zation, or simple atony of fibre? Even where from the symptoms we believe inflammatory action to be present, we must still be very cautious in recommending complete abstinence and leeching, which may produce a degree of exhaustion or contractility of the parts, that may require years for its reparation. Diminution of food will, however, then be required, as well as mild counter-irritation applied in the form of dry-cupping, sinapisms, and frictions to the abdomen. When the irritation has subsided, mild tonics and a gradually improved diet are indicated. When the diar. rhoea is passive, tonics combined with anti-spasmodics may be given in very decided doses. M. R..P. speaks highly of the utility of theriacum, and especially when united with calumba. Diascordium is often useful, but sometimes too stimulating. Alumnized and laudanized waters, or small doses of acetate of lead, also cure the affection. The following formula is recommended by the author. R. Mucous Extract of Opium, gr. j. ; Powder Acacia, grs. xij.; Powder of Calumba, 3 ij.; Mint Sugar, iv. mix for six doses. The employment of light wine diluted with sweet infusion of lime or orange leaves or camomile; the drinking but small quantities of fluid; the selecting aliments as dry as possible, as crusty or toasted bread in preference to crumb; and the taking food instantly craving is felt, are among the practices recommended.

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Gastralgia or enteralgia is of far more frequent occurrence after severe disease, especially when the alimentary canal has been implicated, than is generally believed. The irregularity of its attacks forms one of its most distinguishing features. The poignant feeling of hunger, sometimes so acute in this disease, suddenly changes into a state of insupportable gastric languor." In this disease, a superabundant nourishment is injurious, but in a far less degree than a too scanty one. Abstinence cannot be borne, nor do the epigastric pain and traction cease until a certain quantum of food has been swallowed; while, if its administration be too long delayed, digestion does not take place, and diarrhoea is produced. "Wo be to the patient whose attendant mistakes a gastralgia for a gastritis!" First among medicines adapted for gastralgia may be named the sub-nitrate of bismuth (indeed an admirable remedy in this class of affections) given alone or with opium or calumba. External revulsives, as blisters, cupping-glasses, or sinapisms, should be applied to the abdomen. The endermic use of morphia is often very useful; as are also equitation, gymnastics, travelling, &c.

Whatever means we have recourse to for the restoration of the energy of the digestive process and the establishment of the normal equilibrium between the sensibility and contractility of the canal, a prolonged employment of a variety of measures is demanded. "Perseverance and variety must never be lost sight of by the sagacious and prudent physician in an obstinate, troublesome convalescence, during which health and disease are constantly vibrating.'

On the Employment of Plates of Lead in the dressing of Wounds and Ulcers about to cicatrize.

No one has oftener than the military surgeon occasion to exemplify the truth of the proverb, that necessity is the mother of invention; and our author, finding himself destitute of numerous appliances at the siege of

1846.] ON DRESSING WOUNDS WITH LEADEN PLATES.

161

Saragossa, 1808-9, was obliged to tax his ingenuity to discover appropriate substitutes. The want of lint, however, was his most serious privation, for although moss and heath served to fill the pads for compound fractures, and tow for the dressing of large and abundantly suppurating wounds, yet there was no means of supplying the place of fine lint in dressing granulating, sensitive sores. He was, in fact, obliged to leave such uncovered, until the happy idea struck him that thin leaden plates might serve as a protection for the surface. Balls there were in abundance, and the author and several soldiers set to work with all their energy to hammer these out into plates, some of which were no thicker than a leaf of paper. To his surprise and satisfaction he found that these not only did not oppose but favoured cicatrization; and since that period he has continued to derive the greatest advantage from their employment.

A wound which is disposed to heal requires only that its surface should be protected while Nature conducts the healing process. LINT is an excel. lent protection of this kind, maintaining also a mild temperature of the part favourable to its union. It is also an excellent means of absorbing the pus, when this is secreted in too large a quantity. The moderately stimulating effect which some suppose it to exert upon the wound, thereby hastening its healing, is very doubtful. Among the inconveniences of this substance is the difficulty of obtaining it of sufficient good quality, at least when large quantities, as in armies and hospitals, are required. If it is too coarse and hard it irritates and inflames the wounds, while, when too fine and thin, it adheres to them so tenaciously, as to be removed even by soaking only with difficulty, often detaching the tender cuticle with it. The edges of the wounds are kept bleeding and irritated, and cicatrization is retarded. The lint sent to the army, from bad packing or selection, often proves a source of great irritation to wounds, while it has not unfrequently, when washed again to be used, been the means of maintaining hospital gangrene and other epidemic affections. The increased and increasing price of this article renders the discovery of a cheaper substitute also very desirable, when very large quantities are in request. The adherence of lint to the edges of wounds has been sought to be prevented by the intervention of strips of cerate. But the thin cicatrizing edge of a wound is eminently sensitive, and the reiterated application of greasy bodies to it often induces pruritus, or almost even erysipelas, especially when the ointment is at all rancid. Moreover, the removal of the layers of these fatty bodies which cake on the edges is often very irritating. Prepared tow has of late been much substituted for lint, but it perfectly supplies its place.

