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        THE






SCIENCE AND AET




        OF





    SURGERY. 
" They be the best Chirurgeons which being learned incline to the traditions of
      experience, or being empirics incline to the methods of learning."
                                                             Bacon On Learning. 
THE
SCIENCE   AND   ART
OF
SURGERY.
BEING
A TREATISE ON SURGICAL INJURIES, DISEASES,
               AND OPERATIONS.
                    BY


          JOHN  ERICHSEN,
    PROFESSOR OF SURGERY IN UNIVERSITY COLLEGE, AND SURGEON TO UNIVERSITY
                COLLEGE HOSPITAL.


                  EDITED BY


       JOHN H.  BRINTON, M.D.


               illustrated by

THREE HUNDRED AND ELEVEN ENGRAVINGS ON WOOD.
       PHILADELPHIA:

BLANCHARD  AND  LEA.

             1854.
3 
1854-
           Entered, according to Act of Congress, in the year 1854,




                    BY BLANCHARD  AND LEA,




In the Clerk's Office of the District Court for  the Eastern District of Pennsylvania.
C. SHERMAN, PRINTER,



  19 St. James Street. 
AMERICAN  EDITOR'S  PREFACE.
   In presenting an American edition of Professor Erichsen's  " Science
and Art of Surgery," the Editor feels that no apology is necessary.
Numerous  and important  as have been the works on this subject issued
within the last few years, still,  the Profession in this country cannot fail
to  welcome the production of a  man  of Mr. Erichsen's position  and
experience,  fortified as it  is by the  strongly-expressed approbation of
the English medical press.
   For many years the author has  been  Professor of  Surgery in Univer-
sity College, and Surgeon  to its hospital, having under  his charge the
wards once graced by Liston.   The  present volume bears witness that
he has not  only improved the  opportunities thus afforded of  acquiring
great surgical knowledge  and  experience, but that he has also labored
earnestly in the departments of his science  closely allied to  Physiology.
He has thus  brought  to bear not only his great practical acquirements,
but also an intimate  acquaintance  with all the physiological  and patho-
logical doctrines of the day.  A work like this, combining " the Science
and the Art of Surgery," the Editor therefore feels assured, cannot fail
to prove a most useful book of reference to  the  practitioner;  while its
extreme beauty and clearness of style must render it valuable  as a text-
book for the student.
   In  a treatise so recently issued, the  Editor has of course found but
little to add or correct, except those views and operations which belong
essentially to American surgery.  These will be found distinguished from
the text by brackets.   Numerous additional illustrations have been intro-
duced, which  he hopes may increase the  value of the  work, without
adding materially to its bulk.

  Philadelphia, April, 1854.
                                 2 
 
PREFACE.
   The following pages contain the substance of the Lectures on Surgery
 which I have been in the habit of delivering at University College since
 my appointment to the Chair of Surgery in that Institution.   My first
 intention had been to confine myself in this work to the consideration of
 Surgical Injuries and Diseases, and of the operations required by them.
 But it appeared  to me that it  might be rendered more useful to the
 student, and that much repetition might  be  saved, by prefixing to it,
 under the head of First Principles, some remarks  on the Nature  and
 Treatment of Inflammation, and some General Observations on Opera-
 tions,  and more particularly on Amputations.   The more Special Opera-
 tions I have considered as part of the Treatment of the  different Injuries
 and Diseases for which they are required; a plan that,  I thought, would
 be more practically useful  than to describe them apart as a separate
 subject.  I have omitted the consideration of Diseases of the Eyes and
 Skin,  as being special  subjects,  that  would require for their proper
 description more space than could be allotted them in this Work.

   In discussing the numerous topics that are embraced in a systematic
 Treatise on Surgery such as this, I have endeavored, so  far as lies within
 its scope, and without  entering into anything like an historical account,
 to  ascribe to whomsoever it may be due the merit of improvements in
 Practice or of discoveries in Pathology.   In some cases, I may perhaps
 have  accidentally omitted doing so, and in  other instances, where  the
 observation had become as it were the established and common property
 of the profession, I may purposely have avoided encumbering the text
with names and references.   In order to remedy this deficiency to some
extent, I would  beg to refer the reader to the more special Treatises on
the subject-matter of the different chapters.  Thus, I would particularly
direct his attention to the admirable Lectures on Pathology by Mr. Paget, 
XX
PREFACE.
 to which I have been much indebted in preparing the chapters on Inflam-
 mation and on Tumors;  to the works by Sir B. Brodie on  Diseases of
 the Joints and Urinary Organs, to the Treatise of Stanley on the Bones,
 of Lawrence on Hernia, of Fergusson on Practical Surgery, of Cooper
 on Fractures and Dislocations, of Travers on Injuries of the Intestines,
 of Guthrie on Wounds of  Arteries, of Sir R. Carswell on the  Elemen-
 tary Forms of Disease, and to those of Acton  and Langston Parker on
 Syphilis.  To the most excellent works of my former teachers, Samuel
 Gooper and Robert Liston, whose names I cannot mention without a
 ready and deep-felt expression of gratitude for much valuable instruction
 and  personal kindness received from them in former  years,  I would
 especially refer the reader.

  The wood-cuts with which this work  is  illustrated  have  been  made
 under my immediate superintendence.  With the  exception  of  some of
 the diagrams scattered through its pages, and of some of the cuts in the
 chapters on Diseases of the Urinary Organs, which are from the collec-
 tion of drawings by Sir R. Carswell in the possession of the  University
 College, they have been taken from nature by Mr. Fairland, and engraved
 by Mr. Dickes.   The Microscopical Drawings are from sketches made
 by my former House-Surgeons, Messrs. Lister and Gamgee.

  For any clerical errors in the work, I must beg the reader's indulgence.
 It has been prepared and written in the  midst  of the harassing and
 onerous duties that devolve  upon a  Hospital Surgeon, a Teacher  of
 Surgery, and a Private  Practitioner  in  the Metropolis, and which  are
but little favorable to literary pursuits.
                                           JOHN ERICHSEN.
  London, September  25th, 1853. 
CONTENTS.
                     DIVISION   FIRST.

                           FIRST PRINCIPLES.

                                 CHAPTER I.
Increased Vascular Action—Congestion—Determination—Inflammation—Its Nature
  and Treatment—The Effusive, Adhesive, Suppurative, Ulcerative, and Gangrenous
  Forms of Inflammation,      .......       1-74
                                 CHAPTER II.
Operations  in  General—Causes of Death after Operations—Incisions—Sutures—
  Dressings—After-Treatment,  .            .      .      .      .       •      74-82
                                CHAPTER III.
Amputations and Disarticulations—Stumps—Structure and Dressing of—Diseased
  Stumps—Statistics of Amputations,  ......      82-92
                                CHAPTER IV.
Special  Amputations—Amputations  of Fingers,  Thumb,  Wrist, Forearm,  Arm,
  Shoulder, Toes, Great Toe, Little Toe, Foot—Chopart, Hey's, and Syme's  Opera-
  tions—Leg, Thigh, Hip,      .     .      . "     .      •     •      •-.    92"105


                     DIVISION   SECOND.

                          SURGICAL  INJURIES.

                                 CHAPTER V.
Effects of Injury—Shock—Traumatic Delirium, Varieties and Treatment of,  .     106-109
                                 CHAPTER VI.
Injuries of  Soft Parts—Contusion—Wounds—Incised—Modes of Union of Incised
  Wounds—Treatment—Contused and Lacerated Wounds—Traumatic Gangrene—
                                                                       109-120
  Amputation in,"      ..••••
                                CHAPTER VII.
Gun-shot Wounds—Apertures of Entry and Exit, Symptoms and Treatment of—
   »                                                        .      •     121-128
  Amputation in,      ..-••••
                                CHAPTER VIII.
Punctured and Poisoned  Wounds—Stings of Insects—Snake-Bites—Hydrophobia-
  Dissection Wounds,  ..•••••
                                 CHAPTER IX.
Injuries of Nerves—Wounds of Bloodvessels—Hemorrhage—Transfusion,   .     137-139

                                 CHAPTER X.
                  a •  •  ir •                                        .     140-146
Wounds of Veins—Air in Veins,     .      .      .       •      • 
xxii
CONTENTS.
                                  CHAPTER XI.
 Injuries of Arteries—Hemorrhage—Arrest of Arterial Hemorrhage—Surgical Treat-
   ment of Hemorrhage—Styptics—Pressure—Torsion—Ligature—Collateral Circu-
   lation—Treatment of Wounded Arteries — Traumatic  Aneurisms — Aneurismal
   Varix—Varicose  Aneurism—Accidents  of Ligature—Secondary Hemorrhage
   Gangrene,.........146-172

                                  CHAPTER XII.
 Wounds of Special Arteries—of Carotid—Subclavian—Axillary—Brachial—Radial
   —Ulnar—Palmar Arches—Femoral and  its Branches—Tibial, and Plantar,      172-178

                                 CHAPTER XIII.
 Injuries of Muscles  and Tendons—Sprains and Strains—Ruptures of  Tendons and
   of Tendo Achillis,    ........     179-180
                                 CHAPTER XIV.
 Injuries to Bones—Bending of Bone—Fractures—Causes, Varieties,  and Signs  of—
   Union of Fractures—Treatment of Simple Fractures—Starch Bandage—Accidents
   in Treatment of Fracture—Spasm—Extravasation—(Edema—Gangrene—Compli-
   cations—Compound Fractures,  Treatment of—Amputation in—Resetting of Frac-
   tures—Ununited Fractures and False Joints, .....     180-202
                                  CHAPTER XV.
 Special Fractures—of Nose—Malar and  Maxillary Bon.es—Lower Jaw—Clavicle—
   Scapula—Humerus—Forearm—Elbow, Wrist, and Fingers—Pelvis—Femur—its
   Neck and Shaft—Patella—Leg—Ankle—Foot—Ribs,       .      .       .     202-231
                                 CHAPTER XVI.
 Injuries of Joints—Contusions—Wounds—Dislocations—Reduction of Dislocations—
   Complication with Fracture—Spontaneous and Congenital Dislocations,     .    232-241

                                 CHAPTER  XVII.
 Special Dislocations—of Lower Jaw—Clavicle—Shoulder Joint—Elbow—Wrist—
   Fingers—Hip—Knee—Ankle and Pelvis,   .....    241-266
                                 CHAPTER XVIII.
 Injuries of Head—Cerebral Disturbance—Concussion—Compression—Encephalitis—
   Treatment of  these Injuries—Suppuration within  Cranium—Injuries of Scalp—
   Cephalcematoma—Wounds of Scalp—Fractures of Skull—Contre-Coup—Fracture
   of Base—Discharge of Blood and Serum from the Ears—Depressed Fractures—
   Punctured Fractures—Wounds  of the Brain—Trephining,  .      .        .    266-288

                                 CHAPTER XIX.
 Injuries of the Spine—Division and Compression of Cord—Dislocations of the Spine
   •—Injuries of the Face—Nose—Ears—Foreign Bodies  in—Injuries of Orbit—Eye-
   ball—Tongue,  and  Mouth—Injuries  of  the  Throat—Cut Throat—Asphyxia__
   Drowning—Hanging—Artificial Respiration—Foreign Bodies in  Air-Passages—
   Scalds of Air-Passages—Injuries of CEsophagus,     ....    288-309

                                 CHAPTER XX.
Wounds of Lung—Emphysema—Pneumonia—Empyema—Hernia of Lung—Wounds
   of Heart and Large Vessels,  .......    309-315

                                 CHAPTER XXI.
Injuries of Abdomen  and Pelvis—Rupture of Viscera—Wind Contusions—Buffer
   Accidents—Wounds  of  Intestines—Traumatic Peritonitis—Injuries   of Bladder,
   Urethra, and Rectum—Foreign  Bodies in those Canals—Laceration of Perineum, 315-324

                                 CHAPTER XXII.
Effects of Heat and Cold—Burns and Scalds—Frost-Bite,     .      .       .    324-329 
CONTENTS.
XXI11
                       DIVISION  THIRD.

                           SURGICAL  DISEASES.

                                CHAPTER XXIII.
Abscess—Varieties—Diagnosis, and Treatment of—Sinus and Fistula, .      .     330-337

                                CHAPTER XXIV.
Ulcers—Healthy—Weak—Indolent—Irritable—Inflamed—Sloughing—Varicose and
  Hemorrhagic, .........     337-340

                                CHAPTER XXV.
Mortification—Varieties of—Causes and Treatment—Spontaneous and  Senile  Gan-
  grene—Amputation in,       .......     340-348

                                CHAPTER XXVI.
Gangrenous  Diseases—Bed-Sores—Sloughing Phagedena—Hospital  Gangrene—
  Cancrum Oris—Boils—Carbuncle,    ......     348-354
                               CHAPTER XXVII.
Erysipelas—Causes, Varieties, and Symptoms—Cutaneous—Cellulo-Cutaneous, and
  Phlegmonous—of Newly-born  Infants—Head  and Face—Scrotum—Pudenda—
  Fingers—Whitlow—Internal  Erysipelas—Erysipelatous Laryngitis—Arachnitis—
  Peritonitis,     .........     354-368

                               CHAPTER XXVIII.
Purulent Affection or Pyemia—Visceral Abscesses—Theories of Treatment,  .     368-374
                                CHAPTER XXIX.
Tumors—Innocent and Malignant—Encysted Tumors—of Scalp—Horns—Cysts—
  Simple and Compound — Hsematoma — Cheloid — Sarcomata — Wens—Polypi—
  Fatty and Fibro-Cellular Tumors—Fibrous—Malignant Fibrous—Recurring Fibroid
  —and Fibro-Plastic  Tumors—Enchondroma — Malignant   Tumors—Cancer—
  Schirrus—Encephaloid—Melanosis—Colloid—Treatment of Cancer by Compres-
  sion—by Operation—Epithelial Cancer—Operations for the Removal of Tumors, 374-400

                                CHAPTER XXX.
Scrofula—of Tissues and Organs—Tubercle—Causes and Treatment of Scrofula,   400-407

                                 CHAPTER XXXI.
Syphilis—Primary Syphilis—Chancres—Varieties and Treatment of—Mercurial and
  Non-Mercurial Treatments  compared—Consecutive Symptoms—Chancrous Indu-
  ration—Bubo—Venereal Warts—Constitutional  or  Secondary Symptoms—Causes
  and Treatment of—Syphilitic Diseases of the Skin, Hair, and Nails—Mucous Mem-
  branes—Lips—Tongue—Throat—Larynx—Nose—Periosteum and Bones—Nodes
  —Necrosis—Iritis—Sarcocele—Infantile  Syphilis—Symptoms and Treatment of, 407-437

                               CHAPTER  XXXII.
Diseases of the Skin and its Appendages—Warts and Corns—Onychia—Ingrowing of
  the Nail—Cheloid and Fibro-vascular  Tumor—Lupus Non-exedens, and Exedens
  —Cancer of the Skin—Varieties of,  ......     437-444
                               CHAPTER XXXIII.
Diseases of the Lymphatics and their Glands—Inflammation of—Adenitis—Enlarge-
  ment of,      .........     445-448

                               CHAPTER XXXIV.
Diseases of Veins—Phlebitis—Adhesive—Suppurative—and Diffuse—Pathology and
  Treatment—Varix, Operations for,    ......     448-453 
XXIV
CONTENTS.
                                 CHAPTER XXXV.
 Diseases of Arteries—Arteritis,  Adhesive and Diffuse—Spontaneous Gangrene—
   Structural Diseases—Plastic and Fatty Deposits—Atheroma—Calcification of Coats
   —Ulceration—Rupture—Contraction and Occlusion, .      .      •      •     453-4b2

                                CHAPTER  XXXVI.
 Aneurism—Varieties of Structure of Sac—Pressure-Effects—Symptoms—Suppuration
   and Sloughing of Sac—Spontaneous Cure—Diagnosis—Causes—Medical Treat-
   ment—Surgical Treatment—Hunterian and Distal  Operations—Accidents  after
   Ligature—Recurrent Pulsation—Suppuration and Sloughing of Sac—Gangrene—
   Treatment by Compression—Comparison between Ligature and Compression—
   Galvano-Puncture,    ....••••     462-494

                                CHAPTER  XXXVII.
 Special Aneurisms—Inguinal Aneurisms—Ligature of External Iliac Artery—Liga-
   ture of Common  Iliac—Ligature of  Aorta  and of Internal Iliac—Femoral and
   Popliteal Aneurisms—Ligature of Femoral Artery—Accidents following it—Am-
   putation in Popliteal Aneurism—Ligature of Tibial Arteries,       .       .     494-509

                               CHAPTER  XXXVIII.
Aneurisms of the Neck and  upper  extremity—of Innominata Artery—Distal Opera-
   tion for Aneurism of the Carotid—Diagnosis of—Ligature of Carotid Artery—Liga-
   ture of both Carotids—Distal Ligature of Carotid—Aneurism of Internal Carotid
   —Aneurism of Subclavian—Ligature of Innominata—Ligature of Subclavian, in
   different parts  of its  course—Aneurism of Axillary—Ligature  of Subclavian—■
   Accidents that follow—Ligature of Axillary Artery—Aneurisms of Arm, Forearm,
   and Hand—Ligature of Brachial, Radial, and Ulnar Arteries,       .       .     509-543

                               CHAPTER  XXXIX.
Aneurism by Anastomosis—Treatment of—Nevus—Varieties of—Mode of Ligaturing
   —Hemorrhagic Diathesis,    .      .      .      .       .       .       .     543-549

                                  CHAPTER  XL.
Diseases  of Nervous System—Neuritis—Neuralgia—Tic—Division  of Nerves  in—
   Neuroma—Tetanus—Symptoms and Treatment,    ....     549-557

                                 CHAPTER XLI.
Diseases  of Bones—Periostitis—Osteitis—Suppuration of Bone—Abscess in Bone__
   Trephining—Caries, its Nature, Symptoms, and Treatment—Operations  for Caries
  —Necrosis—Symptoms—Pathology—Formation of New Bone—Treatment  of__
   and Operation for,     ........     557-570

                                 CHAPTER  XLII.
Structural Diseases of Bone—Hypertrophy—Rickets, Mollifies and Fragilitas Ossium
  —Tubercle in Bone—Tumors of Bone—Exostosis—Enchondroma—Cystic Tumors
  —Spina Ventosa—Hydatid s — Osteo-Cancer—Osteo-Cephaloma — Osteo-Aneuris-
  mata—Diagnosis and Treatment of,  .      .      .       .       .            570-582

                                 CHAPTER XLIII.
Diseases  of Joints—Synovitis—Hydrarthrosis—Arthritis—itq  Pathology, Causes and
   Treatment—Strumous Diseases of  Joints—White  Swelling—Anchylosis or  Stiff
  Joint—Excision of Diseased Joints—of Shoulder—Elbow—Wrist__Ankle__Astra-
  galus—Os Calcis—Knee Joint—Influence of Phthisis on these Operations__Loose
   Cartilages in Joints—Neuralgia of Joints,    .                                 583-603

                                 CHAPTER XLIV.
Diseases  of the  Spine—Angular  Curvature—Caries—Psoas  and  Iliac Abscess__
  Lateral Curvature—Symptoms and Treatment of—Spina Bifida,     .       .     603-613 
CONTENTS.
XXV
                                  CHAPTER XLV.
 Disease of the Hip Joint—Symptoms, Pathology, and Treatment—Excision of Head
   of the Femur—Chronic Rheumatic Arthritis, .       ....     613-622

                                 CHAPTER XLVI.
 Diseases of the Bursas—Inflamed and Enlarged Bursas—Bunion—Ganglion—Inflam-
   mation of  Tendons,  .....      .                   622-625

                                 CHAPTER XLVII.
 Strains,  Contraction  and  Retraction  of Muscles—Tenotomy—Squint—Wry-neck—
   Club Foot—Talipes Equineus,  Varus, Valgus, Calcaneus,  and other Varieties-
   Weak Ankles—Knock-Knee—Contraction of the Knee—Deformities of the Hand,
                                                                            626-636
                                CHAPTER XLVIII.
 Diseases of the Head and Neck—Otitis—Ear-ache—Otorrhcea—Epistaxis—Plugging
   the Nostrils—Ozaena, Nasal Tumors, and Polypi—Mode of Removal—Diseases of
   Frontal Sinuses and Cheeks—Salivary Fistula—Hare Lip—Operations for—Cancer
   of the Lips—Operation for—Plastic Surgery of the Face—Rhino-Plastic Operations
   —Cheilo-Plastic Operations—Diseases of  the  Tongue—Tongue-tied—Prolapsus,
   Fissures and  Cancer of the Tongue—Operations  for Cancer  of  the Tongue—
   Ranula,       .........     636-656

                                 CHAPTER XLIX.
 Diseases of the Jaws—Epulis—Dropsy, Suppuration, and Tumors of the Antrum—
   Operations on the Antrum—Removal of the Upper  Jaw—Diseases, Tumors, and
   Removal of the Lower Jaw,  .......     656-663
                                   CHAPTER  L.
 Diseases of the Throat—Cleft Palate—Staphyloraphy—Diseases and Excision of the
   Uvula  and Tonsils—Diseases of  the Pharynx—Diseases of the (Esophagus—
   Spasmodic and Organic Stricture of—Diseases of the  Larynx—Acute and (Edema-
   tous Laryngitis—Aphonia—Chronic Laryngitis—Cauterizing the Larynx—Necrosis
   of the Laryngeal Cartilages—Polypi in the Larynx—Operations on the Windpipe
   —Laryngotomy — Tracheotomy—Difficulties  in and Comparisons  between —
   Trachea Tubes—Diseases of the Parotid—Parotitis or Mumps—Tumors of  the
   Parotid—their Extirpation—Hydrocele of the Neck—Bronchocele—Treatment of, 663-683

                                   CHAPTER LI.
 Diseases  of  the  Breast—Supernumerary Breasts—Neuralgia—Hypertrophy—Ab-
   normal Secretion of Milk—Inflammation  and Abscess of the Breast—Encysted
   Abscess—Tumors  of the Breast—Non-Malignant—Chronic, Mammary, Cystic—
   Sero-Cystic, Cystic Sarcoma, Scrofulous and Hydatid—Malignant Tumors—Scirrhus
   Encephaloid and Colloid—their  Diagnosis and  Treatment—by Compression and
   Amputation—Question of Operation in Diseased  Breast considered—Amputation
   of the Breast,  .........     684-704

                                  CHAPTER LII.
Hernia—Structure of a Hernial Sac—Contents of Sac—Symptoms of Hernia—Nature
  and Treatment of Reducible Hernia—Irreducible Hernia—Inflamed, Incarcerated,
  and Strangulated Hernia—Seat  of  Stricture in Strangulated Hernia—Symptoms,
  Diagnosis,  and  Treatment of Strangulated  Hernia—the Taxis  and Operation—
  State of Intestine and Omentum—Wounds of Intestine—Wounds  of Arteries—
  Accidents of Operation—Artificial Anus—Faecal Fistula—Operation  without open-
  ing Sac—Reduction  in  Mass—Hydrocele of Hernial Sac—Inguinal Hernia—
  Oblique and Direct—Diagnosis of—Operation for—Caecal Hernia—Congenital and
  Infantile Hernia—Femoral Hernia—Diagnosis and Treatment of—Operation for—
  Umbilical, Ventral, Obturator, Perineal, Vaginal, Pudendal, Sciatic, and Diaphrag-
  matic Hernia, .........    704-748 
xxvi
CONTENTS.
                                  CHAPTER  LIU.
Intestinal Obstructions—Symptoms—Diagnosis—Causes and Treatment—Gastrotomy
   —Formation of Artificial Anus in Lumbar Region,  .      .      .              -
                                  CHAPTER  LIV.
Diseases of the Large  Intestine and Anus—Congenital Malformation of Anus and
   Rectum—Stricture and Cancer of Rectum—Cancer of Anus—Spasmodic Contrac-
   tion of Sphincter—Ischio-Rectal Abscess—Fistula in Ano—Varieties of, and Ope-
   rations  for—Piles—Varieties—Causes—Diagnosis  and  Treatment  of—Operation
   for, by Ligature, Excision, and by Caustics—Prolapsus Ani—Operation for Recto-
   vesical and Recto-Vaginal Fistula—Tapping the Abdomen, .       .      .    757-783

