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derable time without causing much distress, until some unusualexertion induced a call for blood which could not be suppliedthrough the obstructed vessels, and hence the sudden syncopewhich carried off the patient. Is there anything improbablein the supposition that some of the cases of so-called "idio-

pathic syncope" may really have been of the same kind, withthis exception, that the patient rallied and survived, and thatthe obstruction in the artery has been eventually removed ?

(To be concluded.)

ON A

NEW METHOD OF TREATING COMPOUND

FRACTURE, ABSCESS, ETC.

BY JOSEPH LISTER, ESQ., F.R.S.,PROFESSOR OF SURGERY IN THE UNIVERSITY OF GLASGOW.

PRELIMINARY NOTICE ON ABSCESS.

IN anticipation of the more detailed account which I hope- will soon appear in THE LANCET, I will now give a descriptionof a new method of treating abscess, which has afforded resultsso satisfactory that it does not seem right to withhold it longerfrom the profession generally.

It is based, like the treatment of compound fracture, * on theantiseptic principle, and the material employed is essentiallythe same-namely, carbolic acid, but differently applied inaccordance with the difference of the circumstances. In com-

pound fracture there is an irregular wound, which has pro-bably been exposed to the air for hours before it is seen by thesurgeon, and may therefore contain in its interstices the atmo-spheric germs which are the causes of decomposition, andthese must be destroyed by the energetic application of the

antiseptic agent. In an unopened abscess, on the other hand,as a general rule, no septic organisms are present, so that it isnot necessary to introduce the carbolic acid into the interior.

, Here the essential object is to guard against the introductionaf living particles from without, at the same time that a free,,exit is afforded for the constant discharge of the contents.The mode in which this is accomplished is as follows :A solution of one part of crystallised carbolic acid in four

parts of boiled linseed oil having been prepared, a piece of ragfrom four to six inches square is dipped in the oily mixture,and laid upon the skin where the incision is to be made. Thelower edge of the rag being then raised, while the upper edgeis kept from slipping by an assistant, a common scalpel orbistoury dipped in the oil is plunged into the cavity of theabscess, and an opening about three-quarters of an inch inlength is made, and the instant the knife is withdrawn the rag is dropped upon the skin as an antiseptic curtain, beneathwhich the pus flows out into a vessel placed to receive it.The cavity of the abscess is firmly pressed, so as to force outall existing pus as nearly as may be (the old fear of doingmischief by rough treatment of the pyogenic membrane beingquite ill-founded); and if there be much oozing of blood, or ifthere be a considerable thickness of parts between the abscessand the surface, a piece of lint dipped in the antiseptic oil isintroduced into the incision to check bleeding and preventprimary adhesion, which is otherwise very apt to occur. Theintroduction of the lint is effected as rapidly as maybe, and underthe protection of the antiseptic rag. Thus the evacuation of the

original contents is accomplished with perfect security againstthe introduction of living germs. This, however, would be ofno avail unless an antiseptic dressing could be applied that wouldeffectually prevent the decomposition of the stream of pus con-stantly flowing out beneath it. After numerous disappoint-ments, I have succeeded with the following, which may be reliedupon as absolutely trustworthy. About six teaspoonfuls ofthe above-mentioned solution of carbolic acid in linseed oil aremixed up with common whitening (carbonate of lime) to theconsistence of a firm paste, which is in fact glazier’s puttywith the addition of a little carbolic acid. This is spread upona piece of sheet block tin about six inches square; or commontinfoil will answer equally well if strengthened with adhesiveplaster to prevent it from tearing, and in some situations it is* See THE LANCET of March 16th, 23rd, and 30th, and April 27th of the

present year.

preferable, from its adapting itself more readily to the shapeof the part affected. The putty forms a layer about a quarter ofan inch thick; it may be spread with a table-knife, or pressed out’

! with the hand, a towel being temporarily interposed to preventthe putty from sticking to the hand or soiling the coat-sleeve.The tin thus spread with putty is placed upon the skin so’that the middle of it corresponds to the position of the incision,the antiseptic rag usetl in opening the abscess being removedthe instant before. The tin is then fixed securely by adhesiveplaster, the Inwest edge being left free for the escape of thedischarge into a folded towel placed over it and secured by abandage. This dressing has the following advantages :-Thetin prevents the evaporation of the carbolic acid, which escapesreadily through any organic tissue such as oiled silk or gutta-percha. The putty contains the carbolic acid just sufficientlydiluted to prevent its excoriating the skin, while its substanceserves as a reservoir of the acid during the intervals betweenthe dressings. Its oily nature and tenacity prevent it frombeing washed away by the discharge, ’which all oozes out be-neath it as fast as it escapes from the incision; while theextent of the surface of the putty renders it securely antiseptic.Lastly, the putty is a cleanly application, and gives the sur-geon very little trouble ; a supply being daily made by someconvalescent in an hospital, or in private practice by the nurseor a friend of the patient; or a larger quantity may be madeat once, and kept in a tin canister. The dressing is changed,as a general rule, once in twenty-four hours; but if the abscessbe a very large one, it is prudent to see the patient twelvehours after it has been opened, when, if the towel should bemuch stained with discharge, the dressing should be changed,to avoid subjecting its antiseptic virtues to too severe a test.But after the first twenty-four hours, a single daily dressingis sufficient. The changing of the dressing must be methodi-’cally done, as follows :-A second similar piece of tin havingbeen spread with the putty, a piece of rag is dipped in the oilysolution, and placed on the incision the moment the first tinis removed. This guards against the possibility of mischiefoccurring during the cleansing of the skin with a dry clothand pressing out any discharge which may exist in the cavity.If a plug of lint was introduced when the abscess was opened,it is removed under cover of the antiseptic rag, which is takenoff at the moment when the new tin is to be applied. Thesame process is continued daily till the sinus closes.