very im

The employment of leaden plates seems much more fitting for favouring the cicatrization than any other means. They are to be retained in situ by compresses and bandages, or by adhesive plaister. Their suppleness and flexibility, and the ease with which they may be cut or shaped into any form, render them a very convenient and expeditious mode of dressing wounds. The action of the lead is purely mechanical, for the same effects may be obtained by plates of tin, gold, or silver, but its ductility and cheapness render it the most eligible substance. As the lead contracts no adherence with the edges of the wound, fatty bodies are not required, the dressing is far less painful, and the newly-formed skin is in nowise irri,

No. 105.

11

tated or torn. The dressings are also required to be renewed only every two or three days, according to the quantity of the discharge and irrita bility of the wound. As Nature is thus secured from interruption, the work of cicatrization proceeds much more rapidly. Infection, moreover, can never be communicated, as it may be by the employment of old lint; for the same plate, if not too thin, may be used for successive patients with perfect safety, if the precaution be taken to have it well cleaned and slightly polished. Many practitioners have tried this plan of treating wounds since it was first proposed by the author, and have confirmed his statements of its efficacy. Some, however, believing he had recommended it only for ulcers, have failed in deriving advantage from it. His object was, however, different.

"From the title I have given to this essay it is easy to see that I allude to wounds and ulcers only which are disposed to cicatrize, that is to large, superficial, red, granulating, painless wounds, covered with a fibro-purulent layer, and surrounded by a deep, rose-red margin. On the contrary, when the wound is deep, when it does not present any of the conditions favourable to a speedy cicatrization, if there is pain, whencesoever this may arise, if there is abundant suppuration, or if the wound is kept open by a virus, and it is deemed desirable to treat it by local applications, such as cataplasms, &c., I do not think this mode of dressing is ever attended with success, at least such is the result of the numerous trials which I have made. Nevertheless, it is proper to have recourse to it whenever, the obstacles to cicatrization being removed, the solution of continuity tends to a cure. In spite of these numerous exceptions, this mode of dressing will thus prove suitable to the great majority of wounds; and farther than this, there are cases in which it has succeeded, although in a different manner to that already alluded to. Thus, in certain examples of abscesses forming in encysted tumours, after the contents have been evacuated through a small aperture by the aid of the cupping-pump, a strong leaden plate bound over the part, has in a short time effected a cure, by producing adhesion of the walls of the abscess. To return to our proper subject. Whenever a wound is brought into a simple condition, and the obstacles to its cicatrization no longer exist, this is the best of all dressing, and its success is certain. However, large and superficial wounds are those in which it has seemed to me to be most suitable. Burns offer a remarkable example of this. If they are slight we may at once resort to the lead; but if they are deep we must wait until the consequent suppuration has sufficiently diminished. In both cases, the leaden plates, applied at more or less long intervals, will effect a cure of the wounds, as they will also those resulting from the application of blisters in irritable subjects, or at the end of long diseases. Many practitioners have observed that patients in these cases bear the application of lint or cerate to the ulcerated surface with great difficulty. Every dressing is accompanied by adhesions, bleeding, excessive suffering, loss of rest, fever, and delay of cicatrization. A simple leaden plate, which is occasionally removed, at once remedies all inconveniences of this kind.

"This mode of dressing succeeds equally well in wounds situated upon certain parts where cicatrization is usually obtained with difficulty, as over the elbow, the shin-bone, the ankle, and the tendo-Achillis. Every surgeon must have experienced the difficulty and anxiety which sometimes attend the endeavour to produce cicatrization of even small wounds situated on these parts. This new plan effects this with certainty. * * There are wounds with loss of muscular substance which no means will cicatrize, and the leaden plates offer no particular advantage in this respect; but the dressing by their aid is far more promptly and conveniently performed than with lint, while they offer a kind of artificial integument as a substitute for the natural one.

*

*

1846.]

TREATMENT OF WOUNDS BY SUCTION.

163

"No one is unaware that large cicatrices are very easily torn, and that the healing of the part is subsequently obtained only with great difficulty. In these cases the dressing with lint and ointments irritates the newly-formed skin, and re-opens the wound again and again, so that this is at last sometines deemed incurable. But under the use of the leaden plate the healing is completed, although requiring a longer period than under other circumstances. Moreover, a new cicatrix may be rendered more firm, and is seldom then torn, by protecting it with one of these plates."