                                  CHAPTER  LV.
Diseases of Bladder  and Prostate—Cystitis—Vesical Catarrh—Cysts in Bladder—
   Irritability of Bladder—Tumors  and  Paralysis of Bladder—Retention  and  Incon-
   tinence  of  Urine—Extroversion of Bladder—Prostatitis—Enlarged   Prostate—
   Retention of Urine from—Tapping the Bladder,    ....    784-796
                                  CHAPTER  LVI.
Diseases of the Urethra—Urethritis—Urethral and Perineal Abscess—Gonorrhoea—
   Nature, Symptoms, and Treatment of—Complications of Gonorrhoea—Cliordee—
   Dysuria—Hemorrhage—Sequences of Gonorrhoea—Impotence—Inflammation of
   the Testes and Eyes—Gonorrhoeal Rheumatism and Eruptions—Gonorrhoea in the
   Female—Stricture of the Urethra—Spasmodic, Congested, and Organic—Treatment
   by Dilatation—Catheterism—False  Passages—Division of Stricture—Perineal Sec-
   tion—Complications of Stricture—Retention and Extravasation of Urine—Urinary
   Abscess  and Urinary  Fistulae—Vaginal  Fistulae—Urethro-Vaginal, and  Vesico-
   vaginal Fistulae—Tumors of the  Urethra,    .....    797-829
                                 CHAPTER  LVII.
Stone in the Bladder—Diseased Conditions of the  Urine—the Lithic, Oxalic, and
   Phosphatic Diatheses—Cystine—Xanthine—Structure of Calculi—Renal Calculi—
   Vesical Calculi—Encysted Calculi—Symptoms  of Stone—Sounding, Difficulties in
   —Operation for Stone—Lateral Operation  of Lithotomy—Instruments required for
  —Mode  of  Performing—After-Treatment—Lithotomy  in  Children—Difficulties
  and Dangers during and after Lithotomy—Causes of Death after Lithotomy—High
  or  Supra-Pubic  Operation—Urethral  and  Prostatic Calculi—Lithotrity—Mode of
   Performing  and Instruments required for—Accidents and Dangers of Lithotrity__
   Comparison  between Lithotrity and Lithotomy—Recurrence after Operation__Stone
   in Women,   .      .      .       .      .       .       .       .      .     829-870
                                 CHAPTER LVIII.
Diseases of the Penis and Scrotum—Hypospadias—Epispadias—Phimosis__Circum-
   cision—Paraphimosis, Operation  for—Balanitis—Warts and Cancer  of  Penis__
   Amputation of Penis—Hypertrophy of Scrotum—Chimney-Sweep's Cancer     870-875
                                  CHAPTER  LIX.
Diseases of the Testes and Cord—Malposition of the Testis—Neuralgia of the Testis
   —Orchitis and  Epididymitis—Hydrocele—Spermatozoa in  Hydrocele of the Cord
   —Hematocele—Varicocele, Operations  for—Tumors of the Testis__Simple Stru-
   mous, Syphilitic, and Cystic Sarcocele—Cancer of the Testis—Operation of Cas-
   tration—Diagnosis of Scrotal Tumors,      .       .      #                  876-8Q5
                                   CHAPTER  LX.
Diseases of the Female Genital Organs—Introduction of the Speculum and of the
   Female  Catheter—Hypertrophy  of the Labia—Condylomata—Cystic  Tumors—
   Imperforate Vagina and  Hymen—Enlarged Clitoris—Prolapsus Vaginae—Vaginal
   and  Uterine Discharges—Displacements—Tumors—Polypi  and  Cancer of the
   Uterus—Ovariotomy—Mode of performing the  Operation,   .                  895-902 
LIST   OF   ILLUSTRATIONS.
FI<J.
 1. Web in the Foot of a Frog, inflamed
 2. Changes in Blood Globules,
 3. Irrigating Apparatus,  .
 4. Application of Seton,
 5. Pus-cells,
 6-8.  Pus-cells from Phlebitis and Pyemia
 9. Pus from a Scrofulous Abscess,
10. Circular  Amputation of Thigh,
11. Stump left by Circular Amputation,
12. Obliterated Vessel after Amputation,
13. Thickened Nerve after Amputation,
14. Necrosed Bone after Amputation,  .
15. Aneurismal Varix of a Stump, .
16, 17. Amputation of Finger, .
18, 19. Amputation of Thumb,
20. Amputation at the Wrist,  .
21. Amputation of the Forearm,
22. Amputation of Arm,
23-24. Amputation at Shoulder-Joint,
25.  Stump, after same Amputation,
26.  Disarticulation of First Metatarsal Bone,
27.  Disarticulation of Fifth Metatarsal Bone,
28.  Chopart's Amputation at the Foot,
29-31. Syme's Amputation at the Ankle,
32.  Stump left by Syme's Amputation,
33, 34. Flap  Amputation of the Leg,   .
35.  Vermale's Amputation of the Thigh,
36, 37. Amputation of the Thigh,
38-40. Amputation at Hip-Joint,  .
41.  Interrupted Suture,
42. Quilled Suture, .
43. Hare-lip  Suture,
44. Apertures of Entry and Exit in Gun-shot Wounds,
45. Gun-shot Wound of the Humerus,  .
46. Field Tourniquet,
47, 48. Bullet-screw and Forceps,
49. Forceps,  for Extraction of Foreign Bodies, 
xxviii
LIST  OF ILLUSTRATIONS.
 no.
  50. Artery Forceps,   .
  51-55. Appearance of Arteries after Amputation,
  56. Collateral Circulation,    .
  57. Circumscribed Traumatic Aneurism, .
  58, 59.  Varicose Aneurism,   ....
  60, 61.  Varicose Aneurism laid open,
>  62. Oblique and Longitudinal Fracture,
  63. Seutin's Pliers,       .
  64. Starched Apparatus,     ....
  65. Starched Apparatus laid open,
  66. Starched Apparatus for Compound Fractures,
  67. Gangrene of the Forearm,
  68. Fracture of the Clavicle,  ....
  69. Fox's Apparatus for Fractures of the Clavicle,
  70. Fracture of the Acromion,
  71. Extracapsular Fracture of the Neck of the Humerus,
  72. Fracture of the Condyles of the Humerus,
  73. Fracture of the lower extremity of the Radius,
  74, 75. Appearances of same Fracture,
  76. Nelaton's Splint,     .....
  77. Bond's Splint,     .....
  78. Intracapsular Fracture of the Neck of the Femur,   .
  79. Attitude of the Limb in Intracapsular Fracture of Neck of the Femur,
  80. Extracapsular  Fracture of the Neck of the Femur,  .
  81. Impacted Extracapsular Fracture of the Neck of the Femur,
  82. Appearance of Callus in Extracapsular Fracture,
  83. Apparatus for Compound Fracture of the Thigh,
  84. Desault's Splint, as modified by Dr. Physick,
  85. Fracture  of the Shaft of the Femur in the lower third,  .
 86-88. Fractures of the Patella,  ....
  89. Fracture  Box,     ......
  90. Pott's Fracture,      ....
  91. Fracture  of the Os calcis, ....
  92  Extension by the " Clove-hitoJi" Knot,
  93. Dislocation of the  Lower Jaw,
  94. Dislocation of Sternal Extremity  of Clavicle,
  95. Dislocation of Humeral Extremity of Clavicle,
  96. Dislocation forwards of the Head  of the Humerus,
  97. Dislocation backwards and downwards of Humerus,
  98. Reduction of a Dislocated Humerus,  .
  99. Dislocation of the  Elbow, ....
100. Dislocation forwards of the Head  of the Radius,
101. Dislocation backwards of the Head of the Radius,
102. Reduction of Dislocations of the Elbow,
103. Dislocation of the  Wrist,   ....
104, 105.  Dislocations of the Finger,
106. Dislocation of the  Femur upwards and backwards,
107. Reduction of the Ilio-Sciatic Dislocation,
108. Dislocation of Femur into the Foramen Ovale,
109. Reduction of the Dislocation of the Femur into the Foramen Ovale
110. Dislocation of Femur upon the Pubes,
111. Dislocation of  the Patella outwards,
112. Dislocation of the Patella inwards,
113, 114.  Lateral Dislocations of the Tibia,
     PAGE
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     156
     159
     163
     165
     166
     183
     191
     191
     192
     192
     192
     205
     206
     207
     209
     211
     213
     214
     215
     216
     218
     218
     221
     222
     223
     224
     225
     225
     226
     228
     229
     230
     237
     241
     243
     244
     245
     246
     247
     249
     250
     251
     251
     252
253, 254
     255
 .    256
     257
 .    258
     258
 .    259
     259
 .    260 
LIST  OF  ILLUSTRATIONS.
FIG.
115. Dislocation of the Foot,
116. Compound Dislocation of the Astragalus,.
117. Fracture of the Cranium,
118. Coxeter's Aural Scoop,
119. Establishment of Artificial Respiration,
120. Lumbar Abscess,  ....
121. Abscess-bistoury,
122. Application of Seton,
123. Arteries in Senile Gangrene,  .
124. Senile Gangrene of the Foot,
125. Microscopical Appearance of an Atheromatous Cyst,
126. Atheromatous Tumor on the Head,
127. Microscopical Structure of Fibrous Tumor,
128. Cancer-cells from Scirrhus of the Breast,
129. Cells from Encephaloid of Tongue,  .
130. Cells from an Epithelial Cancer of the Lip,
131. Corpuscles from a Chimney-sweep's Cancer,
132. Fibrous Cysts in Epithelial Tumors,
133. Scrofulous Ulcer of the Leg,  .
134. Malignant Onychia,
135. Microscopical Appearance of Lupus, .
136. Cancerous Ulcer of the Leg,
137. Ligation of Varicose Veins,  .
138. Plastic Deposits in Aorta,
139. Plastic Plugs occluding the Axillary Artery,
140. Fatty Deposits in the Internal Coat of the Arteries,
141. Appearance of Early Stage of Atheroma,
142. Appearance of Advanced Stage of Atheroma,
143. Calcareous Deposition,
144. Flattening of the Posterior Tibial Nerve by a Popliteal Aneurism,
145. Aneurism of Aorta producing an Erosion of the Vertebrae, .
146. Aperture in (Esophagus, produced by Pressure of Aortic Aneurism
147. Rupture of Aortic Aneurism into Pericardium,
148. Hunter's Operation for Aneurism,
149. Brasdor's Operation for Aneurism,
150. Wardrop's Operation for Aneurism,
151. Femoral Artery, Ligated for Popliteal Aneurism,
152. Inguinal Aneurism,       ....
153. Consolidation of Aneurism,   ....
154. Contraction of Aneurismal Sac,  .
155. Compressor for the Groin,
156. Compressor for the Middle of the Thigh, .
157. Obliteration of Venous Trunk, producing Gangrene, .
158. Aneurism of the Profunda Femoris,
159. Aneurism of the Innominata, .       •       •      •
160. Operations for the Cure of Aneurism of the  Innominata,
161. Aneurism of the Arch of the Aorta,   .
162. Aneurism of the Subclavian,
163. Liston's Case of Subclavian Aneurism,
164-167.  Strangulation of a Nevus,
168. Neuroma,     ...•••
169. Suppuration of Bone,    .
170. Abscess in Head of Tibia,    .
171. Trephine,  .•••••
172. Cloacae of Femur,     .
PAGE
262
264
280
294
302
332
335
336
343
344
377
377
383
386
389
398
398
398
402
439
442
444
453
454
454
457
457
457
458
467
469
472
472
479
479
479
480
487
489
489
490
490
496
501
511
512
518
529
 530
547
552
559
 559
 559
 565 
XXX
LIST  OF ILLUSTRATIONS.
FIG.
173. Separation of the Diaphysis and Epiphysis of Tibia,
174-178. Bone Forceps,    ....
179. Cystic Tumor of Lower End of Femur,   .
180, 181. Osteo-Cephaloma of Humerus,  .
182. Aneurism by Anastomosis of Parietal Bone,
183. Anchylosis of Hip,                        •
184. Excision of Shoulder-Joint,
185. Excision of Elbow-Joint,
186. Caries of the Spine,      .       .       .      •
187. Lateral Curvature of the Spine,
188. Curvature of Spine,      ....
189. Lonsdale's Apparatus for Curvature of the Spine,
190. Deformity in Morbus Coxarius,
191. Anchylosis of Hip-Joint, resulting from Chronic Rheumatic Arthritis,
192. A Bunion,  ....
193. Tenotomy Knife,
194. Talipes  Equinus,  .
195. Talipes  Varus,
196. Boardman's Everting Iron,
197. Mutter's Extending Apparatus,
198. Talipes Valgus,   .
199. Talipes  Calcaneus,
200. Tamponnement of Posterior Nares,
201. Extraction of Nasal Polypus, .
202. Tumor of the Cheek,
203, 204. Operation for Hare-Lip, .
205. Hare-Lip Suture, .
206, 207. Double Hare-Lip,
208, 209. Operation of Rhinoplasty,
210, 211. Excision of  Lower Lip,  .
212, 213. Plastic Operation on the Face,
214. Modified Nevus Needle,
215. Operation for Cancer of  the Tongue,
216. Vulsellum Scissors,
217. (Edematous Infiltration of Glottis,
218. Probang and Sponge,  .
219. Canula for the  Application of Nitrate
220. Laryngeal Polypus,
221. Tracheal Hook,
222. Tracheotome,  .
223, 224. Obre's Tracheal Tubes,
225. Hydrocele of the Hernial Sac,
226. Hernia Knife,
227. Hernia Director,
228. Position of Hernia Knife, .
229. Portion  of a Strangulated Intestine,
230. Dupuytren's Enterotome, .
231. Application of  this Instrument,
232. Double Inguinal Hernia on same Side,
233. Double Direct Inguinal Hernia,
234. Operation for Inguinal Hernia,
235. Congenital Hernia,
236. Infantile Hernia,  .
237. Dissection for Femoral Hernia,
of Silver to the Throat, 
LIST  OF  ILLUSTRATIONS.
XXXI
FIG.
238. Dissection for Femoral Hernia, showing the relation of the Sac to the Epi-
       gastric Artery,
239. Hernia protruding at Saphenous Opening,
240. Phrenic Hernia,
241. Strangulation of Intestine through Opening in Mesentery or Omentum,
242, 243.  Anal Specula,
244. Bistoury for Operation for Fistula in Ano,
245. Mode of Performing the Operation,  .
246. Vulsellum Forceps,       .*....
247. Bushe's Needle for the Ligature of Internal Piles,
248. Speculum Ani,     .......
249. Prolapsus Ani,  .......
250. Microscopical Appearance of Urinary Deposit in Vesical Catarrh,
251. Cyst of the Bladder,   ......
252. Enlargement of the Prostate Gland, causing Dilatation of Ureters,
253. Introduction of Catheter,     .....
254. Operation for Puncture of the Bladder,  ....
255. Modification of Lallemand's Porte-Caustique,
256-259.  Organic Stricture of the Urethra,   ....
260. Urethrotome,  .......
261. Female Catheter of Dr. Sims,    .....
 262. Microscopical Appearance of Lithic Acid,
 26.3. Microscopical Appearance of Lithate of Ammonia,
 264. Microscopical Appearance of Oxalate of Lime,
 265. Microscopical Appearance of the Ammoniaco-Magnesian Phosphate,
 266. Microscopical Appearance of Cystine,
 267. Lithic Acid Calculus,     ....
 268, 269. Calculus encysted in the walls of the Bladder,
 270, 271. Operation of Sounding,
 272. Canulated Sound,     ....
 273. Detection of an encysted Calculus by Sounding,
 274, 275. Instruments for the Performance  of the Lateral Operation of Lithotomy,
 276-278. Forceps for Extraction of Calculus,  .
 279. Scoop for removal of Fragments,
 280. External Incision in the Lateral Operation of Lithotomy,
 281. Division of Parts in the Lateral Operation of Lithotomy,
 282. Direction of Incision of Prostate Gland,
 283. Physick's Forceps,
 284. Physick's Gorget,  .
 285. Dupuytren's Lithotome,
 286. Urethral Calculus,
 287. Prostatic Calculus,
 288. Weiss's Lithotriptor,
 289. Charriere's Lithotriptor,
 290. Scoop of Civiale,  .
 291. Urethral Lithotriptor, .
 292. Urethral Forceps,  .
 293. Phimosis,     ...
 294. Phimosis accompanied by Sloughing of the Prepuce,
 295. Paraphimosis,        ....
 296. Venereal Warts on Penis,
 297. Mode of Strapping the Testicle,
 298. Hydrocele of the Tunica Vaginalis,
 299. Operation for Hydrocele, 
xxxii
LIST  OF  ILLUSTRATIONS.
300. Encysted Hydrocele of the Epididymis,
301. Spermatozoa contained in Cysts,
302. Needles for Treatment of Varicocele,
303. Operation for Varicocele,
304. Vidal's Operation for Varicocele,
305. Scrofulous Tumor of Testis,   .
306. Cystic Sarcocele,  .
307, 308.  Complications of Hydrocele,
309, 310.  Vaginal Specula,
311. Uterine Porte-Caustique,
PAGE
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887
890
891
893
895
898 
DIVISION     FIRST.

           FIRST PRINCIPLES.
                            CHAPTER  I.

                   INCREASED VASCULAR ACTION.

  Increased vascular  action lies  at the bottom of all  surgical processes; no
important surgical action taking place without it.  No process by which the sepa-
ration of dead parts is effected, or by which the repair  of wounds or ulcers is
carried  out can  occur without an  increased activity of the  vessels of the parts
concerned.  Every tissue is susceptible of it;  and the surgeon often  excites it
intentionally as one of the most efficient of his therapeutic means; hence an ac-
quaintance with the  elements  and  the  details  of the process, with its nature,
symptoms, causes, results, and terminations, is of the first moment.
  Increased vascular action is  of three distinct kinds:  1st. Congestion;  2d.
Determination; 3d. Inflammation.   These three conditions though in practice
most commonly found more  or less conjoined, require to be studied separately.
   Congestion  plays an important part in surgery, being, very apt to occasion se-
rious structural changes, and to  run into inflammation in tissues affected by it.
Congestion is always a passive and mechanical condition, hence  the term active
congestion should not be employed.  Indeed what has been described as active
congestion is in reality a variety of the inflammatory process.
   Congestion  is a  true  hyperaemia; in  it  we  find not only that the blood is
greatly increased in quantity, but that it circulates languidly through the part,
and is of a darker color than natural.  The arteries are at most of their normal
size, perhaps even contracted; the veins  and capillaries being greatly distended
by the slowly moving fluid.  When the circulation in the  congested part becomes
completely arrested, stagnation is said to have occurred.
   The symptoms of congestion  are well marked when  the part affected can be
seen or felt; when occurring in  an internal organ they are  often  very obscure.
Congestion of an external part, may be recognised by the changes it induces in
the color, the feel, the size, the sensibility, the temperature  and the functions
of the part that it affects.   The color of a congested  part ranges from purplish
red to a dusky  brown; its  size  is increased;  it feels  soft,  and  pits under  the
pressure of the  finger.   The patient is often conscious of a  heavy, dull, aching
sensation in it, scarcely amounting to pain, but yet  attended with much uneasi-
ness.   The temperature is not above  the  natural standard; there is often a feel-
ing of cold, and the functions become lessened in activity.
  The existence of congestion  in an internal organ  is  chiefly determined by
finding  its size  increased, with a sensation  of weight  complained of, and its
functions modified.
  The effects of congestion are of much surgical importance.  The first change
that usually takes place is an effort in the vessels of the part to relieve themselves 
34
INCREASED  VASCULAR  ACTION.
by a transudation of the more watery constituents of the blood, into the surround-
ing cellular tissue.  Hence  distension of the  cells of this tissue by the eilused
fluid, which gives rise to oedema.
   If the turgidity of the vessels be great, and their walls at the same time weak-
ened, rupture will occur and hemorrhage on to the surface, or into the substance
of the part ensue.
   In consequence of  the  infiltration of the cells of the part with the (edematous
fluid, softening takes place, nutrition becomes less  and  less perfectly performed,
arid ulceration  at  last occurs.   These changes we not unfrequently see in the
integuments of the legs of old people.   In  other cases the  vessels becoming
permanently dilated, the  part  assumes habitually a  redder or darker tint, be-
comes  swollen, or thickened.   If it be a mucous  surface it may be roughened
and papillated,  as is often observed in a congested  conjunctiva.
   The causes of congestion, always mechanical, may be divided into two  great
classes, which we often find  conjoined.  1st. Those causes that act by obstructing
the return of the blood through the veins;  2d. Those that act  by enfeebling the
walls of the capillaries and veins so that they are no longer able to withstand the
outward pressure of the contained blood.  Amongst the first set of causes may
be  specified any condition  that directly and  immediately  interferes  with the
proper return of blood through a vein, as for instance the pressure of a tumor
upon such a vessel producing  congestion  of the part from which it carries off
the blood.
   Venous obstruction does not always act in so direct a manner as  this, for it not
unfrequently happens  that obstruction to the return of blood from one organ will
occasion a congestive  condition  of the vessels  in a distant  one.  Thus  we find
that some forms of congestion of the eyeball are due to obstruction in the branches
of the portal veins.
   The long-continued  dependent position of a part  may occasion  its congestion
by the blood mechanically gravitating into it, and overcoming, by the pressure
thus brought to bear upon the  vessels, the onward movement of the fluid within
them.  Thus we see congestion of the legs from long-continued standing; of the
hemorrhoidal veins in those who habitually lead too sedentary a life; and of the
posterior  part of the lungs of those  who have been long confined  to the  recum-
bent position.
   Amongst  the most  common  causes of congestion  that act by enfeebling the
vessels, we find the debility of old  age, acting partly by lessening the  tone  of
the vascular system generally;  and partly by inducing a diminution of the pro-
pulsive power of the heart.   So also cold, by lessening the vitality and retarding
the circulation  of a part, produces congestion of it.  Certain typhoid, or adynamic
states of  the system, favor the  occurrence of congestion, in the  more dependent
parts.  And lastly, inflammation may terminate in this condition.
   The obstructive causes  are especially apt to  induce this state when they  occur
in connexion with a feeble condition of the vascular system.
   The treatment of congestion  has strict reference to its cause.
   The first indication  consists in the removal of any source of obstruction to the
return of  blood from  the part, as by unloosening  a ligature, or  elevating a part
that had been too long dependent;  or, less directly, as in the case of many  inter-
nal  congestions, by restoring the freedom of the circulation through the larger
viscera.  Thus, a congested eye or pile may be relieved by the removal of hepatic
or portal obstructions.
   The next indication consists  in lessening the quantity of blood in the congested
part.  The  mere  removal of the obstructing  cause  may effect  this.   In°other
cases, the direct  removal of the blood by scarification, as in  a congested con-
junctiva, or by leeches, as  around a turgid pile, affords immediate relief.   In
some parts again, the judicious application of  a bandage will prevent or remove 
DETERMINATION  OF BLOOD.
35
congestion.   "With this view the hand and arm are bandaged before the apparatus
for a fractured clavicle is applied;  and the leg is supported by an elastic stocking,
to lessen the pressure  of blood in a varicose vein.
   The third indication  in  the treatment of congestion, consists  in constringing
the dilated vessels  by the direct application of  an astringent to  them; thus we
habitually apply nitrate  of  silver to  a  congested mucous  membrane, and cold
douches to many external forms of the disease.

                              DETERMINATION.

   In determination, the blood is increased in  quantity, of a bright arterial color,
and circulates through the  parts with great rapidity.  This condition, which is
often called "increased  action/' consequently  resembles congestion, in the blood
being in excess, but differs from it in every other respect.
   Determination of blood is a vital process, often of a very transitory character,
and frequently occurs as a normal action in  those conditions of the  system in
which, for  temporary purposes, an increased afflux of blood is called for by par-
ticular organs.  The  enlargement  of the mamma before lactation and the turgor
of the erectile tissues afford familiar illustrations of this act.  The surgeon  often
employs determination of blood for Therapeutic  purposes.   Under these circum-
stances, therefore, it cannot be considered a disease.
   When determination of blood is  of a chronic or continued  character it may lead
to such changes in the appearance, structure, and functions of a part as materially
to modify its nutritive and secretory activity, and then it becomes truly a disease.
 Under these  circumstances the part is often said to be in a  state  of " chronic irri-
 tation."
   The symptoms that characterize  determination of blood to a part, are those
 that  we should expect to result from  an increased quantity of blood rushing with
 increased velocity through the affected textures.   There is redness of a bright
 scarlet hue, swelling from turgescence of  the  vessels, heat cognisable  to the sur-
 geon as well  as to the patient, a feeling of fulness and of throbbing, with  an in-
 crease in the quantity of the secretions  of the part.   In fact, all  those symptoms
 that  characterise  inflammation in its  milder form, but in a minor degree, and of
 a less persistent character.
   The effects of determination of blood, when acute, consist either of rupture of
 the affected  vessels, and a natural  relief by the hemorrhage which ensues, as
 happens in piles after a dose  of aloes  has been given;  or, in the  pouring forth of
 the secretions of the part,  if a free surface or gland, considerably augmented in
 quantity  and deviating  somewhat perhaps from their normal  character,  as in
 lachrymation after the introduction of a grain of snuff into the eye.   When this
 occurs within shut serous  sacs, dropsical accumulations may ensue, as in hydro-
 cele of the  tunica vaginalis.
   The more remote  effects of chronic  determination  of blood to a part, consist
 in permanently increasing  the nutritive activity, and thus leading to  induration
 and hypertrophy.  Lastly: determination of  blood may result in true inflamma-
tion.
   The causes of determination of  blood are threefold:
   First, An external  irritant directly applied  to a part will  induce it, as when a
grain of dust is blown upon the conjunctiva.   Secondly, Internal irritation; as an
increased use of a part will determine  an increased flow of blood to  it.   Thus,
using the eyes much in microscopical investigations will produce redness, watering
 and irritation of those organs.  To this class of causes may be referred the various
 forms of normal determination.
   The last  class of causes  consists in the repercussion of blood from one part to
 another. 
36
INCREASED  VASCULAR  ACTION.
   The treatment of determination of  blood is nearly identical  with that of the
milder forms of inflammation; hence we shall reserve the  consideration of it until
we come to treat of that disease.
                                 INFLAMMATION.