The results of this treatment are such as correct pathological.knowledge might have enabled us to predict. The pyogenicmembrane has no innate disposition to form pus, but does soonly because it is subjected to some preternatural stimulus.In an ordinary abscess, whether acute or chronic, the originalcause that led to suppuration is no longer in operation, andthe stimulus that determines the continued pus formation isderived from the presence of the pus pent up in the interior.When an abscess is opened in the ordinary way this cause ofstimulation is removed, but in its place is substituted thepotent stimulus of decomposition. If, however, the abscess beopened antiseptically, the pyogenic membrane, freed from theoperation of the previous stimulus without the substitution ofa new one, ought, according to theory, to cease to suppurate,while the patient should be relieved from any local or generaldisturbance caused by the abscess, without the risk of irrita-tive fever or hectic.

Such, accordingly, is the fact. Abscesses of large size have,after the original contents have been evacuated, furnished nofurther pus whatever, the discharge being merely serum,which in a few days has amounted only to a few drops in thetwenty-four hours. Whether the opening be dependent ornot is a matter of perfect indifference, the small amount ofunirritating fluid being all evacuated spontaneously by therapidly contracting pyogenic membrane. At the same time,we reckon with perfect certainty on the absence of all consti-tutional disturbance.As an illustration, I may mention the last case which has

come under my care. It is that of a young woman, twenty-five years old, with psoas abscess, which had of late beenrapidly on the increase, and caused a large swelling below Pou-part’s ligament, communicating with a fluctuating mass, dullon percussion, reaching to a considerable distance up the abdo-men, the femoral vessels being raised over the communicationbetween them. Six days ago I opened, in the manner abovedescribed, the swelling in the thigh at the anterior partof the limb where it was nearest the surface, giving exit totwenty-seven ounces of pus, thin, but containing numerouslarge curdy masses. I introduced a piece of lint, dipped in thecarbolic acid and oil, into the incision; and this prevented anydischarge from escaping during the next twenty-four hours,

96

when, on removal of the plug of. lint under an antiseptic rag,three ounces of turbid serum escaped. For the next three daysthere was scarcely any discharge, the deeper parts of the in-cision having cohered. On firm pressure, however, the productof seventy-two hours escaped, and amounted to four drachmsof serum. Meanwhile the girl’s general health, which had notbeen interfered with by the abscess, continued perfectly good,neither pulse, tongue, appetite, nor sleep having been disturbed.

In this case, though there is no deformity of the spine, thereis great probability that caries of the vertebrae is present. Buteven though such be the case, there is good reason to hope fora favourable issue. Regarding caries as merely the suppurativestage of chronic inflammation in a weak form of tissue, I havebeen not surprised, though greatly rejoiced, to find that it ex-hibits the tendency of inflammatory affections generally-viz.,a disposition to spontaneous cnre on the withdrawal of irritation.Hitherto, in surgical practice, caries has had to contend againstthe formidable irritation of decomposing matter, which, undercircumstances of weakness, is often sufficient to cause ulcera-tion, even in the soft parts ; yet, in spite of this irritation,caries is often recoverable in the child where the vital powersof all the tissues are stronger. If, therefore, this serious com-plication can be avoided, there seems nothing in theory againstthe probability that caries may prove curable in the adult. And even should portions of necrosed bone be present, as isnot unfrequently the case, our experience of the treatment ofcompound fracture with carbolic acid has taught us that deadbone, if undecomposed, not only fails to induce suppuration inits vicinity, but is liable to absorption by the granulationsaround it.* *

Such were the hopes which I ventured to express severalmonths ago to my winter class. Since that time I have openednumerous abscesses connected with caries of the vertebrae, thehip, knee, ankle, and elbow, and in all cases I have found thedischarge become in a few days trifling in amount, and in manyit has ceased to be puriform after the first twenty-four hours.Finally, three days ago-viz., on the 4th inst., (July, 1867,)I had the inexpressible happiness of finding the sinus soundlyclosed in a middle-aged man, in whom I opened in Februarylast a psoas abscess, proved to be connected with diseased boneby the discharge, on one occasion, of an osseous spiculum. Formonths past we had persevered with the antiseptic dressing,although the discharge did not amount to more than a drop ortwo of serum in the twenty-four hours, well knowing by bitterexperience that so long as a sinus existed the occurrence ofdecomposition might produce the most disastrous consequences;and at length our patience has been crowned with success.

