medicatrix, and that this case it alone suffices; whence the conclusion, that in traumatic iuflammation the surgeon's first duty is to do nothing. Do nothing ! An important dictum this that needs interpretation. Nature, at the commencement, we have said, is essentially a medicatrix, but upon the condition that her work is not interfered with. Wait to act until she wanders or deviates, and then intervene, to place her again in the right path. Watch like a vigilant sentinel, in order to remove whatever may interrupt her proceedings. To fulfil this great therapeutical indication, which of itself constitutes three-fourths of surgery, we are obliged to modify the treatment of the most obstinate as well as the most simple diseases. What has a surgeon to do in a simple fracture ? Nothing. Nature alone will well repair the damage, provided she is protected from interruption during her labours. Among the most frequent obstacles is movement of the parts; and our care is limited to securing, by the best-adapted apparatus, the complete immovability of the part. As to bandages, what is their effect but to deprive the part of the vivifying action of the air, and etiolate it, even if they do not produce a local scorbutus. We may say as much of resolvents, such as white lotion, spirits of camphor, &c. What is there to resolve in a fracture ? The swelling which accompanies the inflammation ? Is it not necessary for the consolidation. The effused blood ? Nature will remove that without your aid. If there is displacement of the fragments, the hand of the surgeon is required; and this is mechanical, or, if you like, operative medicine. Restore the forin of the limb, fix it conveniently, and retire. Let Nature resume her place, and do not say that you have effected a cure. You have reduced the fracture; the cure comes from Nature alone.

Simple surveillance is also our essential and only duty in all those simple inflammations, which in all their symptoms and progress are analogous to traumatic inflammation, and which come on from unknown causes, or under the problematical influence of cold, draughts of air, &c. The same principles will apply, e. g. to white swellings, diseases whose cause often traumatic, and which continue long in the condition of simple inflammation before acquiring the gravity which subsequently characterizes them. At the commercement, and indeed as long as the disease has not passed beyond the limits of simple inflamtion, prevent the movement of the part, that so frequent obstacle to the efforts of Nature. Remove all causes of pain, and especially such as arise from faulty position, of such common occurrence when the disease has been of long continuance; and discard all that perturbatory medicine which only can make use of leeches, blisters and moxas. Of these means, the employment of which now seem the general rule, some may be useful in rare and special cases; but what shall we say to a blister put on for the relief of pain which only depended upon faulty position. The common result of such therapeutic procedure is to convert an ordinary synovitis into a fuugous tumour, and to give the surgeon occasion to shew his dexterity in depriving the patient of a limb, which, by proper care, he might have preserved for him.

The considerations we have entered into give rise to new views, which may serve to establish the superiority of surgery over medicine. The facility with which we may ensure immovability to a limb, and the impossibility of procuring the inactivity of the heart, lungs, &c. explain why surgical inflammations are generally so much easier of cure than medical ones. In conclusion, expectation in surgery cannot be too highly recommended ; but an intelligent cxpectation. Nature is not always a vis medicatrix, and then it will not do to remain a simple

spectator. Direct the vital force, govern it, resist it if necessary by the most energetic surgical means; and even in certain desperate cases abandon it to itself. Resume your passive character, the power of diagnosis and prognosis alone remaining to you. It is better to deplore a case as desperate, and to let the patient die at least naturally, than hasten his end by an operation that nothing can justify:-Gazette des Hópitaux, No. 57.

TREATMENT OF EPILEPSY.

While detailing some unsuccessful experiments he had been making upon the employment of Ether in epilepsy, M. Moreau delivered the following important observations :-“ Every medicinal substance has in turn failed when employed against this terrible neurosis, as everybody knows. But what every one does not so well know is, that all, or almost all, these remedies succeed during the first periods of their employment. That is to say, the attacks diminish, or cease entirely, and even suddenly. But just in proportion to the extent of the apparent amelioration, the more the attacks seem to have yielded, the more terrible do they become when they are reproduced. They may then even place life itself in danger, which they never did before. This fact is of great practical importance, and I have seen hundreds of examples of it during the now near seven years that I have sought, by all the remedies proposed at home or abroad, and some of my own devising, to coinbat this dreadful disease.—- Gazette des Hópitaux, No. 38.