   The study of the inflammatory process is one of the most complex and difficult
 on which the surgeon can enter, but the labor required to master  its  details is
 well bestowed, inasmuch as an acquaintance with  its nature, symptoms, and  pro-
 gress, gives an insight into a great part of the science of surgery.   The manage-
 ment of inflammation as it affects different tissues  and organs,  and thus constitutes
 distinct diseases, comprises a great part of the duties of a surgeon.   The  theory
 of inflammation is a  purely physiological and pathological study, and however
 interesting its investigations may be, yet as the discussion of this subject belongs
 rather to the domain of general pathology than to  that of practical  surgery, it
 cannot consistently be  entered upon  here; but regarding the subject from a sur-
gical, rather  than from a physiological or pathological  point of  view, we must
discard all hypothesis and confine ourselves to the results of trustworthy observa-
tion.
Fig. 1.
  We have seen that in congestion the quantity of blood is increased, but the
rate of its motion  is lessened ; in determination we have  everything augmented
there isan increased size of the vessels, and an increased quantity of bloo'd within
them, circulating  through them  with  increased velocity.   In inflammation we
have a combination of these conditions;  we have an increased size of the vessels
an increase in the quantity and rapidity of the motion of the blood, but conioined
with this we have a tendency to its arrest, to its stagnation at points.  In study-

 , Fl_'.V-^ eXac,1 cnpJ of a P°rtion °f the web in the foot of a voun<- fTM ,fi„.  a
alcohol had been placed upon it.  The view exhibits a deep-seated InJll n_?\ "   * drop of s,ronS
focus, the intermediate or capillary plexus runnin- over them inH ni™I . y u  7elns' somewhat out of
over the whole. On the left of the" figure, the cirouE^ is?tin actT/e and",? '* °f va»ou« ««. scattered
more slow, the column of blood is oscillating, and the corpuscles c owd«l S  !. ttbo_ lhe  middle h is
lion, followed by exudation, has taken place, constituUnir iXmm«„rv nn!i«S *hel5 °" the  r,°ht> con&es"
  a. A deep-seated vein, partially out of focus. The curremTb ood ,*T *Vhe part"
rapid as that in the artery.  It is running in the opposite direction  Ti,» f,   ? deeper color,  and not so
with  slightly yellowish  blood-plasma, is very apparent, containing nn,^mPh"SpaCe on each side,  tilled
clinging to or slowly moving along the sides of the vessel!  6  A deen „,,.T '*   colorless  corpuscles,
current of blood allowing nothing to be perceived but a reddish-vellou,vi,  f   y',out of focus>the raPia
at the sides.  Opposite c, laceration of a capillary vessel ha* nrodi pVh  °„oacl,streak' with lighter spaces
resembles a brownish-red spot.  At d, congestion has occurred and th- l l ex'ravasatl°n of blood, which
merged into one  semitransparent, reddish mass, entirely filli'ns- the vJ   id"C0_rPuscles are  apparently
between the capillaries, are rendered thicker and  less transnarVm «,«?  ,  *._"   sPaces of the  web,
partly by the exudation. This latter entirely fills up the spaces  or only co t  tl  ^'"j" °f the alcohol< 
INFLAMMATION.
37
ing the phenomena of inflammation in the web of the frog's foot under the micro-
scope, we observe that the first change on  the  application of a stimulus is  the
momentary  contraction followed by dilatation of the  artery; the flow of blood
through it and the  capillaries is  accelerated, retardation  from congestion then
ensues,  and  lastly, stagnation at points.
  At these  centres  of  commencing stagnation, it will be  seen  that the blood
appears to ebb and flow,  oscillating  to and fro, and then  stopping at last;
the immediate stagnation  taking place in  those capillaries, which are not  in
the direct line of passage from an artery  into a vein, and  the arrest  taking
place by the adhesion of the red corpuscles coalescing by mutual adhesion into
masses, which after being  carried bodily up and down  more and more slowly,
at last appear to block up the vessel, partly by overcrowding and distending  it,
and partly by becoming adherent to its walls; this adhesion usually commencing
at the angle of union between two capillaries.  Arqund the  stagnant  part  the
vessels  are  crowded by an aggregation of  the red corpuscles, which appear to
be  more closely  packed in  consequence of the draining away  of  the liquor
sanguinis (W. Jones).
   At this part also, where the circulation is retarded, the white corpuscles may
be  seen to be increased in quantity, and appear to be adherent to the wall of
the vessel, along which they are either stationary, or at most roll but languidly.
Around the whole of this  area, in the centre of which there  is stagnation with
retardation  of the blood, there is that- increased rush of an increased  quantity
of  blood characteristic  of determination.
   These are the general phenomena presented by an inflamed part when studied
under the microscope.  In order to become  acquainted with the elements of this
process we must analyse the condition of the vessels and of the blood.
   First as  to the  Vessels:—The arteries,  capillaries, and veins are all enlarged,
not only in  the part inflamed, but those around and leading to it, so that more
blood is conveyed with greater rapidity to the seat of  disease.   Is this enlarge-
ment of the inflamed vessels primary or not ?  This would  appear  to depend
greatly upon the stimulant that excites the inflammation, and  perhaps on other
circumstances that we cannot  readily appreciate ; thus if a weak solution of salt,
or if ice-cold water  be  applied to the web of a frog's foot,  there is a momentary
constriction of the  arteries and retardation of the  flow of blood, followed by
rapid dilatation and accelerated flow.  In other cases again, as W. Jones has
observed, the dilatation may be primary, no contraction  preceding it, as happens
when a strong solution  of salt or of sulphate  of copper is applied to the part.
   Though  the vessels generally are  enlarged the arteries  especially  become
dilated, and this  dilatation   implicates the  afferent vessels  to  a considerable
distance, which  can be felt, by the volume  of their pulsations, to be increased
in  bulk.  That the coats  of those vessels  leading  to  the inflamed  parts  are
dilated  in  consequence of being relaxed,  is evident from the fact that the
pulsation  in them  is  stronger and  more  forcible than in other parts of the
arterial system, though equally dependent  upon the  heart's action,  to  which
their diminished tonicity offers less resistance.  This may be readily observed
in the pulsation of  the digital arteries in a case of whitlow.   That the vessels
convey  more  blood  through as  well  as  to the inflamed  part  is proved  by the
observation  of Lawrence, who found that in  bleeding a patient in both  arms,
with whitlow of one hand, more blood flowed from the inflamed than from the
sound limb, in the same space of time.
  In consequence of the dilatation of the smaller arteries and capillaries of the
part, red corpuscles are admitted in crowds where single  files could only pene-
trate before; hence an appearance of new vessels is presented, though none  are
in reality formed. 
38
INCREASED  VASCULAR ACTION.
   Besides this dilatation of the smaller vessels of the  part, the arteries become
 elongated, tortuous and waved, increasing in length as well as in diameter.   Ihe
 German pathologists,—Kolliker, Hasse, and  Bruch, whose views  are  confirmed
 by Paget and W. Jones,—have observed that the arteries of the  inflamed  part
 have a tendency to become dilated at points, so as to present small _ varicose, or
 aneurismal pouches projecting from their walls, or fusiform  dilatations of their
 whole diameter.   These changes would  appear to arise from one of two  causes;
 either that the vessel  is constricted at  points  between which it  maintains its
 normal width,  and thus that the dilatation is apparent and not real; or, that it is
 actually dilated where it appears to be so.
   I shall  not enter upon the  question as to the causes of these changes in the
 vessels;  how a stimulant acts in giving  rise to them, and what share the nerves
 of the part may have  in their production; as these are points out of the scope
 of this work, and which, indeed, appear as yet to be altogether undecided.
   The changes that the blood undergoes in inflammation are fully of as great
 importance as those presented by the vessels.
   The most apparent physical change met with in this fluid, is, that it appears
 to have become  thinner, as was long ago pointed out  by Hewson.   But there
are other changes that can only be appreciated  by chemical  and  microscopical
research.   These we must  study as  they affect the different constituents of the
blood.
Fig. 2.
   The red particles have been shown by Andral and Gravarret to be  increased
in quantity in  the early stages of inflammation, but as the  disease continues,
they speedily diminish m number;  falling below the natural standard  in  this
respect as W. Jones and Simon have pointed out.   No other apparent  change
takes place in these particles, except the tendency to their aggregation  into
 Fig. 2.—a. Colorless globules, adherent,  b. Blood-disks, still circulating  c  TVn
geneous mass. d. Corpuscles in oscillatory movement, becoming detnr-hori  rLZ. .u'- sta£nam> nomo-
Williams.                                         ° aetacneu  <r°m the impacted mass.— 
SYMPTOMS OF INFLAMMATION.
39
 clusters by the cohesion of  their flat  surfaces.   This clustering of the  red
 particles, first pointed out by W. Jones, takes place in the vessels as well as out of
 them, and  is  considered  by its discoverer and by Henle, to be owing to in-
 spissation of the plasma.
   The white corpuscles have excited  much attention of late years  in connexion
 with the arrest of  circulation  in inflammation.  Dr. Williams has shown  that
 they appear in increased  numbers  in the  inflamed part, and  by their  adhesion
 to the walls of the vessels become one principal  source  of  the  arrest of the
 circulation.  There are several questions, however,  with  reference to  the white
 corpuscles.   1st. As to their actual  increase;, 2dly. As to the cause of this
 increase  in  their  numbers;  and 3dly. Their greater disposition  to adhere to
 the vessels. _ Their increase in inflammation is stated by W. Jones to be partly
 relative, owing to  the diminution in  the red  particles;  and  Paget, as well  as
 other observers, is  of opinion that it is only in sickly and  young animals, kept
 for the purpose of  experiment, that this increase has been observed, never being
 met with in healthy animals, or in the human  blood taken  from  inflamed parts.
 Hence he infers that they are  only met with in large numbers  in  inflammation,
 when existing numerously elsewhere.   Their appearance in  large numbers in the
 vessels in  the inflamed part,  and their  accumulation  here, is ascribed by W.
 Jones simply to retardation of the circulation; this condition being consequently
 the effect,  and  not the cause of the obstruction,  which,  however, they  may
 mechanically increase when it has been once induced.
   The natural adhesiveness of the white  corpuscles  to the sides of the vessel is
 such as to require a brisk current to sweep them  along,  hence when  the  force
 of this is lessened, as is the case in an inflamed  part, they are not readily de-
 tached ; but as it has been shown that the  tendency to cohesion is increased  in
 the red corpuscles,  it is but reasonable to  believe, with  Dr. Williams, that  the
 adhesiveness of the white ones may also be augmented.
   The liquor  sanguinis undergoes  important changes in  inflammatory blood.
 Quesnay, Hey, Thackrah,  Babington, and Grainger, have all observed that the
 quantity of fibrine  in it increases, and Andral and Gavarret  have  shown  that
 it may rise  from 2% per 1000 as high as 10 per 1000.  This superfibrination of
 the blood probably results from  waste  or oxidation of the  tissues, and its aug-
 mentation must not  be  looked upon as an increased  development of nutritive
 power.   It  is in fact the consequence  of  changes taking place  in the blood  and
 parenchyma of the  diseased part.
   The  proportion of albumen and of saline matter is somewhat below the natural
 standard, whilst that of the water is increased above  it.
   "When  inflammatory blood is drawn  from the body it coagulates more slowly
 than healthy blood;  the coagulum also is harder and  smaller, and the quantity of
 serum apparently greater.  The surface of  the coagulum is commonly covered
 by a tough layer of yellow fibrinous matter, the huffy coat; and  its upper surface
 is depressed in the  centre,  having elevated edges, being cupped, as it is usually
 termed.   By this buff and cup the practitioner  commonly  estimates  the intensity
 of the inflammation; but it must be borne  in mind that buff may occur in certain
 conditions of the system, as in plethora, pregnancy, or  after exercise, without
 the occurrence of inflammation; and  that  the tissue affected, rather than  the
 severity of the  inflammation, influences its  quantity: thus,  it is greatest if the
 fibrous or serous tissues, and least when the  mucous or tegumentary are inflamed.
 The  cupped shape  of the clot  may  likewise be owing, in some  degree, to the
 kind of vessel in which the blood is received, being most evident in those which
 are rather narrow and deep.
  These are the principal changes met with in  the vessels and blood of the af-
fected part, but it must not be  supposed that the inflammatory process  consists
simply in these changes; the nerves  and parenchyma doubtless exercise an im- 
40
INCREASED VASCULAR  ACTION.
 portant influence, the precise nature and extent of which can scarcely at present
 be appreciated, though the observations of Paget and W. Jones demonstrate its
 existence.
   The symptoms of inflammation are local and constitutional.  In  order that
 these  should occur,  so as to establish the existence of the inflammatory process,
 it is necessary that those actions  that  constitute it continue for some length of
 time;  as they gradually pass from determination  and congestion into inflamma-
 tion, it is difficult to say, except by the persistence  and intensity of the symp-
 toms,  that  the physiological state  has ended, and the pathological one com-
 menced.
   The local signs of inflammation may be referred to five heads; viz., alteration
 in color ; alteration in size ; modification  of sensation ;  increase of'temperature,
 and modification of function of the part affected.   Each  of these  conditions
 may separately occur, or two or more be associated together without the existence
 of inflammation.  But it is the  peculiar grouping together of them all  that
 characterises the presence  of this  pathological condition.
   The relative intensity of these changes  varies  greatly, according to the tissue
 that is the seat of the inflammation; thus, in inflammation of mucous membranes
 and of the skin, the alteration in color is  most marked;  in  inflammation of the
 cellular tissue, the  change in size always attracts special attention; and when
 a fibrous tissue is inflamed, its sensibility becomes greatly increased.
   Alteration in  Color is an invariable, and one of the earliest and most striking
 local signs of inflammation; parts  that  are naturally perfectly pale, as  the ocular
 conjunctiva, assuming the most vivid crimson color when inflamed.  Some parts,
 though they change in color, do not become red.   Thus, the iris, when inflamed
 assumes a grayish or brownish tinge, and the mucous membrane of the bladder,
 and of a portion  of  intestine, often becomes  slate-colored.   The redness of in-
 flammation varies from a bright crimson to a  dull purple, the tint depending
 greatly upon the  state of the constitution, and upon the presence of more or less
 congestion.  The duller and darker the tint, the  more local congestion or con-
 stitutional depression do we usually find.   The redness is  evidently due to the
 increased quantity of blood in  the inflamed  structure, and in  the earlier stages
 of the  disease, it  is owing to the increase of the size of the vessels, the admission
 of new red corpuscles and the absence of plasma, and their distension with them.
 In some low or asthenic forms  of  the  disease the coloring  matter of the blood
 appears to undergo changes that allow its  ready transudation through the walls
 of the  vessels; and in more chronic cases the vascularisation of the products of
 inflammation tends to render it more permanent.
   Alteration in Size.—Dilatation  of the vessels  being an essential element of
 the inflammatory process, swelling must be an invariable accompaniment of this
 disease.   In the  early stages it is  due to this dilatation of the  vessels;  in the
 more advanced conditions, chiefly to the occurrence of cedema and effusions of
 various kinds.
   The swelling varies  greatly  in  different localities.   It is greatest in those
 which  are of a loose texture, and least in those that are firmer and denser.   Thus
 for instance, in inflammation of the cellular tissue of the  scrotum, the swelling is
 much greater than in the same  disease affecting  the  testes.   The inflammation
 of the  conjunctiva occasions great swelling, that of the sclerotic but little.
   The swelling of chronic inflammation may terminate  in permanent hypertrophy
or thickening of the  affected parts, partly in consequence of persistent dilatation
of the vascular system of the part,  but chiefly from the deposition of plastic mat-
ters in the substance of the part.
   Modification of the sensibility of the Part, owing partly to increased sensibility
of the  nerves, but chiefly to the pressure exercised on their terminal branches
by the dilated bloodvessels, manifests itself by the occurrence  of pain  or by 
CONSTITUTIONAL  SYMPTOMS.
41
some  alteration  in the special nervous sensibility of an organ: thus in the eye,
by the patient perceiving flashes of light, and  in  the  ear, by noises of various
kinds; in the bladder, by a constant  desire to expel the urine, and by a desire
to urinate in inflammation of the kidney.
  Pain is one of the most prominent symptoms of inflammation, and its existence
serves a useful purpose by preventing  the patient using or  moving the inflamed
part.   The intensity of the pain depends  more upon the structure  affected than
on the violence  of the inflammation.  As a general rule, it may be observed that
the intensity of  the pain is in the inverse ratio of the swelling of the part affected.
Thus, the pain  of inflamed bone or fibrous tissue  is excessive;  that of cellular
membrane trifling.  In erysipelas of the scalp, most pain  is experienced in the
ears; the pain of the inflamed sclerotic  is far greater than that of the conjunc-
tiva.
   In some forms of inflammation pain can scarcely be said to exist, though the
disease may assume the most destructive form.  Thus, in certain inflammatory
affections of the throat and of the peritoneum there is  little or no pain.   Inflam-
matory pain is always increased on pressure.   The character of pain varies ac-
cording to the seat of the inflammation.   Thus, when mucous membranes suffer,
it is often of a gritty, itching, or burning- character, as  in conjunctivitis and scle-
rotitis ; when the serous membranes of the  chest or abdomen are attacked, it is
of a  lancinating or stabbing character; aching in bones; throbbing when pus is
 about to  form ;  sickening when the testis is affected.   When the pain is princi-
 pally elicited by pressure, the part is said  to  be  tender.   This  tenderness is of
 great service in a diagnostic point of view;  it may be elicited by direct pressure
 upon the part,  as  by squeezing  an inflamed testis, or  by pressing two  surfaces
 together, as in an inflamed  joint.   In inflammatory pain, especially of osseous
 and fibrous tissues, there is very commonly nocturnal exacerbation.
   ' It  is  important to bear in  mind  that inflammatory pain is often not seated
 merely in the part affected, but radiates extensively along the course of the nerves,
 the terminal branches of which are implicated to a limited extent perhaps.  Thus,
 in inflammation of the testis we  have  pain in the loins and groins.   In deep-
 seated ophthalmia there is  hemicrania in the branches of the Fifth Nerve over
 the, whole side  of the head or face, in consequence of  the  ciliary branches of the
 nasal, which are distributed to  the  iris and  choroid, becoming compressed or
 stretched.
    The temperature of an inflamed part usually rises above its normal standard.
 Hunter has, however, remarked that  it  does not  increase above that of the left
 ventricle :  thus, in a case of hydrocele, he found the tunica vaginalis  at 92°
 Fahr. before inflammation had  been excited in it, and at 98f ° after _it had been
 set up.   In a case of extravasation of urine, with severe inflammation, I found
 the temperature in the incision made  in the perineum  98° Fahr.   It is probable
 that there is always  a  local increase of heat in inflammation.  This, however,
 appears  to  the sensations of the  patient to be far greater than it is in reality.
 Travers truly remarks, "that the nerves measure  the  sensation, and not the de-
 gree of heat."   In many cases the sensation to the patient is that of burning in
 the  part, though the  actual rise in temperature may be but trifling.  This is
 owing to the exalted sensibility of the nerves.
    The cause of the increase of temperature is interesting.  In all processes in the
 economy in which determination of blood takes place, as in blushing or parturition,
 the temperature rises.   This can clearly not be owing to any production of heat
 during respiration, which may account for the  general heat of the blood, but not
 for its"local increase.   It is more probable that as the ordinary and general sup-
 ply is derived from the waste of the tissues, so that of inflammation may be due
 to increased destruction of organic matters in the part inflamed.
    Modification of Function, Use, or Nutrition, invariably occurs in inflamma- 
42
INCREASED  VASCULAR ACTION'.
tion, and furnishes important local  symptoms.   The  functional activity  of  an
oraan is increased, in the earlier stages at least of inflammation, and the character
of the secretions from the part materially modified.   Thus when the  mucous
membrane of the urethra is inflamed, there is copious discharge from it, and this
is not mucous, but purulent.
  The use of the part affected  is greatly interfered with;  thus, the bladder can
contain no urine, the eye cannot bear the light,  nor  a joint be  moved when in-
flamed.
  The nutrition of the inflamed tissues is arrested;  hence, wasting, softening, or
contraction,  are common accompaniments of this process.
   Constitutional Symptoms.—The  severity of the constitutional symptoms de-
pends on the intensity and extent of the disease, or the vital importance of the
part affected by it; on the amount  of local irritation, and whether it is owing to
external or internal causes.  Thus, a moderate  degree of  inflammation in  a part
of no vital importance,  as the shin,  and occasioned by an abrasion,  gives rise to
no  appreciable constitutional  disturbance.   But  if  the  inflammation be wide
spread, as that of diffused  erysipelas, or if there be much local tension, as in
whitlow, or if the part affected be of great importance, as the larynx or the eye,
then the general symptoms become proportionally severe.
  The constitutional disturbance  in inflammation always assumes  the  form of
fever—inflammatory or symptomatic fever, or Pyrexia.   It is invariably secon-
dary, being  consecutive  to the  local affection.   It is the true surgical fever,  no
febrile disturbance occurring in surgical  practice except  as a  consequence of
local disease or injury.  This fever appears to result  primarily from deterioration
of the blood by the local  inflammation, and from consequent reaction on the  circu-
latory  and  nervous systems.   Andral states that  increase of the fibrine of the
blood in inflammation is simultaneous with the accession  of the  fever, and that
when once this increase of fibrine has taken place, the spread and intensity of the
inflammation is increased by it.  And he has observed that in inflammation without
fever, there is no increase of fibrine, and that when  the fever  ceases the pro-
portion of fibrine falls  to its  normal standard.   Thus,  the local  inflammation
occasions the superfibrination of the  blood, and this  the general fever.  In this
respect, the fever of inflammation   differs from all  other forms of febrile dis-
turbance.
  Inflammatory fever or pyrexia, presents, however,  an infinite variety of forms;
the type which it assumes being finally dependent on the state of the blood;  on
the condition of the nervous system; and on  the  occurrence of certain local or
specific symptoms, dependent on the seat of the  inflammation.   These varieties
in  the type of  the  fever,  arrange  themselves practically into three  classes.
1.  Sthenic,  or typical inflammatory fever.   2. Asthenic,  or  typhoid  fever.
3. Irritative, or nervous fever.' In  all  these forms of fever, there are three dis-
tinct stages  : that of invasion, exacerbation, and decline.
  The sthenic form of inflammatory  fever, true pyrexia, occurs in individuals of
healthy constitution, young,  or middle-aged, in connexion  with those forms of
inflammation that are of an  active,  acute  character, and not unfrequently  conse-
quent upon  injury.
   In this form of fever, the  stage of invasion is very slightly marked, though it
always occurs.   There are rigors, with some slight depression of the nervous sys-
tem ; but these symptoms may be so transient as to  escape observation entirely,
and speedily terminate in  the stage  of febrile reaction.  In the majority of cases,
it is not until the constitutional disturbance has reached this stage that it attracts
attention.   The skin is  now hot and usually dry; the pulse full, bounding, often
thrilling, and quickened by thirty or forty beats in the minute  above its normal
rate; its character depending greatly on the tissue or organ affected : if this be
the mucous membrane,  skin, or a glandular structure, as the testis  or mamma, it is 
INFLAMMATORY FEVER.
43
compressible, though full; if a serous membrane be inflamed, it is small and in-
compressible—wiry, as  it is termed;  if a fibrous tissue  be the seat of disease,
it is hard and full.   The secretions are arrested or diminished in quantity;  hence
the urine is high colored and acid, the bowels confined, the tongue coated with a
white fur, and the  mouth clammy, usually with much thirst;  there is a feeling
of great languor, and the head is often heavy and hot.
   As the fever declines, if a favorable termination occur, the system not uncom-
monly relieves itself by a critical evacuation;—from the  skin, by abundant acid
perspiration ;—from the kidneys, by the free deposition of lithates in the urine;
—from the bowels, by diarrhoea;—and from  some of the mucous surfaces by
hemorrhage.  The  tongue cleans, the  pulse  subsides in frequency and strength,
the secretions generally become freer, the thirst lessens, and strength and appe-
tite return.   Should the fever not take a favorable  course, death may ensue by
the occurrence  of  serious visceral complications; the lungs and brain  being
especially apt to suffer, becoming the seats of fatal inflammatory mischief; or the
sthenic form  of the disease may gradually merge into those types that are
characterized  by debility and irritation.
   The asthenic form of inflammatory fever principally occurs in those indivi-
duals whose constitutions  are  broken  by privation, dissipation, or by any of the
depressing causes of disease, as grief, anxiety, or long residence in  a vitiated
atmosphere.
   In constitutions  such as these, so frequently met with in all classes, but espe-
cially amongst the  poorer residents in large  towns, inflammatory fever especially
assumes a  low  form.  There  is also, in this  variety of the  disease,  a special
tendency to its  complication with visceral mischief; the lungs being peculiarly
apt to become affected  by a low form of pneumonia.
   The asthenic form of the disease may come on as a sequence  of the sthenic
variety that has just been  described; the symptoms gradually merging into those
of a low form, and  being  characterized by  debility rather than  by strength of
action, the pulse becoming weaker though  its frequency is kept  up, the tongue
becoming brown and dry, with a tendency to  great prostration of strength, and
to the early supervention of delirium of a muttering kind.
   When the fever assumes the asthenic form from the very first, the period of
depression is strongly  marked,  and  prolonged  often for many hours,  reaction
coming  on  gradually, and imperfectly alternating with  the  depression against
which the system is struggling.   Even when fully established, the symptoms of
this stage of reaction are not of a very active  character;  there is throughout an
appearance  of heaviness or stupor about  the patient, with little  activity of the
intellectual  faculties, and an early tendency  to delirium of a low form, especially
at night; the pulse is feeble, though quick; the skin either moderately hot, or
else pungent and burning;  the tongue brown and dry,  with sordes rapidly accu-
mulating about the lips and teeth; the cheeks are  often  flushed, and the eyes
bright and staring.   As the third stage comes on, if the patient recover, critical
evacuations, often of a  hemorrhagic or diarrhoeal character, come on; the pulse
subsides, the tongue gradually and slowly cleans from the sides and tip, and the
patient regains his  strength but slowly and imperfectly; the convalescence being
often  interrupted by intercurrent  disease, and  the powers of the constitution
being frequently broken for months, or for life.   If the disease take an unfavor-
able course,  the  weakness of pulse, and dark incrustation of tongue increase; the
skin becomes cold;  hiccup, subsultus,  dyspnoea, or coma  supervene; and  death
occurs from  exhaustion  or as the result of visceral complication.
   The irritative fever is of a less specific type.   It is usually associated with the
asthenic  form, the nervous system being especially indicated.   It  occurs in indi-
viduals whose mental powers have been overwrought, or whose nervous systems
have been shattered by intemperance.   It is characterized by irregularity in its 
44
INCREASED  VASCULAR ACTION.
actions, sudden exacerbations, and a rapid  decline.  The several  febrile symp-
toms run high in the  early stages.  The pulse soon becomes  sharp and small;
there is high delirium of a furious kind, wildness of eye, and heat of head.  But
these symptoms soon give way to signs of debility and exhaustion, and death
takes place from coma and cerebral irritation.

            TERMINATIONS AND EFFECTS OF INFLAMMATION.