Hence I no longer feel any hesitation in recommending theearly opening of .such abscesses, because, while they remainunopened, the disease of the bone is necessarily progressive,whereas when opened antiseptically, there is good ground tohope for their steady, though tedious, recovery.The putty of the strength above recommended, though it

generally fails to excoriate the skin, sometimes produces thiseffect when long continued. In such case it may be reducedin strength so that the oil contains only one part to five or sixwithout disadvantage when the discharge is very small inamount.The application prevents the occurrence of cicatrisation in

the little sore caused by the incision, and perpetuates a triflingdischarge from it. Hence it is impossible to judge whether ornot the sinus has closed, except by examining it from time totime with a probe, which should be dipped in the antisepticoil, and passed in between folds of the antiseptic rag. This

may seem a refinement, but if we could see with the naked eyea few only of the septic organisms that people every cubic inchof the atmosphere of an hospital ward, we should rather wonderthat the antiseptic treatment is ever successful than omit anyprecautions in conducting it.The putty used in treating abscesses has proved very valu-

able in simplifying the treatment of compound fracture, andenlarging the range of its applicability, and also in dealingwith incised wounds on the antiseptic principle. But I mustdefer a notice of these matters to a future occasion.

Glasgow, July, 1867.

* See THE LANCET of March 23rd, p. 359.

THE magnificent hotel of the English Company atthe Esbequiah at Cairo will he partly opened in November foitravellers. It is a splendid building, certainly the finest inEgypt, and will be replete with every accommodation for invalids who seek the climate of Egypt during the winter time.

ON THE

PATHOLOGY OF TINNITUS AURIUM,OR THE

CAUSE OF THE NOISE WHICH SPONTANEOUSLYOCCURS IN THE EAR;

WITH REMARKS ON SOME OF THE ACOUSTICS OF THE

SENSE OF HEARING.

BY JOHN BISHOP, F.R.S., F.R.C.S.

(Concluded from page 68.)

EVERY practical surgeon is well acquainted with the nume-rous accidents to which the bones of the head and the mem-branes of the brain are liable, and is aware that some of thesemay and really do affect the mechanism in the labyrinth, moreespecially since we know that the membranous tissues, as wellas those of the osseous framework of the parts, are all liable tobecome inflamed. Let us now ask ourselves what are thecause and seat of those sounds in the ear which arise sponta-neously, and which not only trouble the invalid, but whichcause so much embarrassment for the aurist to relieve. It can-not be true, as some have supposed, that this malady ariseseither from the spontaneous movements of the organs ex-ternal to the labyrinth, or otherwise from the immobility ofthe membrana tympani, as Sir W. Wilde has imagined, sincewe know that by plugging the external meatus, so as to pre-vent the vibratory movements of the external air from reach-ing the tympanum, we merely hear the sounds produced by therush of blood in its transit by the ear to the brain, and we canvery clearly distinguish the sound of a tuning-fork in thestopped ear when applied in a state of vibration to the oppo-site side of the head, whilst the ear whose auricle has beenleft perfectly free receives no sound, thus proving that thevibratory movements are transmitted to the stopped ear bythe bones of the head to the semicircular canals, as Weber hassuggested. However, the history of the cases under considera-tion proves that they take their origin in a deeper seat than theexternal organs of hearing. The cases of tinnitus auriumwhich I have more recently examined have been caused byexposure of the head in warm or tropical climates, or theyhave occurred in persons who have suffered from violent blowson the head on being thrown from open carriages &c. If theexternal organs of hearing were the seat of the malady, itmight justify some of those experiments which have so oftenbeen tried and have so signally failed. If we include in theterm all the sounds affecting the organ of hearing resulting indefective states in the external mechanism, as well as thosewithin the labyrinth, the seat of this complaint must neces-sarily remain vague and undefined; but if we restrict it tothose sounds which are traceable to some existing defects inthe nervous structure of the labyrinth, we shall then beenabled not only to form a more correct diagnosis of themalady, but shall be able to form our determination of thekind of treatment best calculated to procure relief, if notentire recovery.The most practical and common-sense views for the treat-

ment of these affections have been discussed in the work bySir W. Wilde, who is very justly severe against the nostrumsrecommended by empirics. He puts no faith in the vauntedvirtues of galvanism, which might have been predicated to bean agent unsuited to the pathological states of these nervousstructures; and with respect to the injection of liquids, vapourof ether, or any other agents into the tympanum through theEustachian tube, as recommended by Kramer and practisedby others, he declares that he has never seen the slightestbenefit from this practice, either in cases under his own careor under the treatment of others. According to Cheselden,the injection of water into the Eustachian tube was followedimmediately after by deafness; and although Saunders has

. described a case in which the hearing was improved as long aswater was retained in the ear, this effect might have beenproduced by its supplying a medium for the transmission of

’ sound: at any rate, deafness returned as soon as the fluid waswithdrawn. Indeed, it is difficult to discover, on any acoustic

. or therapeutic principles, that good can arise from injectionsinto the Eustachian tube; and experience teaches us that its