TREATMENT OF BURNS.

M. Jobert and M. Malgaigne pursue very different modes of treating Burns at the St. Louis, where a great number of these cases are admitted. M. Jobert ernploys refrigerants, laying bladders of ice upon the parts, previously covered with simple dressing. From this treatment he states that he obtains, 1, prompt cessation of pain : 2, an abolition or diminution of inflammatory action : 3, a diminution of the suppuration which precedes or follows the separation of the eschars; and 4, a more rapid and prompt cicatrization; but it is, however, contra-indicated when thoracic complications exist, or when a predisposition to these is present; or when the burn, situated in the chest or back is very extensive, M. Malgaigne prefers the oleo-calcarous liniment and carded cotton; associating the two because the cotton alone does not so rapidly relieve the pain, and the liniment alone does not protect the surface from friction. Like M. Velpeau, he prefers equal parts of lime-water and olive oil; but M. Miquel recommends 2 parts of the former to 1 of the oil. This produces a speedy cessation of the pain.-Gazette des Hôpitaux, No. 59.

[We have employed with much advantage the application recommended by Mr. Bulling, viz., covering the parts with lint soaked in a mixture of i part treacle, 3 water-using it at a temperature of 98°,- Rev.]

ECTROTIC TREATMENT OF SMALL-Pox.

Dr. S. Jackson states that he has found the free ation of the Tincture of lodine by means of a sponge, causes an abortion of the eruption, and prevents pitting or the disagreeable discolouration which usually follows the disease. Philadelphia Medical Examiner.

1847)

Rinino on Chronic Diffused Arteritis.

257

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Notes or Cases op CHRONIC DIFFUSED ARTERITIS, CURED ANTIPHLOGISTIC METHOD AFTER THE FAILURE OF DIFFERENT Modes OF TREATMENT IN THE HANDS OF OTHERS. By Dr. Rinino of Turin.

The greater importance most physicians attach to mere symptomatic appearances than to pathological conditions in the diagnosis and treatment of diseases, espe.. cially those of a slow and chronic nature, is the frequent cause of the most pernicious errors, into which even practitioners otherwise of great excellence fall; errors which have often led patients to certain death, who, treated conformably to the maxims of modern experience (based upon facts examined by the light of a philosophical pathology and guided by pathological anatomy), might have recovered their lost health, and lived for many years. Such errors are more easily committed in those cases in which certain chronic diseases are marked by nervous symptoms, as in the case of hysteria, hypochondriasis, believed by many practitioners to be dependent upon a totally different state to that of phlogosis. Add to this that, when treating patients of emaciated or cachectic habits, the subjects of hæmorrhage or discharges, women, children and old persons, ill-fed individuals, such as are subjected to prolonged mental employment or abuses of any kind, we are led to suspect their complaints are of an asthenic rather than of an inflammatory nature. And yet, if the symptoms be accurately examined, the indications of slow inflammation will be generally detected; whence it follows that the treatment pursued in these emergencies may be actually injurious, or, if too bland and palliative, will allow the patient to die from the degeneration of tissue and other consequences unsubdued inflammatory action produces. What is true in a general way in regard to morbid conditions dependent upon slow inflarnmation mistaken and badly treated by practitioners, applies to chronic diffused arteritis, of which I now publish a few of the more important cases that have come under my notice during a short space of time.

The first of these occurred in the person of a lady, who, having arrived at the time of life when the menses were leaving her, was tormented at the periods by various vague pains in different parts of her body, and vibratory pulsation at the præcordium, the neck and temples. Sleepless nights, bad digestion, and confirmed melancholy existed. Two practitioners, consulted in succession, observing the feeble state of the patient and the absence of fever, pronounced her ailments of a nervous and asthenic character, and prescribed the usual remedies for these conditions. Dr. Rinino was now called in, and, finding the pulse frequent, “metallic,” and vibratory, he pronounced the case one of arteritis, notwithstanding the absence of fever. Ten bleedings were practised in the course of a fortnight, leeches and then ice applied, a rigorous diet adhered to, and various contra-stimulants prescribed, and the lady entirely recovered her health, which she retained by taking the precaution of losing blood two or three