  There are two ways in which inflammation may terminate without leaving any
traces  of its presence in the part  affected;  these are  by Resolution and  by
Metastasis.
  The termination by resolution simply means a return to health.   The pain and
heat first subside, the swelling disappears, and lastly the redness  passes away:
the constitutional symptoms also  disappear.   With regard to the more intimate
changes in the part itself, it will  be  seen that the  dilated vessels  contract, the
stagnant masses of blood-discs are pushed on and broken up by streams  finding
their way into and against them.  Absorption, which  had been held in check
during the continuance of inflammation, comes into play, and removes the extra-
vasated matters, and  secretion  becomes  more active, and  helps to unload the
part.   Resolution may in this way be  complete, or it  may go on to a  certain
point and then stop, leaving one or other of  the effects  that will immediately be
mentioned.
  By metastasis is meant a change in the seat of the  inflammation, its  sudden
and complete disappearance in one part and  reappearance in another.  This is of
extremely rare  occurrence; it is occasionally seen, however, as in the  inflamma-
tion of the  testis,  that suddenly supervenes on the disappearance of a gonorrhoeal
discharge.
  Besides these true terminations, inflammation commonly passes from the ordi-
nary and  primary condition  into  some  other  form of the disease.  Thus, for
instance, when  plastic matter or lymph is thrown out,  adhesive inflammation is
said to have occurred.   When it  terminates in the  production of  pus, we have
suppurative inflammation.  When an ulcer forms, ulcerative inflammation is said
to have set in, and when the inflammatory action is of such intensity as to cause
the death  of the  part affected, gangrenous  inflammation has  occurred.   These
different conditions of the inflammatory process differ so widely from its ordinary
forms, and from  each other, as to constitute  distinct  diseases, and as  such to
require separate and distinct consideration.
  When inflammation has once been set up in a part it may extend to other por-
tions  of the  system in three distinct ways.   1st. By local extension; this may
occur by the inflammation spreading  along the tissue affected in its continuity;
as, for instance, along the  skin,  cellular or mucous membranes.   It may also
spread by contiguity of tissue, passing from one affected structure to an adjacent
healthy one; thus we see the opposite surfaces of an inflamed joint, involved in
disease at  opposing points.
  2d.  Inflammation  may extend  to  distant parts  through the medium of the
blood.   This fluid being altered  and depraved, and increasing the liability to
inflammation in other parts, as in some  of the erratic  forms  of erysipelas • or
conveying pus to  a distance, as  in phlebitis, and thus  giving  rise   to numerous
centres of inflammation.
  Lastly.  Inflammation may be carried  to  a  distant part  by metastasis as has
already been described.
  Effects of Inflammation. Closely allied to the local symptoms of inflammation
are the local effects of this  disease.   These  consist first, of changes in the con-
sistence of the  part inflamed, which may be of two kinds.   Induration  chiefly
as a consequence  of chronic inflammation, occasioned  by the turo-escent state of 
THE  CAUSES  OF INFLAMMATION.
45
the vessels of the part, or the effusion of plastic  matter within it.   Softening,
chiefly after acute inflammation, depending partly on the infiltration of effused
liquids  into the  textures, and partly on disintegration  of their substance, and
thus lessening the consistence of the  hardest tissues:  thus an inflamed bone
may be cut and pared down with  a knife, or the  ligaments of an inflamed joint
become so soft as to admit of spontaneous dislocation.   This softening may ulti-
mately lead to the interstitial  absorption of a part, which becomes shrunken and
contracted  after inflammation.   Ulceration, as will  hereafter be fully stated, is
not  an  unfrequent  consequence of this softening  and atrophy conjoined  with
rigidity, as we see in those joints that have undergone inflammation.
   In chronic,  inflammation we not  unfrequently find that increased nutritive
activity of the part leads  to an increase in its size  and  growth, partly owing to
actual augmentation in bulk of the tissues of the part; in many cases, however,
rather dependent on effusions into  the cellular membrane.  Interstitial absorp-
tion and gradual wasting of a part without previous  softening, often occurs
as an effect of inflammation.   Thus, a blow on the hip will occasion absorption
and shortening of the neck of the femur.
   Loss of transparency in structures that are  normally translucent is a common
effect of chronic inflammation, as  may every day be observed in the cornea or
capsule of the crystalline lens ; in  some cases this rather depends upon a modifi-
cation of nutrition than  upon the  deposit of new  matter upon  the  part.   In
other cases again it proceeds from the  deposition of plastic matter in or upon it.
   The symptoms, terminations, and effects of inflammation that have just been
described, are those which characterize the more ordinary forms of the disease.
In practice, however, we recognise  many  important varieties of this affection.
These may be referred to three heads, as they affect its duration, its intensity,
or its character.
   1st.  As  to duration.   The disease may be acute or chronic, varying from a
few days to many years, being especially persistent  in those structures that are
naturally least vascular, as, for instance, bones and  joints.
   2d.  As to  intensity.   When the symptoms are well marked, the redness and
heat great, the tension  considerable, and perhaps  the  pain severe, with corre-
sponding  constitutional  disturbance, the  inflammation  is said to be  active or
acute; when of a less intense character, it is termed subacute;  and when there
is merely redness and swelling, with little or no pain,  and but slight constitu-
 tional disturbance, the disease is said to be of a passive  kind.  The duration of
 the inflammation commonly influences its  intensity, which is usually less in the
 more chronic cases; but  very frequently we find the reverse, and  that  when of
 but short duration it may be  subacute  or passive, whereas some forms of a very
 chronic character may retain  great activity, and are especially liable to recurrent
 active attacks.
   3d.  As to  character.   If  the  inflammation is circumscribed, occurring in a
 healthy constitution, and tending, after a  moderate time to terminate in resolu-
tion, it is called  healthy or phlegmonous.   If the vessels become distended and
dilated, the blood slowly circulating, the  redness of a  purplish tinge,  and the
swelling considerable, with but little  heat, the disease is said to be congestive.
Of unhealthy inflammation there are numerous varieties; the diffuse having a
tendency to spread widely unchecked; the strumous being modified by scrofula;
and the specific inflammations, that arise from special causes, and are frequently
capable of self-propagation.

                      THE CAUSES OF INFLAMMATION.

   The causes of inflammation may be divided like those of all other diseases,
into predisposing and exciting, and  these again may either be of a strictly local
character, or act locally,  through the medium of the constitution. 
46
INCREASED  VASCULAR ACTION.
  Local predisposing causes.—Though every tissue of the body is susceptible to
inflammation, yet some parts are more  liable to it than others.  This cannot be
owing to any greater degree of vascularity, for we  find that the tissues lining the
interior of a joint more readily  and more violently inflame, though  they are
almost extravascular, than a portion of the mucous membrane which  is so abun-
dantly supplied with vessels.  Indeed serous and synovial membranes  are more
liable than most other tissues to inflammatory excitement.   Whatever the reason
of this may be, there are two sets of causes that more especially predispose tissues
to inflammation.
  Thus habitual over-use or over-stimulation of a part by producing  determina-
tion of blood to it may readily drive it into inflammation. _
  When a part having once  been  the  seat  of  inflammation, has  been left in a
weakened or impaired state, it will  be  more liable to the occurrence of a second
attack of inflammation,  having  less resisting power; hence also  subsequent
attacks are induced by less active exciting causes than were required to call the
first disease into action; we see this in the inflammatory affections of the eyes and
joints.  Then again a tendency to local congestion or stasis will dispose to in-
flammation, very slight over-stimulation inducing the disease when  the vessels
of the part are already overloaded; this is often seen in the case  of varicose
veins, the congested skin readily running into inflammation.
  It is of great consequence to ascertain whether any constitutional  predisposi-
tion to inflammation exists, and if so, what its precise nature is, for the progress
of the local affection will in a great measure be dependent on the state of con-
stitutional  predispositions in this respect.  The constitutional predisposing causes
are of two  kinds.
  1st. Thus inflammation  is predisposed to by a state of general over-stimulation
of the vascular and nervous  systems.  This condition  may be hereditary,  as in
the sanguine temperament, or dependent  on youth  and sex; or it may be ac-
quired by habitual indulgence at table; the induction of plethora, producing an
inflammatory habit of body, or diathesis.   And inflammations occurring in this
habit of body are usually of the sthenic variety, though not unfrequently accom-
panied in the case of those  accustomed to alcoholic stimulants,  by  fever of an
irritative form.
   A directly opposite condition of the system, it is clear, equally disposes the
person to inflammatory attacks; thus a state of vascular and nervous depression,
by  lessening the reacting power of  the constitution, causing a loss of tone in the
vascular system with ready tendency to dilatation of the  vessels, and to stagna-
tion of blood, disposes to  inflammation.  In this way inflammatory actions are
especially apt to  occur in  scrofulous patients,  in whom the  general powers are
enfeebled,  and in such individuals they occur  under the influence of minor ex-
citing causes than in those in whom nutrition is  more actively carried on.   Here
inflammation usually assumes the passive,  congestive, or asthenic forms.
   The exciting causes of inflammation are very  numerous and simple in  their
action.  Commonly, mechanical injuries are those that occasion surgical inflam-
mations, which are indeed set up by nature as the means of repairino- the effects
of  the injury.
   Chemical agencies, as the application of caustics, and undue extremes of heat
and cold, are also amongst the most common  exciting causes.   The application
 of  the virus of certain morbid poisons, as of syphilis and the malignant pustules,
 directly occasion it.  And lastly, certain states of the blood o-ive  rise to it  as in
 those conditions of the system in which boils, carbuncles, &c, are produced.

                      TREATMENT OF INFLAMMATION.

    The Treatment of Inflammation may be divided into the  preventive and the
 curative. 
TREATMENT OF  INFLAMMATION.
47
  The preventive treatment can only be employed  in  inflammation  supervening
on injury.  In it the principal point to be attended to is the removal of the
local and constitutional  causes of irritation.  By doing this, the occurrence of
inflammation in a part that has been injured or otherwise disposed to its accession
may be entirely  prevented, or if this  be not  accomplished,  much  lessened in
severity.
  The  local preventive  treatment of inflammation  is best carried  out by the
removal of all sources of irritation, by absolute rest of the part, and by the free
application of  cold.   If the  injury be  superficial, and not very  severe,  lint
dipped in cold  water,  frequently renewed,  may  be applied, or  if the  skin  be
unbroken, an  evaporating  lotion may  be  used.  Should  a limb  or joint  be
severely injured,  the cold irrigation will be a preferable mode  of reducing its
temperature.   This may most conveniently  be done by suspending over the
part a large  wide-mouthed  bottle,  full of water, in which a few pieces of ice
may, if necessary, be put; one end of a skein  of cotton,  well  wetted, is  then
allowed to hang  in the  water, whilst the other is brought  over  the side of the
bottle.   This, acting as a syphon, causes a continual dropping upon the part to
which the cold is to be applied.   (Fig. 3.)  In some cases  the application of
pounded  ice in  a bladder,
or  of cold evaporating lo-
tions,  may be preferred to
the irrigation.
   At  the same time all con-
stitutional irritation must be
removed by abstinence, rest,
and a free aperient.
   In undertaking the cura-
tive treatment  of inflamma-
tion, the surgeon must  not
be guided by the name of
the affection that he has to do
with,  but by the actual con-
dition of the patient, and the
state of the diseased part;
for nothing presents  greater varieties than  the management of an inflammatory
process, in different  conditions of  the  patient,  and in the  different phases of
that affection.   We shall accordingly consider the treatment of  inflammation as
applied  to the acute and sthenic,  the  chronic, the congestive,  passive,  asthenic
and specific varieties of the disease.
    Treatment of acute Inflammation with fever of the Sthenic type.—In the
treatment of this  variety of  the disease,  active and energetic measures  must
early be had recourse to, especially if the patient be young and strong.  There
is no  affection that  is  more under  the control  of the surgeon  than  this  when
occurring in a healthy  constitution, and in which more can be done by active
means early employed.   It is consequently of  great importance that  precious
time be not lost by the employment of inefficient measures, otherwise important
local changes and  irremovable alterations of structure may ensue. _ It  is also of
great  consequence to remove the disease fully; not only to subdue it,  but to ex-
tirpate it, lest it degenerate into  some of the more chronic, passive,  and intract-
able forms.
   The first thing to be attended to in the treatment  of the sthenic,  and  of all
the other varieties of inflammation,  is  the removal  of the  cause.   Thus, rest
must be afforded to a diseased joint, light removed  from  an inflamed  eye,  and  a
foreign body taken out of the flesh in which it is lodged.
   The next great indication is to lessen the determination of blood to  the part.
 
48                 INCREASED  VASCULAR ACTION.
The measures for accomplishing this comprise what is termed the antiphlogistic
treatment.   This consists of constitutional and  local means.
   Constitutional antiphlogistics.—The most powerful and efficient that wepossess
is certainly bloodletting, and when  the inflammation is sufficiently extensive and
severe, and the patient's  powers warrant it, we  may have recourse to the abstrac-
tion of blood.  Now blood can easily be  taken away,  but it cannot readily be
restored to a patient, and  we should never remove  it  unnecessarily, lest  perma-
nent ill effects to the health ensue.  It  is  certainly not often required in the
treatment of surgical  inflammations; and should be  especially avoided in very
young and very old subjects; or the inhabitants of large towns generally; or in
those in whom inflammation of a specific character occurs : hence in hospital or
private practice it is now often found advisable to  have recourse to other means
in its stead.  It should never be had recourse to unless an organ of great impor-
tance to the economy, as  the lung, for instance, be  inflamed, or so injured that
inflammation of it is imminent; or unless a tissue, like the transparent structure
of the eye, be affected, in which  it is absolutely  necessary, at any risk, to cut
short an inflammation before it give rise to any change of structure, which, how-
ever slight, would be fatal to the after-utility of the part.   The quantity of blood
that should be taken necessarily varies greatly, according to  the age  and consti-
tution of the patient and the nature of his disease, and it is of importance to bear in
mind that when bloodletting is  required, the system tolerates the loss of the vital
fluid in a way that it does not otherwise do.  The effect produced on the pulse and
on the system should be the guide to the quantity to be taken away.   A decided
impression should be produced by bloodletting, not so much on the frequency of the
pulse, as on its character;  that should guide us and not the number of ounces drawn.
The point to be obtained is the greatest effect upon the system with the least loss to
the patient, hence the blood should be taken from a large orifice in the median
basilic, or cephalic vein, the patient sitting upright.   In repeating the venesec-
tion we must be guided by the impression that has been  made upon the  disease
and by the state of the pulse.   Purgatives should always  be given early, except
in some special cases of acute inflammation of the abdominal organs.   They clear
the intestinal canal, free the secretions, and equalize the circulation.   In _eneral,
it will be found most advantageous  to administer a mercurial, followed bya brisk
saline purge, and this  should be repeated from time to time during the progress
of the case.
  Diuretics and diaphoretics require to  be administered frequently durino-  the
day.  If the skin be hot and  dry, antimonials should be given in smaU  and
repeated  doses; these  may advantageously  be  conjoined  with, or replaced by
salines, such as the citrate of potass, the  acetate of ammonia, or nitre.  In  this
way the force of the heart's action is lessened,  and the skin and the kidneys arc
called into active operation.   It is also probable that  the  salines alter  the  con-
stitution of the blood, dissolving the fibrine and lessening the quantity of water,
both of which constituents are  in excess in inflammation.
  In many  forms of sthenic inflammation, especially in those which affect the
serous and fibrous membranes, we  do not possess a  more efficient  a°-ent than
mercury administered,  not as a purgative, but  as  an  alterative to the system.
Mercurial remedies are of special service in aiding the operation of other medi-
cines.  Diuretics, diaphoretics, and purgatives  will frequently not act properly
unless conjoined with a mercurial.   In inflammation the preparations of mercury
act as direct antiphlogistic agents, lessening  the quantity of  fibrine in the blood
and equalizing  the  circulation.   They are of  especial value in promoting  the
absorption  of exudation   matters, more  especially  of lymph, as we  may  see
happening under their influence in certain diseases of the eye.   They appear
to do this rather by lowering the vascular  action of the  part, and thus allowing
the absorption to be carried on, which had been arrested  during the  persistence 
              TREATMENT  OF  ACTIVE INFLAMMATION.           49

of the inflammation, than by any specific influence  exercised  over  the effused
fibrine.   Care, however, is required in the  administration  of this mineral.  In
irritable or cachectic constitutions it should not  be given at all, or with great
caution.   It is best borne  by strong constitutions, and in acute inflammation  of
the serous and fibrous tissues.
   Calomel, blue  pill,  and mercury and chalk,  are the  preparations  usually
employed when  the  mineral  is given  by the  mouth.   When administered
endermically,  the mercurial ointment is  preferred;  and the use  of  the  mineral
is in general continued until  the gums become spongy, and a red line is formed
at their edge; the  patient experiencing a  coppery taste in the mouth, and the
breath becoming  fetid.  It is  not necessary to induce profuse salivation.
   It is especially the combination of calomel with opium that produces the most
beneficial effects in the treatment of surgical  inflammation.  Two grains of calomel
and a third or half a grain of opium, every fourth or sixth hour,  tranquillise the
system and lessen vascular action in a remarkable manner.
   Opium is not only of use in the  way that has just been  indicated, but  is of
essential service in allaying the pain  and irritability that often accompany inflam-
mation, especially in  many inflammatory affections of the bones and joints.  In
the form of Dover's powder it is of especial  value in this respect.
   [The use of Aconite as an antiphlogistic  remedy has of late attracted the at-
tention of surgeons, and is recommended in the highest terms by many.   The
form of administration, is that of the concentrated tincture of the root (Tinctura
Aconiti radicis of the Pharmacopoeia); a preparation analogous to the one origi-
nally proposed by Dr.  Fleming, by whom its powers  were greatly vaunted.  The
dose is two or three  drops, repeated  two or  three times  in the course of the day.
   It is  supposed to act  as  a powerful sedative and  antiphlogistic, and  to be
especially indicated in all cases attended with excessive activity of the circulation,
whilst on the  other hand it is contraindicated according to Dr. Fleming, " when
there is obvious mechanical impediment to  the passage  of the blood, particularly
through the heart or lungs, and also wherever there is  irritability of the circu-
lation, with great diminution of power, such as occurs after severe venous hemor-
rhage."
   Whenever  this remedy is  made use  of,  its  effects should be most carefully
watched by the surgeon.—Ed.]
   In the treatment of active  inflammation, it is of essential consequence that the
patient should be kept at  rest in a well-regulated temperature on low diet;  in
fact, the more complete the  abstinence in this respect is,  the more  rapidly do
therapeutic means act and the febrile symptoms cease.
   The local treatment of inflammation is of the utmost importance, as it directly
influences the vessels that are deranged in action.   It consists of means of the
most varied and opposite character; heat and cold; iced water and poppy fomen-
tations;  astringents  and sedatives, are  all  employed, and  all  with  success, but
each only in certain  stages and forms of the disease; and the art in conducting the
local treatment of inflammation consists in adapting the  various means at our dis-
posal to the particular  condition of the case  before us.
   Local bloodletting is the most efficient means we  possess in directly lessening
vascular action in a part, as by it we take the  blood directly from the inflamed
and turgid vessels.   It may be used  in addition to, though  it is now  very com-
monly employed in  preference to, general bloodletting; especially if the inflam-
mation be not  severe, if it occur at either of the extremes of life, in  women, and
in persons generally of feeble power.
   Blood  may be taken locally by punctures, scarifications, incisions,  or by leech-
ing or cupping.
   Punctures and  incisions can only be practised in inflammation of the cutaneous
and exposed  mucous  surfaces,  due  attention being had to  subjacent parts  of
                                     4 
50
INCREASED VASCULAR  ACTION.
 importance.   They constitute a very efficient  means of relief to the part; as not
 only is blood removed, but an exit is afforded for effused matters;  tension and
 pain are  consequently materially lessened, and the  tendency to sloughing and
 other after-consequences perhaps prevented.  The punctures should be made with
 a fine  lancet, in parallel rows over the inflamed surface, and not exceed a quarter
 of an inch in depth.  The incisions  must  always be made in  the  axis of the
 limb, and should be so arranged as to  afford the greatest possible relief to the
 tension of the parts.  Their extent superficially and in depth must vary accord-
 ing to the seat of the  inflammation.   Thus in  the inflamed conjunctiva they
 must of course be very limited in this respect, whilst in  phlegmonous inflam-
 mation of a limb  they may be of much greater extent.   Care, however, must
 always be taken not to wound superficial  arteries or veins.  A modification of punc-
 ture is sometimes  practised by opening the veins in the neighborhood of the
 inflamed part at several points at once.   Thus in  inflammation of the testis the
 scrotal veins may advantageously be  punctured.   The bleeding from punctures
 and  incisions should always be encouraged  by  warm fomentations.
  Leeches are usefully applied to the neighborhood of inflamed parts, but should
 not be put upon  the inflamed surface itself, as  their  bites  irritate.   There are
 certain situations in which leeches should not be placed, as over  a large subcuta-
 neous  vein, or in regions where there is much cellular tissue, as the scrotum or
 eyelids, lest troublesome hemorrhage or ecchymosis result.   So also they should
 not be applied near a specific ulcer,  lest their bites  became inoculated by the
 discharge.   The bleeding from a leech-bite should be encouraged by warm poul-
 ticing  or fomentations for some time after the animal  has dropt off.  In this way
 from half an ounce to  an ounce of blood may be  taken by each leech.  There is
 usually no difficulty in arresting the hemorrhage from the bite;  should there be
 so, continued pressure with some scraped  lint, felt,  matico  or powdered  alum,
 will accomplish this.   If this  do not succeed,  as may happen in  some situations
 where  pressure  cannot be conveniently applied, as on the  neck  and abdomen,
 particularly in young children, a piece  of nitrate of silver  scraped to a point, or
 a heated wire introduced  into the bite, previously wiped dry, or a twisted suture
 over and around it, may be required.
  Cupping is the most efficient local  means of removing blood that  we possess,
 and  the quantity extracted may be regulated to a  nicety in this way.  It cannot,
 however, be employed upon the inflamed surface itself, on account of the pain
 and irritation that  would be occasioned, and is consequently chiefly applicable to
 internal inflammations.  As the scars made by the scarificators continue through
 life, cupping should not be practised on exposed surfaces.
  The inflamed part should always be  placed  in  such a position as to  facilitate
the return of blood from it.   Unless  this be done, the  pain is greatly increased,
 and the congestion augmented.  Hence it requires to be elevated  on a level with^
 or above the rest of the body. _ All motion and use must likewise be interdicted'
 as favoring determination and increasing pain.
  In cold and heat we possess two most important local means of controlling in-
 flammation.   They cannot, however, be employed  indiscriminately.
  Cold:—There are two stages  of inflammation in which cold may be employed
 with especial advantage; first,  during  the very early stages, rather with a view
 of preventing or limiting the inflammation, so that it may not pass beyond  the
 bounds of adhesive action;  and next when acute inflammation  has  passed off
 the vessels  of the  part remaining  relaxed  and turgid: the  application of cold
 acting  as a powerful agent in restoring the tone of the parts.
  Cold should never be had recourse to when these stages have passed, and when
suppuration is coming on, or has set  in; still less should it be employed when
there is a tendency to  mortification.   Its long-continued and incautious use may
indeed give rise to extensive sloughing of the inflamed part. 
             TREATMENT OF  CHRONIC  INFLAMMATION.          51

   The modes of applying cold vary according to the part affected.  If the surface
be inflamed, evaporating spirit lotions, to which sedatives may sometimes be ad-
vantageously added, are  the best.   If it be wished  to influence the whole sub-
stance of a limb, irrigation with cold water should be adopted. (Fig. 3.)  If it be
intended that the effect of the  cold penetrate deeply, as in inflammations of the
head, spine, or chest, it may be applied by means of pounded ice;  to which, if an
extreme degree of cold be required, salt may be added.   The ice  is best applied
by being placed in a bladder, gut, or a Mackintosh bag, partiarlly filled.
   Warmth and moisture conjoined are of the utmost service in the treatment of
inflammation.  By these means, tension is relaxed, effusion is favored, and thus
the over-distended vessels  are  relieved.  If continued for too long a time, how-
ever, these means favor  congestion, and sodden the parts.  Warm applications
are especially serviceable in all cases  of inflammation, attended by much pain,
more particularly if this occur from tension; and they are especially useful when
suppuration is  threatening, or  has come on;  and in many cases where there is a
tendency to slough.
   When abscess threatens, or  the surface is broken, nothing  affords so  much
relief as a well-made poultice,  either of linseed  meal or of bread;  this made soft
and smooth, and not spread too  thickly on the cloth containing it, should be applied
as hot as the patient can bear it.
   Water-dressing, consisting of doubled lint, well  soaked in  tepid  water,  and
covered by oiled silk, or thin gutta  percha, extending from  half an  inch  to an
inch beyond it on all sides, may be advantageously substituted for a poultice  if
the  sore be  small, and the inflammation limited.
   Fomentations of warm water, or of decoction of  poppy and camomile  flowers,
applied by means of flannels wrung out of these liquids, or of bags containing
the  boiled plants, well soaked in the decoction, squeezed out, and applied hot, are
very useful in  extensive superficial inflammations.  The flannels and bags should
be well covered with oil-silk or Mackintosh cloth, so as to retain the  heat, and to
prevent evaporation.   Spongiopiline may be conveniently used as a substitute for
ordinary fomentations in those  cases in which the surface is not broken.
   These are the means by which acute active inflammation is arrested and cured.
In their employment, we must endeavor to  proportion the activity of our mea-
sures to the age, constitution,  and vigor of the patients, the seat and intensity
of the  local  disease, and continue them until the inflammatory action is not only
arrested, but has entirely subsided, the part being restored to its ordinary healthy
state.
                 TREATMENT  OF CHRONIC INFLAMMATION.

