midable than they really are, in consequence of their flattened form, caused by pressure. Occasionally the arteries are large, and if so, more easily found. In all my search, I have discovered but a single instance where the arteries were alone tied, and that was the first in this country, that of Prof. Smith, who in removing a cyst, weighing with its contents, 8 lbs., 4 oz., "tied two small vessels," and returned the pedicle. A tumor weighing over 8 lbs. would have pretty large vessels, if those of 30 and 40 lbs. have them of such dimensions as to demand ligation en masse. A Mr. Wilson is spoken of in the Medico Chirurg. Review, as advocating tying the individual vessels, but nothing is said of his putting the idea into practice. Spencer Wells says that on a favorable opportunity he shall tie the vessels separately by wire, and leave the ligature in the abdomen. Yet he does not appear to have adopted the practice.

Simpson has of late resorted to compression, by passing a strong pin with a large head through the pedicle, at a little distance from its edge, if a broad ligament, then back again near the other edge, and then ties over the head and point by a figure 8. Thus the vessels are compressed between the pin and ligature. He then protects the point of the pin by a hood, and so arranges three wires that by drawing on each in succession the hood is withdrawn, then the pin, then the ligature. In this case the pedicle is returned to the abdomen at once. His object in not enclosing the whole pedicle in the pin, was to permit enough blood to pass to the outer end of the stump, to keep up its vitality. Brown has used the actual cautery on a few occasions, a practice constantly and safely used in veterinary surgery and in spaying. He has used it not only with success on the stump of the pedicle, but also on the abdominal walls. I should not consider this practice as safe as the ligature, but it certainly possesses some advantages.

Having had but a limited number of cases of my own, and being unwilling to depart from authority in a matter of so great importance and at the same time so novel, it became me to take the position of learner, not teacher; therefore, throwing aside all prejudices or theoretical objections, I followed the practice usually adopted, by ligation en masse, and either leaving the ligature hanging from the wound, after the manner of Clay, or attached to the wound, after the method of Simpson. A plan has suggested itself to me, which appears free from most of the objections, but I have had no opportunity of putting it to test. It consists in finding the arteries by the finger, before cutting, or after cutting; the pedicle, in the latter case, being tempora

rily secured by the clamp. An armed needle may be now thrust through the pedicle, close as possible to the vessel, and back close as possible on its other side; this is then firmly tied, or twisted, if a wire. Every large vessel may be thus treated, and the veins also, if disposed to bleed.

The advantages of this course will be many. First, the pedicle will not slough at all. Second, the ligature being very small, and of wire, if preferred, may be returned into the abdomen or kept at the wound; in either case making far less trouble than the strong cord now required. Moreover, if wire is left, it will imbed in the pedicle, not in the intestines or walls. 3d, Slipping is impossible, because thrust through the pedicle. 4th, Shrinking, as in Parkman's case, is not likely to occur, as but a very small part of the pedicle would be embraced in each ligature. 5th, No large suppurating surface will be left, on detachment of the ligatures. 6th, The distress caused by the stricture en masse, will be entirely avoided. It is not improbable that much of the nausea, and sickness, and prostration usually following, may be owing to the common method of strangulation, as we know the intimate sympathies of the abdominal viscera. Thus ligature of so comparatively useless a body as the omentum, will closely imitate in its symptoms, strangulation of the bowel itself. 7th, The wound can thus be brought together and safely healed, by the first intention. Here let me say that, although I have not hitherto practiced it, I am satisfied on reflection, that the method of Tyler Smith, of returning the pedicle with the ligature into the abdomen, is preferable to any other as yet used, and will be in harmony with the method proposed by myself. The reason is that patients are most likely to die on the third day or before, of exhaustion. If they rally against this, the chances are pretty good. It is important, therefore, to place the wound in the best condition for present comfort and security, until this dangerous period is passed, without undue solicitude about accidents occurring later in the treatment. If the pedicle lies quiet in the pelvis, secured by a ligature of animal substance, the uterine appendages not put on a stretch, nor the wound partially open by the pedicle in it, according to the method of Simpson, the patient will be in the best possible state for recovery; should, however, effusion of pus occur, (as it will to some degree,) or the ligature make trouble, (although it never seems to have done so,) the system is in a better state to resist, after the lapse of a few days, and probably will do so successfully. In the method proposed by me the ligatures will be exceedingly small, and not likely to lead to any disturbance.

METHOD OF CLOSING THE WOUND.