Case 2.—Signor Panizza had suffered for some years under the symptoms of hypochondriasis. Indigestion, epigastric pain, costiveness, emaciation, insomnia, a chlorotic aspect, and confirmed melancholy were among the symptoms which induced his attendants to consider his case one of asthenic hypochondriasis, and to treat it unavailingly by nutritious diet, pharmaceutical stimuli, and mental distractions. Afterwards, some congestion of the liver being suspected, leeches to the anus and purgatives were prescribed. By the first plan of treatment all his symptoms were aggravated, by the latter only temporarily relieved, and the patient seemed fast sinking into a hopeless state when the author was called in. Notwithstanding the feeble condition of the patient, he declared a chronic arteritis

NEW SERIES, NO. XI.--VI.

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to be the cause of his sufferings, and prescribed free depletion for its removal. He based his diagnosis upon a constant arterial vibration felt and heard at the epigastrium, and upon the sharp, metallic character of the pulse—the patient being however apyretic. Nine bleedings and a leeching rapidly followed each other, a rigorous diet and contra-stimulant remedies being simultaneously employed, and in forty-five days the patient was convalescent.

Case 3.—Signor Sasso (ætat. 60) was seized, in 1845, with a complicated condition of ill health, the chief feature of which was diagnosticated by his attendants as ischiatic neurosis and treated with palliatives, without effect, until at last the patient seemed to be in a state of great danger. He was of a very sanguine temperament and weak constitution, accustomed to good living and little exercise. He complained exceedingly of an epigastric pulsation which tormented him whatever position he assumed, and, although he had no fever, he presented the rapid, metallic, vibratory pulse observable in chronic arteritis. He suffered acute pain in the hip-joint, which the slightest movement exasperated. Nine successive bleedings and a free leeching with a spare diet were resorted to, and the various contra-stimuli, especially kermes, extract of aconite, and secale cornutum, alternating with purgatives, were prescribed. During a month convalescence was satisfactory : insomnia was exchanged for refreshing rest, and the supposed sciatica, which the author believes to have been an arthritis, gradually disappeared.

Case 4.-Occurred in the person of a girl of about four years of age, who for two months had had the eyes closed in consequence of an obstinate psorophthalmia, the supposed residuum of a crusta lactea, and against which various demulcent remedies had been in vain employed. Dr. R. was called in in consequence of a profuse epistaxis, and was struck with the marked arterial vibration in spite of the loss of blood, which amounted to almost two pounds (Austrian). He informed the parents that the epistaxis was in fact a fortunate occurrence, and eventually persuaded them to allow him to abstract yet more blood (which was cupped and buffed), on three separate occasions. Having thus, in some degree, quieted the arterial vibration, he prescribed kermes in union with the extract of aconite and Dover's powder; and in a fortnight the child was able to open her eyes, the psorophthalmia and arteritis gradually yielding to a persistence in the medicines.

Case 5.-No one, says the author, accustomed to the examination of these cases could be deceived in diagnosing chronic arteritis as the cause of the serious and prolonged illness of Signora Pinta. Her countenance was the colour of virgin wax; vigorous pulsations prevailed at the præcordium, accompanied by a sense of weight and anxiety: the cardiac pulsations imparted a very vibratory sensation to the ear, and the pulse was strong and metallic. The arteries of the neck and temples also pulsated rigorously. There was no fever. A sense of universal uneasiness tormented the and in turns violent pains attacked the abdomen and head. She was absolutely sleepless, had become much emaciated, and laboured under an inexpressible sense of prostration of strength. Her illness dated four months back, when Dr. R. saw her, and at first putting on a febrile aspect, her attendant had bled her four times with temporary relief

, and other four times after she had again relapsed. Other assistance being sought, her yellowish aspect and wasting away, and the duration of her illness led to the belief of the existence of a passive congestion of the liver, dependent upon an asthenic diathesis. After leeching the anus, stimulating remedies were employed with the effect of plunging the patient in a worse state than ever. Our author, called in, quickly corrected the error of diagnosis, and proceeding more actively in the same course of the more timid practitioner first consulted, in a very few days had bled the patient thirteen times to the extent of a pound, besides leeching her. In a month she had entirely recovered. — Annali Universali, Vol. cxviii. 29.

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