   The treatment of chronic inflammation  is far more difficult than that of the
acute form  of  the disease.   Chronic  inflammation is so  frequently complicated
with various unhealthy  conditions of the  system,  and with an  impaired state
of the general  health, by which, indeed, it is often kept up, that  much prac-
tical  tact and  skill  are  required  in  carrying  out the therapeutic indications
properly.
   In the treatment  of chronic  inflammation we have not only to subdue inflam-
matory action, but also to remove structural changes and other effects induced by
it.   Hence, our object is not  to produce a great and sudden impression on  the
system, as we are often required to do in the treatment of the acute affection.  In
this way chronic inflammation can never be cured,  or its  effects removed.   The
patient might be bled to death, and still the increased vascular action would go
on in the inflamed part, so long as there was a drop of blood circulating in his
vessels.   It is true that the same antiphlogistic  means are employed in arresting
the chronic, as  in cutting short the acute form of the disease, but  in a less ener-
getic manner; our object being to induce a gradual  and continuous improvement 
52
INCREASED VASCULAR  ACTION.
in the state of the system and of the diseased part.   Local nutrition is always
greatly modified in  chronic  inflammation,  and this  can only be  restored^ to
its normal condition by close attention to all the circumstances that tend to im-
prove the patient's general health, as well as by inducing a strong impression on
the part itself by appropriate  local means.   Hence, in  the treatment of chronic
inflammation  hygienic  measures are of the first consequence.  In most  cases
nothing can be done without proper attention to these;  and much  by these that
cannot be effected by any more direct medicinal means.  The treatment of this
form of inflammation must likewise be varied according as it is of an uncompli-
cated character, occurring in  an otherwise healthy constitution, and  assuming a
sthenic type;  or as it occurs  in a cachectic and feeble system, assuming a con-
gestive or passive character, or as it is met with in an unhealthy constitution, and
affects a specific form.
  In the management of these various forms of chronic inflammation the patient
must be kept as quiet as possible, and, if the disease be at all  extensive, be con-
fined to bed.   He should be in pure air, and, as a general rule, be put on a  light
and unstimulating diet.   The regulation of the diet is of much consequence, and
the amount and quality of the nourishment afforded must be carefully propor-
tioned to the age, strength, and previous habits of the patient, as well as to the
degree and the seat of the inflammation, and the form of constitutional fever that
accompanies  it.  In the more acute form of chronic inflammation,  farinaceous
slops, at most beef tea,  and light puddings,  can be allowed.   In the less active
forms occurring in feeble constitutions,  with depression of general power, animal
food may be given, of a light kind, and the  scale of nourishment increased  until
stimulants, as  beer, wine,  or brandy,  be  allowed.   Nothing requires  greater
nicety in practice than  to proportion the  diet, and  to determine the cases  in
which stimulants are necessary.  It may be stated  generally that the more the
disease assumes the asthenic and passive forms, the more are stimulants required;
until, at last, in the  truly typhoid type of inflammatory fever, our principal  trust
is in these agents; and large quantities of wine, brandy, and ammonia are  re-
quired to maintain life.
  Mercury is of essential service in the more active forms of chronic inflamma-
tion—especially those affecting joints, bones, and organs—but in all cachectic
and strumous constitutions it should, as much as possible, be avoided.  It is not
only of great use in arresting  the  further progress of the disease, but especially
in causing  the absorption of some of the effusions that  result from it, and in
removing some of the other effects of chronic inflammation, such as  thickening,
hardening, and opacity of the parts.   It should be given  in  small  doses  for a
considerable length of time until the gums are slightly affected.  In  many  cases
of depressed power it may be very advantageously conjoined with bark or sarsa-
parilla.   The most useful preparations  are  calomel in half grain or grain doses,
the iodide of mercury in the same quantities; or,  if a gradual and continuous
effect be required, the  bichloride  in doses  from a sixteenth  to an  eighth of a
grain
  The iodide of potassium is an alterative  and absorbent of the greatest value,
especially in chronic inflammations of fibrous or osseous tissues, more  particularly
when occurring in strumous constitutions, in which it may often be  substituted
with great advantage for mercury,  and given in those  cases in which that mineral
would otherwise be administered.  In many cases it is of essential service after
a mercurial course.^  Some  days should, however, be allowed to elapse after the
mercury is discontinued before the iodide is given, otherwise  profuse salivation
or even sloughing of the gums is apt to result.
   Sarsaparilla  is a very valuable remedy if  obtained  good,  and forms an admi-
rable vehicle for the preparations of mercury or iodine.  The fluid-extract of red
Jamaica sarsaparilla, carefully prepared, is that to which I give the  preference; 
             TREATMENT  OF  CHRONIC  INFLAMMATION.           53

and where the inflammation is associated with want of power, its value is certainly
very great.
  The cod-liver oil is of the very greatest value in the various strumous forms of
chronic inflammation; in debilitated,  emaciated, cachectic,  and strumous sub-
jects;  it may be given in some vehicle, such as milk, orange-wine or  juice, that
covers its taste.   In some cases it is advantageously conjoined with the iodide of
potassium,  or, when  there is much want of power, and strumous anaemia is pre-
sent,  with the preparations  of  iron.   It is more particularly in children and
young people that it is of service in  removing the various effects  of  chronic
inflammation.
  Purgatives are  often required in chronic inflammation.   In robust subjects
in whom the disease is active, salines  may be employed;  to which, if there be
a rheumatic tendency, colchicum may advantageously be added.   As a  general
rule, warm aperients, such as the compound  decoction of aloes, with Rochelle
salt, answer  best; and in children a powder  composed of one part of mercury
and chalk, two of carbonate of soda, and  four of rhubarb will be found very
serviceable.

             LOCAL TREATMENT OF CHRONIC INFLAMMATION.
   In chronic inflammation our local means  of treatment are  much more varied
than in  the acute form of the disease.
   Local bloodletting is often required with  a  view of directly unloading the ves-
sels of the part, and this is  accomplished by scarification, leeching, or cupping.
Scarification is principally employed in chronic inflammation of the mucous mem-
branes;  and by directly cutting across the distended vessels  produces their obli-
teration.  Leeches may very usefully be employed, in some forms of chronic  in-
flammation,  by applying  two or  three at a  time and repeating this  application
every second or third day.
   Warmth and moisture  are not so serviceable in chronic as in acute inflamma-
tion, and care should be taken that they be not continued for so long a time as to
sodden the parts.   An astringent or stimulant, such as liquor plumbi or spirits of
wine,  may often advantageously be added to the warm application.
   Cold  is seldom required in any but the advanced  stages of chronic inflamma-
tion, in  which there is debility, want of tone, and passive congestion of the ves-
sels of the part.   In order to remove this state of things, its application should
not be continuous, but be made twice or thrice a day, so as to occasion a sudden
shock, and produce a constricting  effect upon the enfeebled circulation of the
part.  This  is  best done by pumping or pouring cold water from a height,  or by
douching,  and should be  followed by active  friction with the hands.
   Friction is often of great service in some  of the forms of congestive inflamma-
tion, and in  the removal of the thickening, stiffening, and induration that results.
Friction may be  practised either with the naked hand or with some liniment or
embrocation  of a stimulating, oleaginous, or  absorbent character.
   Counter-irritants are amongst the most energetic local means that  we possess
for combating chronic inflammation.   Rubefacients, in the shape of stimulating
embrocations or liniments, to which absorbents, such as mercurial ointment, may
often advantageously be added, may be usefully employed as  adjuncts  to friction.
   By means of blisters  applied either directly over the inflamed part, or at a
little distance from it, the surface being kept raw and exuding by some stimulat-
ing application, effusions and those chronic structural changes that accompany  the
more advanced stages of inflammation may be absorbed and removed.
   In the latter stages of chronic inflammation, the pyogenic counter-irritants may
be  very  advantageously employed.  By these  a powerful derivative action is in-
duced, and chronic thickening, the result of effusion, may be melted away.
   Issues are of especial service in chronic inflammation of the viscera, joints and 
54
INCREASED VASCULAR  ACTION.
bones; they should be applied in the soft  parts over the  affected structures, and
may be kept open for a  very considerable length of time.   They are best made
in the following manner:—A piece of common adhesive plaster, about two inches
square, having a hole the size of a shilling cut  in its middle, is  fixed ivpon  the
part where the issue is to be made; a  piece of potassa fusa, about the size of half
a cherry stone, is then placed on the surface left uncovered by the circular cen-
tral aperture, a square piece  of  plaster being laid over all.   The patient experi-
ences  a burning  pain for about two hours, when  it ceases; on removing  the
plasters a black slough corresponding in size to the central aperture will be found.
This must be poulticed for a few days until it separates, and the raw surface then
dressed with savine ointment, or stimulated by  an  issue-bead._  As  it  shows a
tendency to heal,  it may be kept open by the occasional application of the potassa
fusa.
  When counter-irritation is  to be applied over very deep-seated parts, a seton
is more useful than an issue.  The seton may most conveniently be made in the
following way:—A fold of skin  about two inches or more in breadth is  pinched
up, and its base transfixed  by a narrow-bladed  bistoury.   The  blunt end of an
eyed probe, threaded with the seton, is next pushed along the back of the blade
from heel  to point, which being  withdrawn as the probe is carried onwards, the
seton is left in the wound.   A poultice should then be applied.
  The actual cautery and the moxa are not so often had  recourse to as their
great utility would warrant; the chief objection to their use in the painfulness
of their application may be obviated by the employment of chloroform.
  Astringents directly applied  to  the inflamed parts  are of extreme  service in
those forms of congestive or passive inflammation in which the circulation is
sluggish and the capillaries  loaded, affording relief in these  cases by inducing
contraction of the vessels.  In  order to insure their proper action they must be
employed of sufficient strength, for if too weak  they irritate, and increase rather
than relieve the congested condition.   The  nitrate  of silver is the astringent
that is commonly preferred, and this, applied  either solid  or in  solution  of a
strength from ten grains to  one  drachm of the salt  to the ounce of distilled
water, will  produce  a very marked beneficial influence in congestive inflammation
of the mucous and cutaneous surfaces.
  Pressure by means of well-applied bandages, elastic  webbing, or strapping is
of essential service in supporting  the feeble  and atonic vessels"in congestive 'in-
flammations.  In many cases pressure may  be advantageously conjoined with
absorbents and rubefacients, as  mercurial  and  camphor  liniment, or the plaster
of mercury and ammoniacum.  This treatment, by removing congestion and
promoting the absorption of inflammatory effusion, is especially&useful in chronic
forms of inflammation accompanied by thickening of parts, as  in the joints and
testis.
  Having now discussed the treatment of ordinary sthenic inflammation  in its 
TREATMENT OF LOW  INFLAMMATION.             55
acute and chronic forms, we must next say a few words on the management of
the asthenic and irritative varieties of the disease.  These forms of inflammation
derive their peculiarities more from the character of the constitutional disturb-
ance that accompanies  them than  from any peculiarity  in  the local affection.
Hence it is not in the topical treatment of the disease, but in  the management
of the constitutional condition, that the principal difference  exists between this
and the other varieties of inflammation.
  In considering this part of our subject, it is of especial importance to banish
the term " antiphlogistic ;" for the sa'me treatment that would be anti-inflamma-
tory in one form of the  disease would certainly favor its progress in another.
Here we must be entirely guided in the means that we  adopt by the character
of the symptoms.   If these  from the first partake of the asthenic or irritative
type, we cannot at any period have  recourse to the treatment that  has been
recommended in sthenic inflammation.  If  the  disease  commenced in an active
form, the fever progressively assuming a lower and lower character merging into
the asthenic and irritative conditions, so must we gradually alter the nature of
our  general treatment, which  is always a  delicate  procedure requiring much
caution.   Though the inflammatory fever may at  first assume the sthenic form,
if there is reason to believe, from the broken constitution of the patient, or from
the congestive or passive character of the local  inflammation, that the constitu-
tional symptoms will not long continue of this type, we must be extremely cau-
tious how we lower the patient by active depletion; for however high the fever
may at first run, and in these cases  there is often febrile disturbance of a very
active character for the first few days, the disease  speedily expends its force and
rapidly subsides into a low form.  In such  cases as these, which are of very
common occurrence in London practice, more particularly in hospitals, we should
never bleed, but  content ourselves with  clearing out  the bowels, keeping the
patient quiet on a moderate or low diet, and administering  diaphoretic salines.
As the symptoms gradually merge into the typhoid type, the  pulse with increas-
ing frequency diminishing in power,  the tongue becoming dry and dark, and the
other symptoms of asthenia  beginning to show themselves, we must begin to
give some stimulant in combination with the salines.   The carbonate of ammonia
in five to ten grain doses may be given in an effervescent form, with fifteen grains
of the bicarbonate of potass  and a sufficient quantity of citric  acid, every third
or fourth hour.   The  nourishment must  be increased; and  small quantities of
wine or alcoholic stimulants may be conjoined with it in proportion as the symp-
toms of  debility become more  and more urgent.  In effecting  this  change we
must be careful not to  run  into the error of over-stimulating our patient; this
may be avoided by observing the influence exercised on the pulse and tongue by
the change in treatment.
   In many cases, it happens that the symptoms so rapidly sink into, or, from
the very first, assume so asthenic a character, that the only treatment that holds
out a chance of saving  the  patient's life consists in the early and free admini-
stration of stimulants and mild nourishment, such as ammonia, wine,  or brandy,
with beef-tea and arrow-root, and of these, large quantities may be required in
the four-and-twenty hours; the patient evincing  a  tendency to sink  whenever
their use is interrupted.   The  brandy and egg mixture of the pharmacopoeia, if
well made, combining as it does nutriment and stimulus, is the best remedy that
can be administered in many cases.
  As the asthenic passes into the irritative form, we may find  it necessary to con-
join opiates in repeated doses with the general treatment.   In giving these prepa-
rations, our object should be to procure sleep, and tranquillize  the system, but not
to narcotize the patient.
  In these low forms of inflammatory fever, congestive pneumonia, and asthenic
bronchitis frequently supervene.  In this  complication,  the following draught 
56
INCREASED VASCULAR  ACTION.
may be advantageously civen every third or fourth hour:—R. Tinct.  Camph.
comp. (Tinct. Opii. Camph. U.S.),  r%  20, Ammoniae Carbonatis gr. v.,  Decocti
Senegas, |iss., with rubefacients, blisters, or dry cupping to the chest.   The diar-
rhoea that not unfrequently occurs, must  be  met with aromatic confection, kino
or catechu in chalk mixture;  and if the urine cannot be  passed, it must  be
drawn off by the catheter.

                  SECONDARY FORMS OF  INFLAMMATION.

   Inflammation, if it do not terminate by resolution, passes from the forms that
have just been  described,  into others  of a secondary character.  These are:—
First, the Effusive; secondly, the Adhesive;  thirdly, the Suppurative; fourthly,
the Ulcerative;  and, fifthly, the Gangrenous inflammations.
   Effusive Inflammation.—Effusions are by no means invariably the consequence
of inflammation, and we not unfrequently find effusions of serum and of  blood
occurring independently of this.    In  a natural and healthy state, effusion  or
transudation  of a watery fluid is constantly going on in  all  parts  of the  body
through the walls of the capillaries,  this plasma  serving an important purpose in
the nutritive actions of the tissues which it  bathes.  It is only when  this is in-
creased in quantity and altered in composition, that it becomes a diseased product,
constituting oedema when  occurring  in the  cellular tissue,  and dropsy  when
accumulating in serous or synovial  cavities.  The fluid that is  thus  exuded  in
such quantity as to accumulate, is neither liquor sanguinis nor  serum, not con-
taining  the  fibrine of the  one, or  the proportion  of albumen and  salts' of the
other.   Its transudation  is generally dependent upon  some venous congestion.
Thus, if the  veins of the leg  are compressed, oedema of  the  foot will occur;  if
those of the liver suffer pressure, dropsy will result; or if the renal veins are ob-
structed, albuminuria will ensue.
   If the pressure on the vessels be  still greater, the capillaries  may become  so
distended that they rupture, giving  rise to effusion of blood, as in some forms of
epistaxis and hasmaturia.
   Now, in inflammation, an increased  degree of pressure  exists in the inflamed
parts, the vessels being  over-distended as well as dilated, and blood continuing
to be pumped with augmented activity against those that are already  turgid;
hence there is a mechanical tendency to the occurrence of some effusions, and a
disposition for the inflammation to relieve itself by the distended vessels pouring
out some  of  their contents.  But though effusions in  inflammation  are partly
mechanical, they are not by any means wholly so; for, in many cases, organizable
matter and organisms appear, which did not previously exist, and which are pro-
duced by the local actions of the part.
   The proper effusions of inflammation are—First, blood; secondly, liquor san-
guinis;  thirdly,  serum;  and,  fourthly, secretions of tissues  or  organs.  These
effusions are in a great measure mechanical, depending on the dynamic  state  of
the vessels;  though, doubtless, in many instances, modified by other causes of a
vital character.   Fibrine, or lymph,  though usually spoken of as an inflammatory
effusion,  differs so remarkably in its vital characters  from the  rest  and  is  so
evidently a new formation  in the inflamed part, that  I shall consider it  sepa-
rately.
   The frequency with which one or other form of effusion  occurs  in different tis-
sues, or organs, varies very greatly; as Paget observes, " each tissue has its proper
mode and products of inflammation;" hence particular kinds of effusion are very
rare  in some although of common occurrence in other parts.
   1. Effusion of Blood often occurs in small quantity, tinging  the other pro-
ducts of inflammation.   When this  is  the case, the coloring  matter is  broken
down and dissolved, which  is always indicative of a low state of the constitutional 
ADHESIVE INFLAMMATION.                   57
powers.   In other cases, the hemorrhage may be abundant, the character of the
blood being but little changed.  This effusion is dependent upon over-distension
of the vessels, with softening of the tissues, giving rise to rupture of the  capilla-
ries, without which it cannot occur, there being no such thing as transudation of
blood in inflammation.   Hemorrhage of this kind most frequently occurs from
mucous surfaces, which readily bleed when inflamed.   It may also happen from
the rupture of new vessels in freshly deposited lymph.
   2.  Effusion of Liquor Sanguinis.—In this case, the fluid parts of the blood
transude, leaving the red corpuscles behind.  It is occasionally met with in so-
called serous effusions into the tunica vaginalis, for instance; so also the serum
contained in the bleb of a blister is really liquor sanguinis; and Paget has found
that in this there is  more fibrine  when  there is most strength of constitution.
This  fluid is  not uncommonly met with in the  subcutaneous and submucous
cellular tissues;  about the glottis, and in the scrotum, for instance, giving rise
to a gelatinous  and seniitransparent swelling of the part.  In these cases, the
more fluid portions are  sometimes absorbed, leaving the  fibrine behind,  which
then  constitutes the condition termed solid oedema.  The fibrine in this effusion
often does not coagulate so long as it is retained in the body, but when once it is
removed solidification ensues.
   3.  Serous or  albuminous effusions are very  common in inflammations of  a
slight or subacute form, of serous and cellular tissues, giving rise to dropsies and
oedema.   They  most frequently contain a small admixture of fibrine, approach-
ing somewhat to the characters of the last-mentioned effusion.  The quantity of
the fibrine contained in them  is usually a measure of  the degree of  the  inflam-
mation.   These serous accumulations form and are absorbed with great rapidity,
and their absorption is usually most rapid when  the fibrination is least.
   4.  Secretions of tissues and organs undergo changes in quantity and quality,
under the influence of inflammation.  The quantity is at first increased;  during
the active stage of the inflammation, where  there is much tension, it becomes
diminished, the part being almost  dry;  but as the inflammatory action subsides,
and relaxation of the vessels ensues, it becomes again increased.
   The alteration in quality  in secretions from glands,  is  chiefly due to  the ad-
mixture of morbid secretions from the  mucous  membrane.   When  a serous
membrane is inflamed,  the  secretion  not only accumulates in greatly increased
quantity, as we  see in acute hydrocele, but it becomes turbid by the admixture
of flakes of lymph, which are sometimes so  abundant as  to give it  a  puriform
appearance.  In other  cases true pus is formed from  the surface, as we see in
inflammation of the anterior chamber of the eye, terminating in hypopium.
   In inflammations of the cellular tissue, the quantity of fluid is either  simply
increased, or it becomes fibrinous, occasioning solid oedema and  induration.
   In inflammatory affections  of  the mucous membranes, the most important
modifications of secretion occur.   The first effect is to  cause the transudation of
a serous fluid from the  mucous membrane, the  secretion becoming clear, watery,
and abundant.   As the  inflammation increases, exudation-corpuscles, and  large
quantities of epithelial scales are thrown off,  and mixing with the  mucus, make
it viscid and tenacious, ropy as it  is  termed.   In the more advanced stages, we
find pus, and exudation-corpuscles, with epithelial scales, constituting the  various
form of muco-pus, and of true purulent secretion.

                        ADHESIVE INFLAMMATION.
  The adhesive  is that form of inflammation which terminates in the effusion
of fibrine, lymph, or plastic  matter, it may hence be termed  fibrinous or plastic
inflammation.
  The study of the products of this form of inflammation is of great importance,
not only because  they form  the basis of adhesive action, but that they  are the 
58
INCREASED VASCULAR  ACTION.
media from, by, and  in which all the  reparative effects of inflammation take
place, and the reconstruction of destroyed tissue is effected.  Lymph, the mate-
rial of repair employed  by nature, has an independent and  inherent vitality by
which it is organized, irrespectively of the forces of the parts around it.   It  is
capable of development into various tissues, and of degeneration  into structures
lower in the scale of organization.  Many of the ulterior products of inflamma-
tion being but instances of the development or degeneration of lymph.
  Although lymph is usually observed by the surgeon  in a  semi-solidified form,
hence often termed " coagulable lymph,"  it must necessarily be  separated from
the vessels in a fluid state.   This separation is not a mechanical act, but a vital
phenomenon, analogous  perhaps to the process of nutrition, by which  a  living
organized fluid, possessing  within itself the power of self-development, and of
organization into tissues, is  separated or eliminated from the blood.  It is this
fibrine, lymph, or  plastic matter that plays so important a part as a  reparative
agent in surgery; that is seen as a covering to the surface of recent wounds, glaz-
ing them in a few  hours, and  causing speedy union to take place between their
opposed sides through its intervention.
   Characters  of Lymph.—The plastic (Williams) or fibrinous (Paget), and the
aplastic (Williams), croupous (Rokitansky)  or corpuscular (Paget), are the two
varieties under which it is presented to the surgeon.
   The fibrinous or plastic, \s  the true healthy coagulable lymph.  When first
poured  out  it is liquid, but it speedily coagulates into a  whitish, grayish  or
yellowish-white elastic semi-transparent substance, somewhat resembling the buff
of coagulum.  Chemically  considered, it is not composed  of pure fibrine, but
contains an admixture of oily  and saline matters, which  are necessary for its de-
velopment.   This  form  of lymph is only met  with in perfectly  healthy and
vigorous individuals,  usually  as  the result of  inflammation consecutive  upon
cleanly cut wounds.   Under the microscope it appears filamentous  in structure,
being made up of delicate interlaced fibrillar.
   The  corpuscular, aplastic,  or  croupous lymph differs remarkably from the
variety that has just  been  described.   In this, coagulation does  not take place,
but corpuscles float free  in a thin, clear, serous liquid.   This variety of lymph is
met with in, and is indicative of, a cachectic state of the system.   The corpuscles
which characterize it, commonly go by the name of exudation-cells ; they resem-
ble in general  characters the white corpuscles of the blood, or those met with in
the fluid contained in the  lymphatic vessels.   Gulliver states,  however, that
exudation-cells are larger and  more irregular in size and shape than  these, and
usually exhibit from  two to three nuclei when treated with acetic acid.   They
form in about  four-and-twenty  hours after inflammation has been set up;  and may
either develope, passing upwards  through fibro-cells, caudate-cells, &c,  into fila-
ments; or,degenerate into pus-corpuscles, granule-cells, granular matter, and debris.
  These two primary forms of lymph, the fibrinous  and  the corpuscular, are
almost always found together, but existing in various proportions  in the same
exudation mass; the  relative  quantity of the  one  or  other element determin-
ing whether it shall undergo development or degeneration.   Paget observes that
" the greater the proportion of fibrine in any inflammatory exudation, the oreater
is the likelihood of its organization."   This preponderance  of fibrine beino-  in-
dicative  of adhesive  inflammation.  And  "the greater the proportion of cor-
puscles, the  greater the probability of suppuration or of degenerative process."
The preponderance of corpuscles indicating suppurative inflammation.
  Why does lymph at different times  assume different forms, fibrine prepondera-
ting in  some,  corpuscles  in other cases ?   Or, in other  words, why have we a
tendency to  adhesive inflammation  in  some,  to suppurative inflammation  in
others ?  This question, which has been closely investigated by Hunter, Bichat
Rokitansky, and Williams,  has been very clearly replied to by Paget as referable 
DEVELOPMENT OF LYMPH.
59
to three causes.   1.  The state of the blood;  2. The seat of the inflammation;
3. The degree and character of the inflammation.
   1.  State of the Blood.—Paget applied blisters to thirty different patients in
St. Bartholomew's Hospital,  and collected  the sero-fibrinous fluid that accumu-
lated  in the blebs.  In  those who were suffering from purely local diseases, the
constitution  being otherwise healthy, the  fibrine  was firm,  filamentous,  and
elastic;  in  cachectic or phthisical  patients  it was  almost  wholly corpuscular,
with every intermediate variety, according to the condition of the system; which
could be determined by this mode of examination.   As a general rule in  young
persons, and in those of sound constitution, the fibrine is plastic; hence in sur-
gical  practice, it is in these individuals that we may chiefly look for the union of
wounds by adhesive  inflammation.
   2.  The seat of inflammation modifies its product very considerably, as Bichat
and Hunter long ago pointed out.  Serous membranes are prone to fibrinous—
the mucous  to  suppurative inflammation;  and in  cellular tissue, both fibrine
and corpuscles are found.  This general rule, however, is subservient to the state
of the constitution, and to the influence of certain specific diseases.
   3.  The degree  and character of the inflammation modify  considerably the
product.  In slight inflammations it is almost always  corpuscular; in the more
acute  and active, of a fibrinous character.  Certain forms of  inflammation are
always attended by specific products.  In pyaemia, for instance, all  the products
have  a suppurative tendency, even  when  serous membranes are inflamed.   In
croup, on the other hand, there is a disposition to plastic effusion even on mucous
surfaces.
   After-changes in lymph.—Lymph that has been poured out is susceptible of
three important changes, viz., absorption, development,  and degeneration.
   When  lymph  undergoes  absorption, it probably  breaks up  and dissolves in
the fluids of the part,  being carried  off by the vessels; these changes we not
unfrequently see taking place in an inflamed eye.
   Development of lymph.—In a healthy constitution and with a healthy local
condition,  lymph evinces  an upward tendency  in  the scale  of development,
becoming vascular,  and being  converted  into a fibro-cellular  material.   This
development may be arrested by the three following conditions: viz., the state
of the patient's health; the continuance of the inflammation;  and a congestive
state  of the part itself.
   If  the health be impaired or broken, all development ceases.  This  process
being essentially dependent upon constitutional force  and vigor.   Hence the
necessity of maintaining the patient's powers  if we look for healthy and complete
reparative action in a part.
   The continuance of inflammation beyond a certain  point in intensity, prevents
the development and proper organization  of lymph.  Thus, in  an ulcer which
becomes inflamed, all reparative action  is at once arrested, and the lymph already
deposited may retrograde or become absorbed.   This  property in local inflamma-
tion of imprinting a retrograde course upon  lymph that  has already been depo-
sited,  is taken advantage of by the surgeon, who dissolves away a hard  and
chronic thickening of a part by exciting inflammation  in the  centre of it with
potassa fusa.
   Local congestion of a part effectually prevents the deposit of lymph.  Thus,
no reparative action takes place in an ulcer seated on a congested limb.
   In  undergoing development lymph always  passes  into the fibro-cellular state,
beyond which it very frequently does  not proceed.   This fibro-cellular tissue so
formed, is the common connecting medium of wounds, and  the tissue of which
cicatrices are composed;  we see  it on  the face of a stump binding together all
the tissues, muscles, nerves, and vessels in one common bond.   It is of this fibro- 
60
INCREASED VASCULAR  ACTION.
cellular substance  that  adhesions, bands,  false membranes, thickenings, and
opacities are commonly formed.
   Plastic matter may also be developed into bone, passing through a fibrous, or
fibro-cellular transformation; and, lastly, we see it developed into epithelial scales,
such as are commonly found in cutaneous cicatrices.
   Vascularization of lymph.—In lymph that undergoes development, bloodves-
sels are seen to make their appearance at an early period.  AVith regard to the pre-
cise time of their  formation, Dupuytren and  Villerme state, from t_eir_ experi-
ments  on dogs, that twenty-one days are required;  and Travers, from his expe-
riments on the frog's web, fixed the same period as that in which red blood begins
to pass.  In the human subject, however, the lymph on the surface of an ulcer
or wound certainly appears to become vascular long before this.
   How are  the new  vessels formed ?—by  development in the lymph ?  or by
extension from  surrounding  parts?   Hunter and  Rokitansky  incline to the
former  opinion.  Travers and Queckett, who have recently  investigated the
matter fully, believe that the vessels are always projected into the lymph from
neighboring parts; and  Paget agrees with  these observers.  Travers states dis-
tinctly, as the result  of  his observations, which are borne out by the  results of
the experiments of the late Dr. Tod, of Brighton, that "there is no such thing as
independent vascularization, the whole business of organization  is of and from
the margin of the wound."
   According to  Travers, the following are the periods of development of vessels
in a frog's web which had been wounded :—
   Up to the fourteenth  day, there is stasis in the vessels adjoining the wound.
From the fourteenth  to the twenty-first day, channels are opened in  the plastic
matter, at first colorless, then admitting single blood-corpuscles; from the twenty-
first to the twenty-eighth day, the circulation is more active, the vessels enlarging
and anastomosing; in the fifth week, transparent capillaries pass across from the
colored arteries to  veins; and  in  the  sixth week there is the formation of new
vessels in loops,  half-circles,  &c.
   The steps by which this interesting process is accomplished, are the following.
At first, small lateral  dilatations or pouches  appear at some  points  on  the walls
of the nearest old  vessels; these grow out into the  plastic  mass, bend towards
each other, coalesce, and form a loop or fork.  These loops give rise to secondary
vascular outgrowths;  and thus the vascularization of the lymph is completed.
   Travers states that these  vessels are visible,  like fine striae, before the circula-
tion  can be detected in them.   A single  globule of blood first enters, this is
followed by others, which for some time have a see-saw or oscillatory motion,
which  progresses gradually towards the nearest vessel, and the blood entering this
completes the circulation, which becomes continuous and equable.
   The degeneration of lymph has been especially studied by Paget.  He observes
that it may wither and  harden,_ forming dry, horny  masses or vegetations; that
it  may undergo  fatty  degeneration, and become converted into granular matter.
These two last forms of degeneration are frequently met  with in the coats of
diseased arteries.  Besides these changes, it may calcify, beino- converted into
an inorganic earthy material; it may undergo pigmentary changes; and, lastly,
it  is very frequently converted into pus.