The two modes, adopted most generally, are by ordinary suture, wire, and pins, after the manner of hare-lip sutures. The latter method seems to me preferable. I have seen a wound for ovarian section almost perfectly united by this suture in forty-eight hours, except at the point where the pedicle was attached, (even where the termination was fatal.) The advice of Wells should, however, always be followed, viz: introduce the pins at some distance from the edge of the incision, pass them deep and close to the upper surface of the peritoneum, without penetrating it. These are to be placed about 14 inches apart, and secured by the figure eight ligature. Superficial stitches are to be taken between these deep ones, and adhesive straps applied, where necessary. These pins should have considerable length, say from 2 to 4 inches. In the very fleshy case mentioned above, the largest were necessary. I would suggest that in such a case it would be better to have the pins somewhat curved, like the common surgeon's needle, (though not as strongly,) as these would cause less strain on the abdomen, would bring the edges of the wound more naturally together, and render pads under the ends of the pins unnecessary, and which otherwise might be buried in the skin. Simpson objects to wire sutures, because in withdrawal the peritoneum is scratched and irritated.

TIME OF OPERATION.

My own opinion is in favor of hot weather. The advice to keep the room at a high temperature is unquestionably sound, but that does not meet all the difficulties in the case. The writers on this subject are mainly English, and their climate is very unlike ours, having neither its heat or cold. In winter the vital powers are low; all diseases are then most malignant, except those of malarial origin. Scarlatina, Erysipelas, Rubeola, Variola, Typhus and Typhoid Pneumonia then hold their revel. Brown cautions us to regard atmospheric changes, and to avoid all things which may depress. The statistics of every English hospital would give little certainty as to the best season for operating here, owing to the great difference in climate. So far as my own personal observation extends, summer has appeared the most favorable time, and if so, ought if possible to be selected, for little things often decide the issues of life and death. Heat is no objection to the healing of a wound, even if extreme. Baron Larrey remarked the great facility with which wounds recovered in Buonaparte's Egyptian campaign. Even if a room be kept at

a high temperature during the brief operation, there is a depressing general influence always at work, which must be detrimental to the patient. It is not necessary to expose the intestines extensively, and in one instance I did not see them at all; nevertheless air must enter the abdomen, and if cold, will assist in the general depression of the shock. I endeavored to obtain some statistics from an operator in this department, of considerable experience, but have as yet obtained no reply to the letter. We shall undoubtedly ere long have reliable data on which to form an opinion.

I have now endeavored to contribute a mite, and it is indeed but such, toward the elucidation of this most interesting subject, one which cannot too earnestly engage the attention of the lovers of our art. There is little doubt that not many years will elapse before such improvements and discoveries will be made, as will render this operation less hazardous than it unfortunately is at present.

ARTICLE XVII.

NEBULIZATION OF MEDICINAL SUBSTANCES,

FOR BRONCHIAL, ORAL, AND POSTERIOR NASAL INHALATION, AND FOR THE PRODUCTION OF LOCAL ANESTHESIA.

Bead before the Convention, May 25, 1866.

BY EPHRAIM CUTTER, M. D., 13 PEMBERTON SQUARE, BOSTON, MASS.

IT has long been a serious obstacle to the successful administration of medicinal substances by the ordinary methods of inhalation, that the article to be inhaled was not really introduced into the air passages, and brought into contact with the vascular mucous membrane of the lungs, excepting when the substance used was volatile, as ether, chloroform, &c. Articles dissolved in an agent like those named, were not apt to ascend in the vapor of the menstruum, and thus their inhalation was impossible, or uncertain, to say the least. For instance, if it was attempted to administer the Tinct. of Hyoscyamus, the patient would get more of the Alcohol than of the Hyoscyamus. In the employment of the Tr. of Iodine the case is different. The Iodine seems really to rise in the vapor, and to pass with excellent therapeutic effect on to the pulmonary mucous membrane. The ordinary methods of inhalation are not to be decried for the use of certain substances, but it must be admitted that the new invention received from Germany is admirably designed to supply the deficiencies of the known methods. Reference is here made to the means employed for the diffusion, in fine spray, of medicinal agents which are volatile or non-volatile, or capable of being dissolved in water, alcohol, ether, chloroform, glycerin, or fixed oils.

Various terms have been used to describe the method. The first known to the writer was that of "Nebulization," from "Nebula," a fog, cloud, or mist. Pulverization, vaporization, and atomization, have also been suggested. The latter is obviously improper, as the word atom refers to the ultimate elementary form of bodies-the finest possible state of subdivision. In plain English, the process is that of suspending in the air any substance capable of solution in