The wounds, ulcers, or erosions which form upon ædematous extremities are also advantageously managed in the same mode. So also the spreading ulcers which follow the application of blisters in children. Sometimes, after an issue has been made, it cannot be kept open by reason of an erysipe latous redness which surrounds it, and which is usually increased by ointments, &c. The application of a leaden leaf in a short time allays all irritation. As regards ulcers, properly so called, the lead will not accele. rate cicatrization if they are kept open by any special local or general cause which first requires removal. In varicose ulcers, however, combined with pressure, the leaden plate is highly useful. To secure prompt success in the use of the lead, the plates must be properly selected, so that, without being too thick, they will not become torn upon the least movement. The tin-foil which surrounds chocolate, has been endeavoured to be used as a substitute; but even when trebled or quadrupled it offers scarcely consistence enough for repeated use. The plate must of course be accurately adjusted to the wound, just as any other dressing requires to be. Some surgeons have advantageously employed the leaden plates in even abundantly suppurating wounds, piercing them with a large pin in many places to give exit to the matter.

As connected with the foregoing subject, we may here notice the author's other paper upon the treatment of wounds. It is entitled

A new Method of expediting the Healing of recent Wounds.

As the method has already been published in one of the French journals and copied into our own, we need here only recal the principal points set forth. The great object in the management of wounds is the prevention or diminution of inflammation. Wounds only of a very slight extent and depth, unaccompanied by complication, have hitherto been considered as capable of union by the first intention. This arises from the presence of a foreign body, which, whether solid or fluid, must be eliminated by the suppurative process before union can take place. Foreign bodies, however, impeding union, do not always proceed from without, nor are they always perceptible to the senses, and capable of removal by instruments, &c. Effused or infiltrated blood, the little clots closing up the divided mouths of small vessels, fragments of skin, cellular tissue, or torn and bruised muscle, may produce all the effects of the ordinary foreign bodies. A detritus of this kind induces irritation, inflammation, and suppuration; and what the older surgeons termed the detersion of a wound is only an expression for the elaboration of these foreign bodies by the efforts of Nature, and the consequent placing the wound in a condition for healing. In proportion as the wound is made by a sharp instrument, and is of a clean uncontused character, the amount of detritus will be smaller, and

the chances of adhesive inflammation greater. Thus fire-arms, by the great amount of contusion they induce, produce the description of wound least favourable for prompt union :

"In scientific investigations we should never lose sight of the principle of proceeding from what is real and proved by experience to possible melioration. Experience here proves that the more considerable is the detritus of a wound, the less hopes we can entertain of a cure without inflammation or suppuration. The primary indication is then, at first, either to seek a cure by the first intention, or at least to diminish, as much as possible, the inflammatory action which is to follow. The approaching the edges of the wound, the removal of atmospheric influences, the extraction of external foreign bodies, the support of any flaps that may exist, occasionally the use of compression, and, especially in recent times, the more or less prolonged employment of refrigerants, are the means daily resorted to with more or less success. For my part, I believe that, before having recourse to measures for diminishing inflammatory action, and especially the employment of cold water, there is a more fundamental indication which requires great consideration, viz., the immediate and complete removal of the detritus. Nothing is so likely to prevent or diminish inflammation as the conse quent suppuration. But how is it to be accomplished? The best means is by the exercising a strong aspiration upon the surface of the wound, whether this be done by means of suction as employed by the ancients, or by the application of the cupping pump as I have practised it myself. By this proceedure the effused blood is pressed out from the wound as well as from the extremity of the small vessels, and from the cellular tissue. The same occurs also with regard to a number of small, almost invisible, fragments, furnished by the tearing of the parts. When no foreign body any longer exists, and the wound remains clean and pure, if we can so speak, no cause of irritation being present, there is no inflammation, or, if this cannot be entirely prevented, it is at least much limited in its intensity and consequences-of course taking into account the obstacles to union which the gravity of the wound and the nature of the organs affected may offer."

The suction of wounds was employed in the most ancient times, and even a class of persons devoted to its performance existed. Their offices were chiefly required for the bites of serpents, but were also sometimes ́ employed after the wounds of arrows, spears, &c.; and Percy states that, in the last century, there were men in the French army whose duty it was to perform this suction. At Amsterdam, a treatise on the Art of Sucking Wounds" was published in 1712. There can be no doubt that suction and cupping-glasses have been advantageously used in the management of poisoned wounds; and the observations of Celsus in favour of the practice have been amply confirmed by modern observers. In simple wounds, also, the author has convinced himself, by experiments on animals, that the application of the cupping-glass much hastens the curative process.

In employing this means the cup used should always be rather larger than the surface of the wound, so that this latter be completely submitted to the action of the pump. The application, too, should be resorted to as quickly as possible, for if enough time have elapsed to allow of the setting up of irritation or inflammation, the operation is contra-indicated. The pain occasioned is very slight and bearable, and any bleeding which may be produced ceases after the glass is removed. It is almost needless to add, that this means does not exclude the employment of any of those