                      SUPPURATIVE INFLAMMATION.

   The suppurative is that  form of inflammation which gives rise to  the pro-
duction of pus. _  And pus never occurs  except as the result of this form of in-
flammatory action.
   Pus presents  considerable variety in its  general  character, according  to  the 
CHARACTER OF PUS.
61
nature of the constitution of the patient, or the condition of the part in which it is
formed.
  When formed in a person of healthy constitution, as the result of sthenic in-
flammation, it is  an opaque, creamy fluid, thick, smooth, and  slightly  glutinous
to the touch;  of a yellowish-white color, with a greenish tinge, having a faint
odor, and an alkaline  reaction.   Chemically, it is composed of water containing
albumen, fibrine, saline, and fatty matters in solution and admixture, and usually
gives off a small quantity of ammonia.   Pus presenting these characters is termed
healthy or laudable.
  When admixed and tinged with blood, it  is said  to be sanious.  When thin,
watery, and acrid, ichorous.   When containing cheesy-looking flakes, it is termed
curdy ;  and when diluted with mucus or serum, it is frequently called muco-pus,
or sero-pus.  Besides  these, pus presents many other varieties.   Thus, for in-
stance,  when formed from bone, or in the neighborhood of the alimentary canal,
it has a peculiar fetid odor.   Its chemical composition may  likewise vary under
different circumstances;  thus,  ordinary pus formed in  the soft parts, contains
merely a trace of phosphate of lime, whereas that which is formed in connexion
with diseased bone has been found by B. Cooper to contain  2 J per  cent, of this
salt.   Sometimes animalcules are found in pus; vibriones are met with in some
kinds of pus from the genital  organs.   Pus presents other peculiarities,  which
are only cognizable by their effects on the system: thus, the pus from specific
sores possesses contagious  properties, though in chemical, microscopical, and
physical constitution, it does not differ from other forms  of that fluid.
 Vis. 5. Healthy pus-cells. Figs. 6, 7, 8. Various forms of pus-cell from phlebitis and pyaemia.  Fig. 9.
Pus from a scrofulous abscess.
   On examining pus under the microscope, it is found  to  consist of corpuscles
floating in a homogeneous  fluid, the "liquor puris."  These corpuscles  have
been particularly studied by Gueterbrock, Mandt, Gulliver, and Addison.  They
appear to  be modifications of the exudation-cell; being composed of a semi-trans-
parent cell wall, containing two or three nuclei, which are rendered very apparent
by acetic  acid.   Besides these, a large quantity of granular matter, of particles 
62
INCREASED VASCULAR ACTION.
of fibrine,  of disintegrated  exudation-cells, are usually found  admixed with  it.
The greater the quantity of corpuscles, the richer and more creamy is the pus.
   In many cases, the microscopical characters of pus differ, however, from those
that have just been  given.   Thus, in the thin, greasy,  yellowish-looking pus,
somewhat resembling melted butter, that  we find in the  joints in pyaemia, the
pus-corpuscles are irregular  in  outline,  and not so  distinctly nucleated; and  in
some forms of chronic abscess,  when the pus is thin and curdy, the  pus-corpus-
cles present a somewhat similar appearance.
   Pyogenesis, or the formation of pus, is an interesting study.  The older sur-
geons believed that this fluid was formed  by the breaking up  or  disintegration
of the solid tissues, or that it was the result of their liquefaction or saponification
by the acid products of inflammation.  Quesnay and Haller observed the fallacy
of these opinions, and modern pathologists look upon pus as a direct product of
inflammation.
   Pus-cells have been shown by recent observers to be modified or degenerated
exudation-corpuscles, and the  fluid in which  they float to be  of a  serous cha-
racter.   In many cases the transition from lymph  to pus-cells can be seen  to
take place; thus Paget has observed that the  fluid contents  of the vesicle  of
herpes,  which  are corpuscular exudation-matters, become purulent in twenty-
four  hours.  So again, every  surgeon  must have repeatedly  observed that  in
cutting into some forms of abscess in their early stages, a sero-plastic fluid escapes,
which, in the course of a day or two, becomes  purulent.   So  likewise in ampu-
tating in the  vicinity of an inflamed part, the tissues appear to be infiltrated with
gelatinous exudation-matter, which, in the course of a few hours becomes con-
verted into pus.
   Pus may be formed on the free surface, or in the substance of parts.  The
first constitutes a purulent secretion; the second, an  abscess.
   When formed on a free surface, whether this be serous or  mucous, the pus-
cells appear to  be modified  exudation-corpuscles floating in the watery effusions
of the inflamed part.
   When pus forms in the substance of a tissue, or organ, constituting an abscess
there is in  the first place a high degree of inflammatory action.   Sero-plastic ex-
udation is thrown out, infiltrating the tissues, and in the  centre of this, where
the inflammation attains its  greatest intensity, the exudation-cells become  trans-
formed into pus-corpuscles.  A drop of pus is  thus  formed in  the inside of the
exudation-matter already effused, or at the moment of its  evolution, as the result
of changes  imprinted on it by contact with  the inflamed parts.   Around the pus
thus formed, the lymph deposited in the substance of the  tissues, and filling  up
their interstices, forms a consolidated mass, which plays an important part  in
limiting the further extension of the suppuration.   As the suppurative action
advances, the corpuscles composing the innermost layers of this plastic  mass
gradually transform into pus-cells; the blastema degenerating into liquor puris.
The purulent accumulation  thus formed, constituting an  abscess, is always  re-
tained in healthy states of the system, by an external boundary of consolidated
lymph, which extends itself on its outside by fresh deposits and by the liquefac-
tion  and metamorphosis of its  interior, as  the  central accumulation  of pus  in-
creases.
  This boundary of lymph  has been termed the Pyogenic membrane, and was
supposed by Delpech to be the secreting organ of pus.  This, however,  it is not •
and that it  is not necessary for the secretion of pus, is shown by the facts that it
is not found in the early stages  of suppuration; that on free surfaces suppuration
occurs without it, and that it is absent in certain kinds of  abscesses the diffused
and the metastatic.   A better term for it would be the "limiting fibrine " as  it
limits or bounds the spread  of suppurative  action.  Its absence  is usually indica- 
SYMPTOMS OF  SUPPURATION.
63
tive of a want of power in the system; the suppuration then becoming diffused,
extending itself indefinitely through the  cellular tissue.
  The diagnosis of pus is usually easy, but some fluids resemble pus so closely
to the naked eye, that the microscope becomes necessary to establish their true
characters.   From healthy mucus there is no difficulty in distinguishing pus, but
when mucus has been thickened and rendered opaque by inflammation and is
mixed with exudation-cells, it is impossible, and can never be necessary, to  dis-
tinguish it from pus.
   Turbid  serum, containing broken-down and granular-fibrine, frequently met
with in serous sacs, closely resembles pus; here the diagnosis may be effected by
the absence of cells.
   Softened fibrine, as in clots and in inflamed vessels, often closely resembles
pus to the  naked eye, but the microscope reveals  the true nature of the fluid  by
the absence of exudation-cells.
   Atheroma may be  distinguished from pus by the presence of cholesterine,
granules and fat, and by the! non-existence of the characteristic pus-corpuscle.
In tubercle and  cancer the  absence of the true pus-cell, and the presence of ap-
pearances characteristic of these morbid  products establish the diagnosis.
   When admixed with the blood the detection of pus is often very difficult, and
indeed, cannot  in many cases, be satisfactorily accomplished; the white corpus-
cles have sometimes  been mistaken for  its  cells, to which they have a great re-
semblance.
   AVhen diffused in milk, as in some forms of lacteal abscess, the corpuscles of this
fluid will be seen to be smaller and clearer,  with a more defined  outline than
those of pus.
   Suppuration varies greatly as to duration.  Inflammation very commonly ter-
minates in the formation of pus, in the course of about three days, at other times
a much longer  period than this  is required, the  inflammatory action being of a
passive and languid character.  When once suppuration has been set up it may
continue for an  indefinite time, pus becoming, as it were, the established secretion
of the part.   It is not uncommon to find purulent discharges from mucous mem-
branes continuing for years.
   The characters  of suppurative inflammation vary according as it is healthy,
unhealthy, or specific.
   The Symptoms of suppuration are local  and constitutional.   The local symp-
toms  differ  as  the suppuration occurs on a mucous surface, or in an internal
cavity, or  organ.
   When an inflamed mucous surface is about to suppurate, the membrane pre-
sents  the  ordinary characters of active inflammation, being swollen, red, and
often painful; to these a discharge is speedily superadded.
   When suppuration is about to take place in the substance of tissues  or organs,
the local symptoms of inflammation undergo certain modifications indicative of the
supervention of this  action.  The pain  becomes throbbing, the part swells and
becomes tense,  but after a  time  softens; and fluctuation or undulation  may be
detected in it.   The skin becomes glazed, red, shining, and ©edematous.   In other
cases, again, suppuration occurs  without any  evident local sign of inflammation,
the presence of the pus revealing itself by swelling and fluctuation only.  ^
   Constitutional Symptoms.  On the supervention of extensive suppuration, the
ordinary symptoms of inflammation subside,  and are usually interrupted by the
occurrences of chills, alternations of heat and cold; or if the formation of pus be
extensive,  by severe  and long-continued  rigors.   The fever often assumes  a
somewhat  intermittent character, and its intensity lessens, the pulse  becoming
soft, though continuing  quick.   If pus  be  formed in sufficient quantity for its
discharge to act as a severe drain on the constitution, another  set of  symptoms 
64
INCREASED VASCULAR ACTION.
 speedily sets in, dependent on the loss that  is going on.   The patient becomes
 weak, his nutrition is impaired and hectic is  established.
   Hectic does  not came on unless there is a discharge of pus from the system.
 No hectic occurs so long as an abscess, however large, continues unopened;  but
 it supervenes with great rapidity when once its contents are discharged.  I have
 known a large  abscess exist unopened for  two years, without any constitutional
 disturbance, but so soon as it was opened, well-marked  hectic set  in, which
 speedily carried off the patient.
   Hectic is essentially a fever of debility, conjoined with irritation.  Emaciation
 and general loss of power invariably accompany it.  The  pulse,  which is quick,
 small, and compressible, rises from ten to twenty beats above its normal standard;
 the tongue  becomes red at the edges and tip; the cheeks are often flushed, and
 the eyes glistening, with a dilated pupil; all  these symptoms have a tendency to
 exacerbations after meals and towards evening.   There is also increased action,
 either of the skin, bowels, or kidneys.  Thus profuse sweating, copious purging,
 and abundant red deposits  in the urine take place; these  discharges often alter-
 nate with one another, melting the patient away, and hence are termed colliqua-
 tive.   The  debility gradually increasing, the patient rapidly wastes, and at last
 dies from  sheer exhaustion,  the conjoined  result of fever, mal-nutrition, and
 wasting  discharges.
   In some cases of extensive suppuration, especially in children,  hectic does  not
 occur, but marasmus or atrophy takes  place instead, the  child wasting away
 without fever, and being carried off at last by exhaustion or some intercurrent
 disease.
   Inflammation tends to the suppurative form under the influence of conditions
 very similar to  those that give rise to the formation of corpuscular  rather than
 fibrinous lymph.   Indeed it must be  borne in mind that there are no very defi-
 nite limits between these two products of inflammation,—exudation corpuscles
 and pus-cells.  We see that, in a sore, the same action will generate cells that
 very closely resemble one another.    Some of these are exudation, becoming or-
 ganized ; others again are pus-corpuscles, and become eliminated.
   1st. The  state of the patient's health exercises a  very great influence on the
 probable tendency to suppuration.  The sounder  the  constitution the less the
 chance of inflammation running into the suppurative  form.   And indeed we may
 often, in surgical practice,  look upon  the suppurative  tendency of wounds as  a
measure  of the  state of the patient's  health.   Thus, in  scrofulous constitutions,
the inflammation  that is excited by a  trivial injury, as  the  sprain of a joint,  for
instance, is  very apt to run on to suppuration.   So again in certain cachectic
states of the system, slight  wounds suppurate, or fester, as it is termed.
   2d.  The specific  character of the  inflammation often  determines the  super-
vention of suppuration;  some diseases, such as gonorrhoea  and purulent ophthal-
mia, consisting  essentially in the secretion of pus by  a free  surface.
   3d. The  seat  of inflammation also exercises considerable  influence.   Thus
mucous membranes when  inflamed almost invariably suppurate, the  transition
from  their  normal secretion to pus being very readily effected.  Serous mem-
branes do so but rarely; the  puriform fluid secreted by them  when inflamed
being in  most cases nothing but turbid serum.
   4th. The  more intense the inflammation the greater the liability to the forma-
tion of pus;  hence pus usually forms in the centre  of inflamed parts.   When the
inflammation is  of an active sthenic character in a healthy constitution  it requires
considerable intensity to give rise to  suppuration.  It is only where the system
is  strongly predisposed by struma or cachexy that very slight inflammations ter-
minate in this way.   The degree  of inflammation  required  for the formation  of
pus varies greatly, but it is always greater than that  necessary for plastic exuda-
tion. 
TREATMENT OF  SUPPURATION.
65
   5th.  The local condition of the part influences the probability of suppuration.
Thus a subcutaneous wound, as in tenotomy, does not suppurate; but  if it be
opened, and its interior exposed to the air, then degeneration of exudation-cells,
which constitutes their conversion into pus, takes place.   For the same reason
all ulcers suppurate.   The lodgment of foreign  bodies, as of urine, a piece  of
bone, or a bullet, by exciting intense and continuous inflammation, almost inevi-
tably leads to suppuration, which is  indeed  the means adopted  by  nature for
their removal from the system.
   The treatment of this form of inflammation is divisible into local and constitu-
tional.
   The Local Treatment presents three indications.
   First, the removal of the cause; as by extracting a piece  of dead  bone from
the bottom of a sore.
   Secondly, lessening inflammatory action by appropriate antiphlogistic means,
and thus either removing the inflammation entirely, or confining it within those
limits that are compatible with the effusion of plastic matter.
   The  third  indication  consists in facilitating the escape of the pus,  if it be
lodged in tissues or deep cavities, and in moderating or arresting the amount of
its discharge, when it  is poured out from a free surface, by the use of astringents
of various kinds, or by the proper employment of pressure.
   Constitutional  Treatment.—With the view of preventing the occurrence of
suppuration, a general antiphlogistic  treatment must be employed in the earlier
stages of inflammation; but as the drain on  the  system may eventually be  con-
siderable, we must be careful not to push these measures with too much activity.
After the  discharge has taken place,  nourishing, tonic, and even stimulating
treatment will be required in proportion  to the amount of debility that is induced.
Amongst the most useful medicinal agents are mineral and vegetable tonics, the
mineral acids and cod-liver oil.   Attention to hygienic conditions, with change
of air and residence at the sea side, are also most valuable.   When hectic comes
on, the same  general  tonic plan  must  be adopted, whilst we have recourse to
means adapted to meet the special symptoms.  Thus, acids are required to check
the sweating, astringents to arrest the diarrhoea,  and as much mild nourishment
as the patient will  bear,  to support the strength.

                       ULCERATIVE INFLAMMATION.

   The Ulcerative,  is that form of inflammation  which terminates in the forma-
tion of an ulcer.  An ulcer may be defined to be a solution  of continuity, with
loss of substance; a cavity or hole slowly produced by some  action going on in
the part itself, or suddenly, by chemical  agents,  destroying the textures, and at-
tended by the secretion of pus.   It is that process by which nature separates
parts that have, from whatever cause, lost their vitality, and  is diametrically op-
posed to adhesive  inflammation, being attended by an absorbing, and not a de-
positive  action.  There are two distinct stages described as constituting the
process of ulceration, attended by the most opposite  phenomena; viz., 1st, the
period of destruction; 2dly, the period of reparation.   To the first only  can the
term  be  properly applied, the stage of repair being one of deposition.   The pro-
cess of ulceration must always be confined to the surface, and cannot occur within
the texture or substance of parts.  It is most common on  the cutaneous  and
mucous  surfaces, but likewise occurs on the lining  membrane of bloodvessels
and on serous membranes.
   In what does ulceration essentially consist ?  Is it simply an arrest of nutri-
tion;  a cessation of the deposition of  new materials, whilst the old ones are re-
moved, a passive state in which absorption is normal, and deposition imperfect?
Or, is it an  active condition  of the absorbents, deposition  being normal, but
absorption being carried on with  too great vigor ? or, lastly, is it a process of 
66
INCREASED  VASCULAR  ACTION.
disintegration, of elimination, of ejectment of spoiled and dead matters; a detach-
ment of the disorganized soft tissues, as we see occurring in sloughing ulcers, or
in the removal of carious bone, in its disintegration by pus ?   Probably all these
conditions enter into ulcerative action, but more especially the latter.   It might
be supposed that the  precise share that each  takes  could be determined  by a
reference to the agency by which ulceration is effected; whether by the absorbents
or by the veins;  but this  cannot be determined at present;  and that ulceration
occurs independently of either set of vessels is  evident, from the fact that  it is
met with in parts, as the cornea and in cartilage, where neither exist.   Doubtless,
in many cases ulceration consists essentially in the disintegration, softening, break-
ing down, or, as it has been termed, the "molecular death" of the tissues, and
the detachment of these spoiled matters, by a peculiar action  of the  subjacent
living structures.
   There are certainly two conditions in which ulceration may occur;—with, and
without inflammation.  Inflammation may give rise to ulceration in two ways: 1st.
By directly softening and disorganizing the structures;  and thus occasioning the
more rapid or acute forms of ulceration, that are accompanied with much sloughing
and signs of active  inflammation,  great pain,  heat, and  redness.    2dly.  By
chronically  modifying nutrition,  inducing  induration  and plastic infiltrations,
which, under the continuance of  the inflammatory  process, soften and break
down, becoming converted  into ill-organized  pus, mixed with the detritus of the
part.
   Tissues that have  been congested for a long time are  apt to inflame under the
influence  of some trivial exciting cause, and rapidly to run into ulceration.  This
usually commences in the centre of the part, where the nutrient action is lowest;
here a small  sore forms, which exudes thin  unhealthy pus, and rapidly extends.
So long as the sore is inflamed, it continues  to spread, and reparation cannot go
on in it.  It would appear as if a moderate degree of inflammation were too in-
tense for the vitality of chronically congested tissues, or those in which lowly or-
ganized fibrine has  been effused.   The more the vitality of a tissue is reduced,
the less appears to be the degree of inflammation that is required to produce dis-
integration and ulceration of it.   Indeed, if the vitality of a part be sufficiently
lowered, it may fall  into a state of ulceration without the occurrence of inflam-
mation, or with so slight a degree as scarcely to be appreciable; the ulcerative
action appearing to arise from disintegration dependent  upon the want of nutri-
tion.   Thus^for instance, in scrofula and in  other diseases,  as scurvy or syphilis,
where there is an imperfect nutritive force, a tendency to softening and breaking
down of structure, and consequent  ulceration occurs; and  these tendencies are
much increased by the occurrence of congestive or subacute inflammation in the
part.
  _ Ulceration is so intimately allied with sloughing and  gangrene, that it is very
difficult to separate the causes of the one from those of the  other'conditions
   The predisposing causes of ulceration are chiefly found in those conditions
that interfere in any way with the nutrition of a part.  A feeble circulation such
as often exists in the lower limbs, the alae of the nose,  and in newly formed  or
recently cicatrized parts, tends to  the formation of ulcers.  As a«4 advances
nutrition  becoming impaired, and the circulation less active, slight causes suffice
to disintegrate the structure of a part, and mal-nutrition, or loss of innervation
from any cause, by lessening the vitality and resisting power of tissues  have  a
tendency to give rise to ulceration.  Hence  we  commonly see ulcers of the legs
in elderly people, more particularly amongst the poorer  classes, arise from slight
irritation or pressure.                                                     &

  a In the dogs that Magendie starved by feeding them on su»-ar nm n, «;i „„a a- .-n j
don of the cornea occurred. This must have been the result J^^£^^t^«°°£ 
ULCERATION—CAUSES  OF.
67
   Ulceration may be  directly excited  by the greater intensity of inflammation
at once  destroying  or  disintegrating a part.   By a severe mechanical  injury,
long-continued pressure,  or the application  of a chemical irritant,  producing
direct breach of surface.   And,  lastly, by the influence of certain  specific  dis-
eases, which are accompanied  by want of nutrition, as scurvy and  some scrofu-
lous affections,  the  peculiar character of which consists in the ready production
of ulcerative action.
   Ulceration may  commence  in several  distinct ways on  the cutaneous  and
mucous surface.
   1st. There may be such a degree of acute  local inflammation as rapidly gives
rise to " molecular death"  of  the part.  If the action be not a very acute one,
and the destruction  of  the tissues not very rapid or extensive, the  disorganized .
matters become mixed with pus, and  are discharged  in the form of a dirty,
brownish,  puriform fluid.  If the  action be  more violent than  this, complete
disintegration does not take place in the affected part, but shreds of the spoiled
tissues continue attached for some time to the ulcerated surface, giving it a very
ragged appearance.   If the inflammation be of a more intense character, layers
of disorganized tissue,  constituting  " sloughs," are formed, and remain  in con-
tact with the  ulcerated surface, often  covering it in completely, and invading
with considerable rapidity the neighboring healthy  structures.   Thus some of
the forms of phagedenic or sloughing ulcer are constituted.
   2d. Chronic inflammation  may give rise to ulceration, by so interfering with
the nutritive actions, that the  balance  of absorption and deposition is disturbed
in favor  of the former.   The  ulcerative effects of  chronic inflammation are
especially marked in parts that have been chronically congested;  the  congestion
having given rise to such softening  and loosening of tissue as facilitates  materi-
ally ulcerative  action.
   3d.  Ulceration sometimes commences in the crypts or follicles which open on
the mucous surface, some modification of structure taking place in  their epithelial
linings, which  leads to the formation .of  circular depressed ulcers, as may often
be observed about the tonsils.
   4th.  A vesicle or pustule forming on the cutaneous surface, and shedding its
contents, very  commonly gives rise to an ulcer, as in Rupia and Pemphigus.
   5th.  Suppurative inflammation not unfrequently occurs  in the  subcutaneous
or submucous cellular tissues, and by undermining and consequently  destroying
the vascularity of the skin and mucous membrane, and  thus arresting its nutri-
tion, gives rise to ulcer.
   6th. In some  specific  cases, we find that  ulceration is  preceded by the for-
mation of a morbid  growth, tubercle, or tumor, in which inflammation and dis-
integration of tissue, and  consequent lesion of substance occurs.
   In whatever way ulceration commences, it presents three distinct stages.   1st.
The period  of  extension or of slough.   2d.  The period of arrest or of plastic
deposit;  and 3d, the period of granulation and of cicatrization.
   When the ulcer is spreading, there is always  a circle of inflammation around
it, as evinced  by redness, heat, and burning and throbbing pain; its edges are
jagged, eroded, or sharp-cut;  its surface, which is more or less of  a  circular or
oval shape, spreading pretty equally from one starting-point,  and  being covered
with a grayish  or yellowish, soft, adherent slough.  In ordinary cases this is thin
and shreddy, but in some forms of ulceration it is soft, pultaceous, and elevated
above the  surrounding parts.   There  is  either  no discharge at  all, or else a
bloody, ill-conditioned fluid, hardly deserving  the name of pus, drains from the
surface.
   In the second stage of ulceration, that of arrest, the symptoms of inflamma-
tion diminish, and a layer of plastic  matter is  deposited in the tissues forming
the base  and sides of the ulcer.  This not only serves to arrest or limit  the 
68
INCREASED  VASCULAR ACTION.
 further process of ulcerative action, but  becomes the  medium of  its ultimate
 repair.  The surface  begins  to  clear, the gray adherent slough separating in
 fragments and dissolving away in the discharge, which gradually loses its sanious
 tinge, assuming more the characters of healthy pus,  though still very scanty in
 quantity.   The surface continues flattened or depressed, the edges often elevated
 and hardened, and the  sensibility of the  part diminishes.   In this stationary
 condition an ulcer may remain for many months; and  it is that  in which we
 commonly find chronic sores.
   The third stage, that  of repair, is  characterised by the formation  of  granula-
 tions, which may be  looked upon as  the turning-point in  ulceration.  Until
 granulations are formed, ulceration is a wasting process, or at most  stationary;
 so soon as they are formed, it becomes reparative.   Instead of a  tendency to
 increase, to erosion, and to concavity, we now  have a disposition to  contraction,
 to deposition, and to  convexity of surface, which  assumes a bright-red hue, of
 a vermilion or scarlet tinge, appearing to  be studded with minute papillae;  the
 edges become rounded  and  smoothed down towards the surface, losing their
 sharp-cut  appearance, and the discharge assumes the characters of healthy pus.
   We now proceed to  study the changes that occur in an ulcer during the stage
 of repair,—that of granulation, and of cicatrization.
   1st. As to granulations, their mode of formation, structure, and use.
   So soon as inflammation and extension of ulceration are checked,  the surface
 of the ulcer, as  has already been stated, becomes covered by a  layer of plastic
 matter.  This plastic layer, separating the  ulcer from surrounding and adjacent
 tissues, forms a basis to  it, from  which the granulations, the organs of repair,
 spring up.  Before this  plastic basis can be deposited, it is necessary that the
 inflammation be reduced within  those limits that are compatible with plastic
 effusion.   So long as inflammatory action  exceeds this limit  around the edge or
 at the base of the ulcer,  no lymph is effused.   But so soon as this undue action
 is checked lymph is  thrown  out, which becomes vascular by vessels  shooting
 into it from below; and  assumes  a granular form from its deposition  in papillae,
 or granulations, which are consequently composed of exudative matter which  has
 become vascularized  in the way that has already been described.  In the great
 majority of cases, granulations  are only formed  on  surfaces exposed  to  the  air
 and secreting pus; but they may be formed without  exposure to the air or  the
 formation  of pus, as Hunter has shown to  occur in some cases of fracture, and
 Paget has recently observed in a case of simple fracture, in which the  ends of
 the bone were covered with a  distinct layer of florid  granulations.    That these
 granulations  are in reality composed of lymph  that has become vascular, is evi-
 dent from  the interesting fact observed  by Hunter,  and which every  surgeon
 must have  had occasion  to verify,  both  in wounds and compound  fractures;—
 that a portion of bluish-white  semi-transparent lymph effused on the surface' of
 the sore or denuded bone is seen to become  vascularized, and to  be converted into
 true granulations, in from twenty-four to forty-eight hours.
  The microscope  shows that granulations  are composed of cells heaped up with-
 out much, if any apparent order,  and connected by but little  intermediate sub-
stance.  When single,  they are colorless; when  in clusters, they become ruddy
It is interesting to observe how these cells undergo  different chants in different
 parts of the same ulcer.
  Those situated at the base nearest the attached surface of the granulation con-
stituting its deeper layers, undergo development into filaments a°nd fibro-cellular
tissue.  Those on the surface are either thrown off in a rudimentary  form or
 degenerate into pus-cells; whilst those  at the edges become converted into epi-
thelial scales.  Thus we seethe same action  giving rise to exudation-corpuscles, to
 pus, to epithelium, and to fibro-cellular tissue.
  The development of  vessels  in granulations—-a most wonderful and beautiful 
GRANULATIONS — CICATRIZATION.
69
process, by which thousands may form in a day on a healthy granulating surface
—is identical with their general development in lymph, which has already been
described.   A series of loops and arches being  formed as outgrowths from neigh-
boring vessels.
  The sensibility of granulations varies considerably, being often greatest in
those which spring from tissues that are naturally the least sensitive, as bone, for
instance.   No nerves  have been traced in  granulations, hence their apparent
sensibility would appear to depend upon that of the subjacent inflamed tissues.
  The characters of granulations afford important indications  to the surgeon as
to the condition of the surface from which they spring, and the state of the
patient's general health.  Granulations indicative of a healthy local  and consti-
tutional condition, are small, florid, pointed,  close set, and bathed with healthy
pus; the use of which appears to be to  cover and protect the tender surface with
a soft lubricant  coating, into which  the granulations may sprout without  being
dried by the air, or damaged in any other way.
  In a weak state of the  sore, or of  the constitution, the secretion of pus dimi-
nishes, and it loses  its healthy character; the granulations become large, pale,
and flabby, appearing to be ©edematous from infiltration of serum,  and assuming
a glassy or semi-transparent look, with  a purplish hue.  Occasionally hemorrhage
takes place into them, and they become broken down and sloughy.  If, whilst a
sore is healthily granulating,  morbid action is  set up in it, or in the economy—
as by  the  supervention of erysipelas,  or fever—the granulations  and pus-cells
degenerate at once; the granulations becoming rapidly absorbed, and the surface
of the sore assuming a  grayish, sloughy look, and the formation of pus being ar-
rested.
   2d. The Healing process, or Cicatrization,  is  that by which the ulcer fills up
and becomes  covered by  an integumental investment.   Two distinct processes,
though carried on simultaneously, are  necessary  for the accomplishment of this.
These consist in  the granulations  assuming a healthy character,  and covering
themselves with a new cuticle; and  in  the contraction of the surface of the sore.
   The first change that takes place  in  an ulcer that is about to undergo the heal-
ing process, is, that the granulations become florid, and are bathed with healthy
pus ; the edges  and surface of the sore  then assume the same level—the granula-
tions rising, and the edges subsiding.  So long as there is any inequality in this
respect, the process of cicatrization  cannot go  on.  The granulations nearest the
edges become smooth,  cease to pour out pus, and become glazed over with a thin,
whitish-blue pellicle;  which is the  first appearance  of new skin—composed of
granulation-cells developing into epithelium.   As cicatrization advances, the part
of  the sore immediately inside this bluish-white line will be seen to be occupied
by a red zone, which, in the course of four-and-twenty hours, becomes, in its turn,
new epithelium, and appears to be the link between  granulation and true cuticle.
   At the same time that these changes  are going on,  contraction of the sore takes
place.  This would appear to be entirely a mechanical process, and not a vital ac-
tion ;  and  is owing to the conversion of the exudation-cells of the granulations
into the filaments of cicatrizial tissues, which being more closely packed, and be-
coming drier, occupy less space (Paget).  This  contraction commences as soon
as the sore presents a tendency to cicatrize, and continues for a considerable time
after this is completed.
   Cicatrization advances with greatest rapidity around the edges of the sore; the
centre taking the longest time to heal,  in consequence of the activity of the pro-
cess appearing to diminish,  the farther the new skin extends from the old tissues.
Indeed if the ulcer be  large, there may not  be sufficient  for the cicatrization of
its  centre.   A sore of a circular shape  usually takes  a longer time to heal than
an  oval  elongated one; the reason  appearing to be that the new skin is only
formed at the edge, and  never in the centre of an ulcer; unless it happen that 
70
INCREASED  VASCULAR  ACTION.
islands of old skin are left there undestroyed, which serve as centres of cicatriza-
tion.   It would appear to be necessary for the healing process, that granulations
have some of the old textures to be modelled upon, the characters of which they
then, and  only then, appear to assume;  receiving an impulse from the  plastic
force of the  old tissues on which they are deposited,  that causes their develop-
ment into analogous structure.
   The changes  taking place in a cicatrix, do not cease  with its formation; two
processes continuing for a very considerable length of time afterwards ; viz.—the
gradual contraction and the development of the cicatrizial tissue.
   We have seen that granulations tend to contract during the healing of an ulcer,
and that the diminution in surface  thus produced facilitates greatly its cicatriza-
tion.   Hence a scar is never so large as the original sore.  This contraction con-
tinues, however, and does not attain its maximum until long after the completion
of cicatrization, often occasioning great puckering or deformity.  The degree of
contraction depends partly on the seat of the scar, but principally on  the agent
that produces the ulcer; if the scar be seated on a part where the skin is very
tense,  the  contraction will be  slight; if  the skin be  naturally loose, it will be
considerable.  The contraction that takes place in scars that result from  burns,
is greater than in those that occur from any other cause, often producing serious
deformity and great distress to the  patient.   These results do not supervene in
their fullest extent until after  a lapse of  some weeks or months from the  inflic-
tion of the injury.   This contraction would appear in some  cases to be  due, not
only to the consolidation of the texture of the scar, but  to  the development in
it of yellow elastic tissue.
   Two great changes are wrought by time in the texture of a cicatrix; its tissue
assimilating more and  more to the normal structure  of the part,  and its deep
attachments  becoming  more  movable.   When  first  a  scar  is formed, it is
thin,  reddish, or bluish and shining,  being composed of imperfectly developed
filamentous tissue, covered by  a thin  epithelial layer.  As  it becomes older,  it
assumes a  dead-white color, and becomes depressed, and gradually,  but slowly,
many years being required for the change, it "wears  out;" that  is to say,  its
structure more closely resembles that of the texture of the part on which it  is
seated.  It never, however, becomes developed into true skin, as neither hair nor
sebaceous or  sudoriferous glands form in it.
   Coincident with this change, the scar loosens its  deep attachments, so that  it
can be moved more freely upon subjacent parts.  It  is a long  time before the
scar attains the vitality of the older  structures, if ever it does  so completely; and
the larger it  is, the less its power will usually be.   Under the influence of scurvy
or syphilis, an old scar is apt to open up again; so also if a fresh ulcer is formed
on the old  cicatrix, it will take a  longer time to heal than the original one did.
   The diagnosis of ulcers is readily made when seated on the skin, where  no art
is required to recognise a sore.   On the mucous surfaces, however, it is not al-
ways easy to do  so;  enlarged follicles  and  crypts, or  aphthae, bein's: constantly
confounded with ulcers.   The  difficulty here  proceeds from the  circumstance
that muco-pus may be poured out from a simply inflamed surface, or from one
in which the abraded epithelium and open crypts are mistaken for ulcers.
   In the local treatment of ulcers, the following points should be particularly at-
tended  to:   1st. To subdue inflammation;  for  until this be done  no proper
reparative action can go on.   This is accomplished by the ordinary local anti-
phlogistic treatment.   2dly.  Position  and rest are essential, in order that con-
gestion or determination of blood  may not take place.   3dly. Proper local  appli-
cations adapted to the nature of the case, of  an  emollient, sedative  astringent
or stimulating character must be employed frequently, conjoined with pressure
upon or support to the weakened  vessels of the part. 
GANGRENOUS  INFLAMMATION.
71
  The constitutional treatment must be  carefully attended  to.  Unless this be
done, the best-regulated local plan  may be employed in vain.  Attention to the
digestive organs and improvement of the constitution, if it be strumous or syphi-
litic, will do more in these cases than any other means can accomplish.

                      GANGRENOUS INFLAMMATION.

  Gangrene may result either from the intensity or from the specific character
of an inflammation.
  The intensity of the inflammation may be so great as to kill the part directly,
however healthy its texture  or sound the  constitution of" the patient may be.
More commonly, however, it is not so much the actual as the relative intensity of
the inflammation that destroys the part; there being some debility,  local or consti-
tutional, by which its  resisting or preservative power is lessened.  It is this occur
rence of inflammation in  a part or system in which the vital force is defective,
that is especially apt to result in gangrene;  and it is remarkable to observe what
slight injuries will induce gangrenous inflammation under these  circumstances,
especially in the residents in towns and in those who are debilitated and irritable
in habit.  The  greater the general and local debility, the greater will be the lia-
bility to gangrene.    The  nature  of the  tissue  exercises, however, considerable
influence; thus with a moderate amount  of inflammation some tissues,  when in-
flamed, veiy readily run into gangrene, the cellular membrane especially being
apt to do so;  whilst others, as the proper tissue  of glands and organs, is seldom
so affected.
   The specific character of the inflammation influences greatly the disposition to
gangrene; some forms, as the carbuncular, invariably resulting  in the loss  of
vitality of the part.   In some states of the constitution, the blood appearing to be
diseased, there is a great  liability to gangrene.
   When a part has been violently inflamed in consequence of injury, or some
such cause, we  look upon gangrene as impending if we find that the redness be-
comes of a dusky or purplish hue;  that bullae filled with dark^fluid rise upon the
surface; that the swelling, at  first hard,  tense, and brawny, becomes of a pulpy
or  doughy character; that the pain is  of  a  dull, heavy, or burning kind; and
that the temperature of the part, at first greatly  increased, gradually sinks.  We
know that gangrene has  taken place when there is total loss of sensibility of the
part even to pricking or pinching;  that the motion of the part itself ceases;  that
its  color changes to a peculiar mottled, purplish-red, or grayish-black hue, unlike
anything else in the body; that the temperature falls to a level with that of sur-
rounding parts; or  if the surface affected be  extensive, may even feel colder,
owing to evaporation from it.   There is likewise an odor evolved  differing from
that of  ordinary decomposition, and  evidently depending  upon  gaseous exha-
lations from the part that has lost  its vitality.
   These  signs  constitute  moist or acute gangrene, occurring as  the  result  of
inflammation.   Death and putrefaction are simultaneous in this case, the putre-
faction being evidently the result of changes effected in the  tissue  by the inflam-
matory act, and not by  post-mortem chemical  decomposition, the part being
decomposed at  the same  time that it is killed.   The extent of  tissue affected
may vary from a mere spot to the  implication of the greater portion of a limb,
and the gangrene appears to be finally arrested  by the inflammation  expending
its force as it radiates from the centre, and  reaching a part where there is suffi-
cient vitality for adhesive inflammation to be set up.
  The constitutional symptoms, always of a low  type, vary  according to circum-
stances.   If the blood be healthy, and  the constitution be  sound, the gangrene
occurring as  the  consequence of severe injury, the symptoms will present the
ordinary character of inflammatory fever, though  even in these cases there is a 
72
INCREASED VASCULAR ACTION.
great tendency to  asthenia.  If the  constitution  be broken, or the blood in a
diseased  state, the constitutional  symptoms will  rapidly run into the irritative
form.
  The progress of gangrenous  inflammation would be indefinite were it  not
arrested by^the adhesive process which limits it, just  as it bounds the suppurative
inflammation.   So soon as the gangrene reaches a part,  the vitality of which
cannot be destroyed by the inflammatory action; and where inflammation conse-
quently takes on that form, which  it always does in  healthy tissues—the adhe-
sive ; or, if the inflammation, gradually lessening in severity as it extends from
its gangrenous  centre,  subsides to that degree which is compatible with  the for-
mation of lymph, the line of demarcation, as it is termed, is formed.   This line
is a kind of barrier or septum of plastic matter, poured out into t\ia interstices of
the healthy tissues at  the extreme  limits of the gangrene; the line,  indeed,
along which the dead and living parts touch.   It extends to the whole depth of
the gangrene, completely surrounding it on all its attached  sides.   The inflam-
mation does not cease abruptly in this line, but fades away in the healthy parts
beyond it.
  So soon as the gangrene is arrested, nature endeavors to throw off the spoiled
part.   This is effected  by a process of ulceration, extending along the line of de-
marcation, and loosening the slough  by the  absorption of that layer of living
tissue which lies next to it.  This line of ulceration is termed the line of separa-
tion, and extends itself along the extreme margin of the living tissues ; the dead
parts not being removed, except where partially disintegrated by the pus that is
thrown out.
  This process of  separation commences at the edge of the slough, which gra-
dually loosens, and slowly extends downwards to the  whole depth  of the gan-
grene ; if this affect the  entire thickness of a limb,  the ulceration will  find its
way completely across it.  If the slough be more superficial, the ulcerative  ac-
tion passes underneath it, detaching it gradually.   The  line of separation is
usually oblique, the  soft  parts being first divided,  and the hard tissues then
ulcerated through,  until the ligamentous, or osseous structures are reached, which
are slowly acted upon by it.  This action is most rapid in the soft parts, and in
young subjects.
  After the separation of the  gangrenous part, a more or less  ragged irregular
ulcerated surface is left, which, if  not too extensive, will undergo ordinary cica-
trization.   As ulceration extends across the limb, the  largest arteries  and veins
are cut through by it without  hemorrhage resulting, owing to a mass  of plastic
matter being poured out in their interior, and blocking them up from the line of
separation to the nearest large collateral branch above it.   The  period required
for  the detachment of gangrenous parts varies according to their extent.   Small
sloughs may be detached in a few days, whilst many weeks are  required for the
separation of a limb.
  In the treatment of gangrenous inflammation, antiphlogistic remedies  must be
very sparingly used,  the  patient's  condition being usually not of such a nature
as to bear lowering.  It is very easy to  knock down the inflammation by ener-
getic measures; but, at the same time, the reparative power of the system is de-
stroyed, and the patient may not be able to rally.   Inflammatory fever, however
high it may be in  the early stages, rapidly sinks after gangrene has set in, symp-
toms of an asthenic,  or an irritative  type, ensuing.  Hence it is only before the
occurrence, and during the spread of gangrene that  antiphlogistic remedies  can
be employed;  for when once gangrene  has ceased to  extend, however hi°_ the
action may have been that accompanied its progress, all the powers of the con-
stitution will be required to maintain the process of separation of the sloughs if
they be extensive and deep.
  Venesection is never required in any form of gangrenous inflammation. When 
                    GANGRENOUS  INFLAMMATION.                  73

blood requires to be  taken, local bloodletting should be had recourse to as a pre-
ventive means.  And, in this way, when conjoined with measures for the relief
of tension, and consequently of that strangulation of the tissues which is such a
fertile cause of gangrene, in some forms of inflammation, it becomes an extremely
important adjunct to the treatment.   In  these cases, free incisions into the in-
flamed and tense parts, by which the  vessels are relieved of the blood, and the
tissues of effused fluids will often prevent gangrene.  This is more  especially the
case when loose cellular tissue, as that of the penis or scrotum is inflamed, or in-
deed in any part in  which much tension is conjoined with the inflammation. In
some forms of inflammatory sloughing, nature relieves the part  by free hemor-
rhage, as from the dorsal artery, in  cases of acute gangrene of the penis, and  it
is not until this has taken place that the gangrenous  action becomes arrested.
In this way, also,  irritant effusions and infiltrations are discharged, and thus one
cause of sloughing removed.  Punctures are not sufficient  for this purpose, but
free incisions  from two to three inches long  should  be made, which by gaping
widely allow the escape of blood and other  fluids, and thus effectually relieve
tension.  Mild local antiphlogistic treatment of an ordinary character is likewise
required.   When the gangrene has been arrested, the fcetor of the sloughs must
be diminished by antiseptic applications, such as the solutions  of  the chlorides,
 charcoal, and yeast  poultices.   The separation of the  sloughs should be left  as
 much as possible  to nature, which is  always fully able  to accomplish this, if the
 patient's strength can be kept up.   Any attempt to hasten  this process only irri-
 tates the parts, and causes the gangrene to spread when it might otherwise have
 been arrested.  The vitality of the tissues  in the proximity of, and above the
 line of separation, is very low, and  may readily be destroyed by any fresh action
 set up in them, there being always a  danger of exciting inflammation to such a
 degree as to  exceed that which is  necessary for the adhesive, and  to cause it  to
 ran into the gangrenous form.   Hence no attempt should  be made to pull away
 sloughs not already separated, nor should  stimulants be  applied to the  living
 tissues.  It matters little as to what is done  to parts already dead, which, when
 loosened, may be cut away, but we must not meddle with those that are living.
 Hemorrhage   seldom occurs before the  separation of the sloughs,  but there is
 always danger of its happening during that process.   If it  occur, pressure or the
 actual cautery, will  be found the best  means to arrest it.  And if these fail, liga-
 ture of the artery higher up, or amputation, when practicable, might be required.
    The parts that are already gangrenous should be  enveloped in  lint soaked  in
 the chlorides of zinc, or lime, or in  creasote, or dusted  with charcoal  powder. No
 poultices should be applied if the sloughs are large, heat and moisture hastening
 their decomposition;  but if small, yeast,  carrot, or charcoal poultices  may be ad-
 vantageously applied.
    Parts that are  quite  dead, but that do not readily separate,  such  as tendons,
 ligaments,  and bones, may be  cut through with scissors, pliers,  or saws, and thus
 many weeks or months saved in their separation.   It may occasionally be ne-
 cessary in doing this to encroach on  the living  tissues; this should be done  as
 carefully as possible for reasons already stated.   They  do not bleed much, owing
 to their infiltration  with lymph.
    The line of separation  should be dressed with water-dressing,  or with some
 mild detergent lotion or ointment,  in order to keep the surface clean, and free
 from absorption of gangrenous matters.   If sloughs are not readily separated^ the
 balsam of Peru, either  pure  or diluted with yolk of  egg, or very dilute nitric
 acid, and opiate lotions, are the most  useful  applications.  After  the separation
 of the sloughs the ulcerated surface must be treated on general principles.
    The constitutional treatment of gangrenous inflammation  requires to be con-
 ducted upon  the principles that guide us in  the management of the asthenic and
 irritative forms of inflammatory fever;—by attention to  hygienic  measures, and 
74
OPERATIVE SURGERY.
the moderate employment of antiphlogistic remedies in the early stages;  by sup-
port of the system, oy means of light tonics, nourishment, and stimulants, as the
disease assumes an asthenic form; and  by the administration of opiates  as it sinks
into the irritative type.
                            CHAPTER II.

          GENERAL CONSIDERATIONS ON  OPERATIONS.

  Manual skill and dexterity are necessarily of the first advantage to a surgeon,
and he should diligently endeavor to acquire the art of using his instruments
with neatness, with rapidity, and with certainty; but, desirable as it doubtless
may be to be able to remove a limb, or to cut out a stone, in so many seconds;
important, in a word, as  it is to become a  dexterous operator, it is still of far
greater importance to become a  successful one.  The object of every operation
is the removal of disease that either threatens the life, or that interferes with the
comfort and utility of existence;  and the more certainly a surgeon can accom-
plish this, the better will he do his duty to his patients, and the more successful
will he be in his practice.   Success  then, in  the result of an operation, whether
that result be the preservation of life, or the removal of a source of discomfort,
is the thing to aim at.   To  this, dexterity and  rapidity in  operating are in the
highest degree conducive; but there are various other considerations equally or
still more necessary, the solution of which can  only be afforded  by an intimate
general acquaintance with the science of surgery and of medicine.   The diag-
nosis of the nature, and extent of the connexions of the local disease has to be
made; lurking visceral affections must be detected, and, if possible, removed.
The constitution of the patient must be prepared  for the operation; the best
time for  its  performance seized; and,  after its  completion, the general  health
must be attended to in  such a way  as shall  best carry the  patient through the
difficulties he has to encounter, and any sequelae  or  complications  that  arise
must be  met by, and must be subjected  to, appropriate treatment.   These, as
well as the simple performance of the operation, are the duties of the operator;
and on the manner in  which these are performed, as much, or even perhaps
more, than on the mere manual dexterity displayed in the operation itself, will
the fate of the patient depend.   It is well known that  the result of operations
differs much in  the  practice of  different  surgeons  of acknowledged  dexterity,
and this  variation in the proportionate number of recoveries cannot be accounted
for by any difference in the  degree of manual skill displayed in the  operation
itself;  but must rather be sought in the greater attention that is paid by  some
surgeons to  the  constitutional treatment of  their patients  before and after the
operation, and to their  more  perfect acquaintance with the general science and
practice of surgery.  Indeed, success in operative surgery depends greatly  upon
the selection of proper  cases.  The  practice  of operating in notoriously hopeless
cases with the view of  giving the patient what is called a  last chance, is much
to be  deprecated, and should never be done.   It is by operating under such cir-
cumstances, especially in cancerous  diseases, that much discredit has resulted to
surgery,  for in a  great number of instances the patient's death is hastened by
the procedure; which, instead of giving him a last chance, only causes  him to
be despatched sooner than would otherwise have happened.
  The condition of a patient that principally determines the result of  an opera-
tion is the state  of his  general  health.   Indeed, the state  of the patient's con- 
OPERATIVE  SURGERY.
75
stitution influences the success of an operation far more than the mechanical
dexterity with which the surgeon performs it.   It is no uncommon circumstance
to see patients sink after the most dexterously performed operations for hernia,
stone, the ligature of arteries, &c, owing to some morbid condition of the blood
or the system that disposes to diffuse inflammation; whilst, on the other hand,
some patients  will  make  the most remarkable and rapid recoveries  after they
have been mutilated with but little skill.  Persons of an irritable and  anxious
mind do not bear operations as well as those of a more tranquil mental constitu-
tion.  Those also of a feeble and irritable habit of body, especially nervous and
hysterical women, with little power of circulation, cannot bear up against severe
surgical  procedures,  being  apt to become depressed,  exhausted, and  to sink
without rallying.   The condition of the patient's heart  should also be carefully
looked to before an operation is undertaken.   Fatty degeneration of this organ,
as indicated by its feeble action, by irregularity and want of power in the circu-
lation, by breathlessness, and  by a distinctly-marked arcus senilis, should make
the surgeon careful in undertaking any operation attended with  much loss of
blood, or shock to the nervous system;  though it need not  be an absolute bar
to its performance, if the  disease for  which it is to be practised would otherwise
be speedly fatal.   Disease of the lungs, of a phthisical character, when active or
advanced, is  incompatible with the success of an  operation, but under  certain
circumstances, as will be explained when speaking of diseases of the joints, and
fistula in ano, an operation is justifiable and proper, even though the patient be
consumptive.   Perhaps the  most  serious constitutional affection, and  the one
that more than any other  militates against  the success of an operation, is a
diseased state of  the kidneys with albuminuria; in this condition, the inflam-
matory  action that is set up is apt to run into a diffuse and sloughing form, and
this is especially the  case  in all operations about the genito-urinary organs.  The
contamination of the patient's system by malignant disease must always  prevent
our operating, as a return to the affection will most certainly speedily take place.
And, lastly, no operation, save of the most  urgent necessity, and  to rescue the
patient  from immediate death, as for the suppression of arterial hemorrhage,
should ever be  performed whilst he  is  laboring under  erysipelas,  phlebitis, or
any diffuse inflammation; and even during the epidemic prevalence of these af-
fections, operations that are not  of  immediate necessity, as for the removal of
simple tumors,  especially about  the head, should be  postponed until  a  more
favorable season.   Operations  in  very old people, if of a severe character, and
attended by much shock to the  system,  are commonly  fatal; thus, amputations
in individuals above the age of seventy, are very rarely successful.
   The causes of death after operation are partly dependent upon  the operation
itself, but in the great majority of cases, they are more connected with the con-
stitutional condition of the patient, and with the influences  by which he is sur-
rounded, than with the local injury inflicted during the operation.  How often
do we not see patients carried  off by  fatal diseases  supervening on the most
trifling operations, as the  removal of a finger or toe, or of small encysted tumors
of the scalp, from some condition of the system that is unconnected with the
injury that has been  inflicted; a  condition that only required the  local distur-
bance of the operation to call it into activity.
   The conditions that are most to be  dreaded by the  surgeon and  that most
commonly tend to a fatal  result after operation  are, shock, hemorrhage, and
surgical fever, with its local complications.
   The shock of an operation may prove fatal in various ways: from the  severity
of the mutilation, as in a case of double  amputation;  from  the nervous  centres
being implicated, as  in the removal of large tumors from  the face, that have
connexions with the base of the skull; or, from the state of nervous depression
in which the patient has  previously fallen,  causing him to feel  the influence of 
76
OPERATIVE  SURGERY.
an operation disproportionately to its severity; these various effects of shock have,
however, been much lessened  since chloroform has  been generally administered
in operative surgery.
   Hemorrhage,  if'very copious,  may destroy the patient by inducing  syncope
that may be immediately fatal; or, by increasing the influence of the shock, so
that he cannot rally;  or it may be attended by serious after-consequences,  such
as the supervention of hemorrhagic or irritative  fever.  When occurring a few
hours, or a day or two after an operation, it usually proceeds from the imperfect
ligature of the vessels, or  from arteries bleeding after the setting in of reaction,
which had not furnished  blood whilst the patient was under the influence of
the shock of operation.  Under  these circumstances, it is of far less  moment,
and less  frequently fatal, than when  occurring  at  a later  period, arising from
some morbid condition of the wound or system, and usually associated with a
typhoid  condition, in consequence  of which the  proper formation of plastic
matter is interfered with.   During the performance of the operation hemorrhage
should, as much as  possible, be  prevented; the  operation  itself is a  cause  of
depression, and any great loss of blood would only greatly aggravate this.
   Surgical fever, of an irritative type, associated with cerebral symptoms, may
set in with unusual violence ;  but it  never, I believe, proves fatal without the
manifestation of some local inflammatory mischief.    These local  inflammations
are indeed the most frequent causes of death  after operations; they are all of a
diffused,  congestive, or adynamic character, and are frequently connected with a
prevailing epidemic constitution at the time.   They are of two distinct  kinds;
the first,  taking their origin from a wound as  from a central  starting-point, are
the various forms of  erysipelas, diffuse inflammation of the cellular tissue, in-
flammation of veins, and absorbents, hospital  gangrene, and diffuse suppuration
of bone.   The others  are those secondary affections which fall upon some internal
organ, as for example, the lungs, liver, brain,  or  gastro-intestinal mucous mem-
brane.  The most frequent and fatal of these various complications, is congestive
inflammation of the lungs; which is an almost invariable accompaniment, if not
a cause of death in surgical fevers.  The  membranes of the brain in other in-
stances are found inflamed ; and more rarely the gastro-intestinal  mucous surface
is affected.  Internal organs  may also have been so  injured  by  the accident or
disease, that necessitates  the  operation, as to be unable  to  recover themselves,
and falling into a state of inflammation or  gangrene, may destroy life.   This we
see happen in the intestines in  cases of hernia, and  in the  brain in injuries of
that organ.
   The surgeon being convinced of the necessity of having recourse to operation,
should proceed fully and  unreservedly to lay before   his patient the state of the
case,  and if necessary state the reasons that render an  operation  imperative, in
order to obtain his consent, and that of his family.   In the event of the patient
refusing to submit, what  course should the surgeon  pursue ? In this he must be
guided partly by the nature of the proposed  operation;  and  partly by the state
of the patient, and his capability of forming a correct judgment of hia  case.  If
the operation be one of expediency, merely for the relief of  an  infirmity or the
removal  of an ailment, and does not  directly  jeopardise  life, most  certainly no
surgeon would think of undertaking it without the  full consent  of his patient.
If on the other hand it be an operation  that is imperatively necessary for the
preservation of life, in which the delay of a few minutes  or  hours may be fatal
to the patient, as in the  case  of the  proposed ligature  of a wounded artery, or
the relief of a strangulated hernia, and in  which the patient not  being aware  of,
or capable of being made to understand the necessity for immediate action, is un-
willing to assent to the proposal,  the  surgeon truly will be placed in a dilemma
of anxious responsibility; between  allowing the  patient to fall a sacrifice to his
ignorance  or timidity, and attempting, perhaps  unsuccessfully,  to rescue him 
           PREPARATIONS  FOR  OPERATION--CHLOROFORM.       77

 from inevitable death against his own  consent.  I believe the proper course for
 the surgeon to pursue under such circumstances, is to  judge for the patient in a
 matter in which he is clearly unable to form  an opinion, and to compel him, so
 far as practicable,  to take the  necessary steps for the preservation of his life.
 In the event of the patient being insensible, as after an injury of the head,  the
 surgeon must necessarily take upon himself to act as the case requires.   Children
 cannot be considered capable of giving an  opinion as to  the propriety of an
 operation; the consent of the parents is here necessary, and quite sufficient, and
 in their absence, the case being an urgent  one, the surgeon  must stand in loco
 parentis, and take  all responsibility upon himself.
    These points then having been determined, the patient should be prepared for
< the operation, if the case be sufficiently chronic to admit of the necessary delay.
 This preparation must not consist in any routine system of purging and  starving,
 which is ill-calculated to support the constitution against the call which will be
 made upon its powers; but by adapting our means, according to the condition of
 the patient.   Indeed in many of the more severe cases of compound fracture and
 disease of the joints, it is only by the use of a nutritious diet, and by the admi-
 nistration of stimulants, often in large  quantities, that the patient can be brought
 into a condition to bear the shock and consequent  depression of the operation.
 It will often be found necessary to  administer from half a pint to a pint of
 brandy, with perhaps a  considerable quantity of wine, together with eggs, beef-
 tea, and other nourishment for some days before the operation can be undertaken.
 This is more particularly the case with hospital patients of bad constitution who
 have met with serious accidents, attended by much  suppuration  and  irritative
 fever.   In the more chronic cases, the time should be seized for the operation,
 when the secretions are free, the tongue clean, and the action of the   skin and
 kidneys in a healthy state ; and above  all the mind should be kept tranquil and
 hopeful, being allowed to dwell as little as possible upon the impending  event.
    The immediate preparations for the  operation should always be superintended
 by the surgeon himself.   He must see that the table is solid, and of a convenient
 height, well covered with blankets, and provided with pillows; and that the light
 of the room  is good.  There must be a sufficient supply of sponges and of basins,
 with hot and cold  water; and if the operation be likely to be attended by much
 hemorrhage, a tray filled with sand or  saw-dust should be  provided, in order to
 catch the blood.   The surgeon must then look over his instruments, comparing
 them, if the operation be complicated, with a list previously made out;  he must
 see that they are  arranged in  the  order  that they are wanted, and  properly
 covered with a towel.  Much of the successful performance  of an operation  de-
 pends on the attention and steadiness of the assistants.  Of these there should
 be enough, but not too many.   In all capital operations three or four will be re-
 quired.   One for the administration of the chloroform, another to command the
 artery, a third immediately to assist the surgeon, and the fourth to hand  sponges,
 instruments, &c.   The  duties of the assistants should be performed in silence,
 and each man must carefully attend  to his  own business, and  not neglect this,
 as is too often done, in his  anxiety to  crane  over  and see what the surgeon is
 about.  There should be no  talking when once the  patient is on the table, the
 surgeon's directions being conveyed  by a  brief word  or two, a look, or a sign
 with the hand.
    The surgeon himself must always feel the heavy responsibility that hangs over
 him during  the performance of a great operation—"at that moment when," as
 Dr. Grant has elegantly said, "death everywhere surrounds his knife, and he is
 endeavoring to convey all his knowledge to its point."  But having carefully
 considered each successive step of the operation, provided for every emergency
 that can by any possibility arise in the course of it, and trusting in Him,  from
 whom all knowledge is derived, to strengthen his judgment and guide his hand 
78
OPERATIVE  SURGERY.
aright, he will proceed to the performance of his duty with self-reliance,  and in
the full confidence that he will be able to accomplish all that art can do.
  The administration of chloroform is best commenced before the patient leaves
his bed.   This should  never be given but by a person accustomed to its use, and
in whose capability the surgeon has full reliance, as nothing embarrasses him
more, during the operation, than to have any doubt about the chloroform being
properly administered.  The following is the way in which  chloroform  may, I
think, most conveniently and safely be administered.   On a piece of folded lint,
about two inches square, and consisting of three doubles, about 3J of chloroform
is poured, and the lint is then held at a distance of about three inches from the
nose of the "patient, so  as to permit of the very  free  admixture of air with the
first few inhalations.  After a lapse of about  half a  minute, the lint is brought
nearer to the patient's nose, to within a distance of perhaps an inch, being never
allowed to touch;  at the same  time a porous towel is laid over the face  of the
patient  and the hand of the operator,  so as to prevent the escape of the chloro-
form vapor, but not to interfere with the admission of air.   During the  whole
time it is the duty of the administrator to keep his hand on the pulse,  and occasion-
ally to examine the pupils of the patient.
  The principal points to be  attended  to during the inhalation of this  potent
agent are, that it should not be given too suddenly, or in too concentrated a form,
and that whilst under its influence the patient be not raised up off  the couch  or
table.   If the lint is too much saturated with it, and  be held too closely applied
to the mouth  and nostrils, the patient will not be  able to get sufficient atmo-
spheric  air, and may speedily become asphyxiated, choking violently,  struggling
to get free, and  becoming  purple in the face, with a full  slow pulse.  Whilst
under its influence the  patient should never be raised up, as has just been stated;
for as this agent exercises  a powerful sedative  action on the heart, sudden and
perhaps fatal,  syncope may ensue, by putting the patient in the erect position.
Hence also it is dangerous to administer it in those operations that require to be
performed  whilst the patient is in the erect position.   It is well to  caution the
patient  not to  take anything to eat for two or three  hours before its administra-
tion, lest it induce vomiting of the partially digested  meal.  With due caution
it may be given  with perfect safety to  individuals of  all ages.   I have operated
on infants  less than a  month old, as well as octogenarians,  under its influence.
In administering it to young children,  Dr. Snow recommends that it  should be
diluted  with rectified spirit.  The operation should never be  commenced until
the patient is  fully under the influence of chloroform, so  that the muscles are
perfectly supple and relaxed, as otherwise the semi-conscious struggles of the pa-
tient will only tend to embarrass and increase the difficulties of the operator.
  The first influence of chloroform appears to be exercised on the  nervous sys-
tem ; the patient becoming excited and talkative, but  this passes away speedily,
a state of complete insensibility coming on, the muscular system at the same time
becoming paralysed, and the patient consequently being completely deprived  of
sense and motion.   When the chloroform is given slowly and carefully it  enters
the blood, and being  conveyed by this fluid  to  the heart and  nervous centres,
acts directly upon these organs.  Its influence upon  the heart is well marked;
the pulsations  becoming less frequent and forcible, and are indeed often so much
diminished in  power that the jet of blood from cut arteries  is materially lessened
in force.  The respirations become shallow and feeble in proportion as the sen-
sibility of the nervous system and the energy of the muscular movements are les-
sened,  and the blood becomes dark and venous; in fact,  a  semi-asphyxial condi-
tion sets in.  When in this state, the patient is on the very verge of death and
requires the most  careful watching on the part of the person who administers
the chloroform; his fingers should never be off the pulse or his eyes taken away
from the countenance of the patient; as the inhalation of a small additional quantity 
                 INCISIONS — SUTURES--DRESSINGS.               79

of this potent agent, the application of the vapor in too concentrated a state, or
suddenly raising up the  patient, may occasion a fatal syncope from paralysis of
the heart.
  In certain diseased conditions of the system, the administration of chlorofonn
is scarcely  admissible;  this  is more particularly the case in affections of the
heart and brain.   In disease of the lungs, as in case of phthisis, it may be given
with perfect safety; but as it exercises during the early stages of its administra-
tion a tendency to determination of blood to the head,  and in the more ad-
vanced stages, a decidedly depressing influence upon the heart's action, we should
be careful in administering it in congestive affections of the brain, or in diseased
conditions  of the heart, more particularly when that organ is fatty, and weak in
its  action.   But though these states should render us cautious in the  employ-
ment of chloroform, they do not altogether contra-indicate its use; and when the
patient is so irritable that it is evident that he could not  bear the  shock of an
operation without having his sensibility blunted by this invaluable agent, it may
be  administered, though with great caution.   In an old  man with fatty  and
dilated heart, whom I lately cut for stone, and on whom it would have been im-
possible to  have operated with any chance of  success without chloroform,  on ac-
count of his extreme irritability, no ill  effects resulted from its inhalation.
   When injurious effects have  followed the administration of chloroform, they
 have arisen from  two opposite causes,  the induction of asphyxia or of syncope;
 both conditions being well marked by  the ordinary signs attending them—the
 asphyxia having been induced by the vapor being administered in too concentra-
 ted a form, without admixture of atmospheric air; the syncope, by the depressing
 influence of the agent on the heart's action.  In the first case the treatment must
 consist in the establishment of artificial respiration, if necessary through an open-
 ing in the  trachea, dashing cold water upon the face,  and exposing the surface
 of the body to  a cold current of air.   When syncope has come on, the transmis-
 sion of electro-magnetic shocks through the chest, head,  and spinal cord, with
 the establishment of artificial respiration, will be the most effectual means of re-
 storing suspended animation.
   [In  this country, chloroform  is not generally employed,  preference  in the
 choice of an anaesthetic being given to the sulphuric ether, which is considered  to
 be less dangerous  in its effects, and to be possessed of quite as much practical
 advantage as the chloroform.  The administration is  effected by the application
 over the nostrils of a hollow sponge, saturated with the best washed ether. This
 mode is preferable to the use of any of the complicated inhalers, inasmuch as by
 the admixture in the sponge of a sufficient quantity of atmospheric air with the
 ethereal vapor, all danger of asphyxia is avoided.  To prevent the pungent effects
 of ether on the cutaneous  surface, Dr. Warren  has proposed the anointing  of
 the face with some protective unguent.  The first effects of the inhalation are
 resistance  on the  part of the patient,  and  some slight irritation of the air pas-
 sages, the  pulse  is  increased in  rapidity, rising to one hundred pulsations per
 minute, the face becomes flushed, and the  movements and speech of the patient
 excited.   This stage of excitement soon passes,  and full etherization  is  then
 effected; the pulse falls to  sixty or seventy, the countenance becomes pale, in-
 sensibility to pain is produced, and the whole muscular system is relaxed.  The
 indications of  this state are the dropping of the upper eyelid, and the inability
 of the patient  to sustain his arm when raised.  This is the period most favorable
 for the performance of operations, and especially for the reduction of dislocations,
 and of fractures attended with shortening  of the  limb.   The time required for
 the induction  of the  anaesthetic  state  varies, averaging, perhaps, about five
 minutes, a longer period than  is required in the  administration of chloroform,
 and attended with slightly  more excitement.   The numerous fatal consequences,
 however, which have attended, and are  daily resulting from the employment of 
80
OPERATIVE  SURGERY.
chloroform in Europe, have led to the  almost entire abandonment of its use in
this country.—Ed.]
  The incisions for the operation itself should be carefully and properly planned,
so as to give sufficient space, with as little mutilation as possible, and in some
cases they must  be arranged with a view of subsequent extension, should  the
state of things  discovered  at the  operation  require it.   They should be made
freely without tailing, due attention being at the same time paid to the resis-
tance of the tissues, so that the surgeon does not, by using too much force, plunge
or jerk his scalpel  or bistoury  into the part.   The scalpel should be  set on a
smooth  ebony handle, which is  less slippery than an ivory one when wetted with
blood, and admits of greater delicacy of touch; it should  be light in the blade,
nearly straight-backed, and slightly bellied on the cutting edge.  When very
free and extensive incisions are required, as in the removal of large tumors, &c,
Listen's spring-backed  bistoury of proper size and shape, is a most  convenient
instrument.  Whilst the incisions are being made, care must be taken that too
much blood is not lost.  This may be prevented most conveniently by the use of
the tourniquet, or by an assistant compressing  the main artery in the groin or
axilla.  If the seat of the operation be  such as not to admit of this, the assistant
must compress  the bleeding  vessels as they are divided during the operation;
and as soon as it is concluded, he must remove his fingers from them one by one,
to admit of their being  ligatured.   If oozing continue after all jetting vessels
have been  tied,  this may be arrested  by exposure to the air, or  by pouring a
stream of cold water upon the wound.   In some cases the pressure of pad  and
bandage, and in others  that of a sand-bag will  arrest this bleeding, but in  the
majority of instances position and coaptation of the flaps will suffice.
  The  sutures should be introduced at the  time of the  operation, whilst  the
patient  is  still under chloroform,  but should be left  to  hang loose, and not be
drawn tight until the wound is dressed.   In this way the patient is  saved  the
pain, which is always much complained  of,  of introducing the sutures at  the
time of the dressing.   They should be  made  of dentist's  twist, of moderate
thickness,  so as not to  cut out  readily, and  need  only be  very fine  in case of
plastic operations, where scarring is objectionable.  In some cases, where much
tension is exercised, hare-lip pins are preferable to ordinary sutures.
   When the wound is small, and all oozing has ceased, its lips may at once be
brought together.   This may also be done even when large, if the patient be of
a very irritable constitution and sensitive to  pain, the whole dressing being  per-
formed whilst he  is still under the influence of chloroform.   But in  general,
when the wound is extensive,  as  in cases of amputation, I prefer, and almost
invariably adopt, the plan recommended  by  Mr. Liston, of leaving the wound
open, with a piece of wet lint interposed between its lips, for two or three hours,
until its surface has become glazed; the lint is then carefully removed, any small
coagula gently  taken  away, and the  sides  of the  incision brought into  ap-
position, the sutures being drawn  tight  and tied.   Long strips of plaster of
moderate width should  now be applied;  these may either be of the isinglass or
the common adhesive  kind, both  having  advantages that recommend them in
particular  cases, with corresponding disadvantages that exclude them  in others.
The isinglass plaster is clean, unirritating, and being transparent,  allows  a good
view of subjacent parts, but it has the disadvantage of loosening and  stripping
off when moistened by the discharges or dressings, which often renders it a very
inefficient support.  The common adhesive plaster is more irritating and dirty,
but it is much stronger, and holds tighter, not loosening so readily when mois-
tened.  In large wounds, as in  those of amputation, I prefer the isinglass for the
 first dressing, and leave it on until loosened by the discharges,  and then use the
 common adhesive plaster for subsequent applications, when less irritation is likely
 to be induced. 
AFTER-TREATMENT  OF  OPERATIONS.
81
  The position of the part should be carefully attended to, so that the edges and
surfaces of the incision be  brought into proper contact; more  may  be done  in
this way, without pain or  uneasiness to the patient, than by any amount of trac-
tion and pressure that can be exercised.   The part should be so  arranged that
one end  of the incision  may  be the most dependent, so as to facilitate the
escape of discharges.  The ligatures should be cut off at a moderate length, and
be left to hang out of the lowest part of the wound, provided that by so  doing
they do not cross its whole line.  A narrow strip of water-dressing should then
be applied along the  edge of the incision.   The first dressings need not  be
changed until about the third day after the operation,  unless they become  loose,
or are too tightly applied, when they may be snipped across.  About this time,
or earlier, in many cases, a serous  bloody fluid will be discharged from  between
the strips of plaster and the sutures.   The escape of this must be facilitated  by
removing any obstacles that are in its way.   If, however, the sutures do not in-
terfere with the escape of the discharges, and are not producing undue irritation
or excessive traction, they may  be left in for a few days longer.  In amputations,
especially in cachectic subjects, they may frequently be  left undisturbed for six or
eight days, with much advantage.
   If union do not take  place by adhesive inflammation, and suppuration has
commenced, with much tension and heat about  the  part, the substitution of a
poultice  for the water-dressing will be  advantageous.   AVhen suppuration has
fairly set in, these applications  should be changed at least twice or thrice in the
twenty-four hours.  The neglect of this precaution often gives rise to much irri-
tation, and retards the healing  process by the accumulation of discharges  in and
around the wound.   Care should also be taken that there is a free escape for the
pus, which may sometimes  be  pent up  by  the too early cohesion of the  edges,
without a corresponding agglutination of the deeper surfaces of  the wound.  As
granulations spring up, it may become necessary to substitute astringent dressings
for the emollient ones, and the  parts must  be well supported, especially in am-
putations, and in all cases where  there is a tendency  to  bagging of matter,  by
bandages.
   The constitutional after-treatment of operations demands as much attention on
the part  of the surgeon,  as  the management  of the wound itself.  Immediately
after the operation, and before  the effects of the chloroform have passed off, the
patient should be comfortably arranged in bed, with the  clothes supported by a
cradle, or other contrivance, away from the  part  implicated; an opiate  should
then be administered, or  a  little wine and water, if there is faintness, and the
patient kept as quiet as possible.
   With regard to the diet after the operation, this must  depend entirely on the
patient's constitutional powers,  and upon the  severity of the operation to  which
he has been subjected.  If the patient's strength be good, not having been broken
by previous disease or suffering, and if the operation be a slight one, as the am-
putation of a finger, or the removal of a  small tumor, he may have half his usual
diet allowed for a few days,  but without  any stimulants.  If the operation have
been more severe, but not capital, no solids should be allowed,  but  broths and
nourishing liquids alone given.  If the operation be a capital one, the patient's
health and strength being otherwise good, he may be restricted to  farinaceous
slops and beef tea until suppuration has  come on;  some light pudding may then
be added, and the diet may, as the case  proceeds, be gradually improved  by the
successive addition of  fish and  the lighter kinds of meat, with a moderate quan-
tity of stimulants, as required,  until it nearly reach the normal standard.   It not
unfrequently happens, however, that a totally different course must be  pursued.
If the patient have been  much reduced  by long-continued suppuration, or other
depressing causes before the operation, or has been in the habit of taking  a very
considerable quantity of stimulants, it will be absolutely necessary to depart from 
82
AMPUTATIONS.
the routine plan, and to adopt a tonic and stimulating  mode of treatment.  In-
deed, in hospital practice especially, I find  this by far the most useful mode of
treating patients after severe operations; without it, many would have sunk whom
I have seen saved  by the free administration  of large quantities of brandy,
wine,  eggs, and beef tea, from  the very time  of the  operation.   I believe,
also, that this plan of treatment is the best preventive to those low and diffuse
forms of inflammation that are so commonly fatal in these cases, and when they
come on, I know of no better remedy than the brandy  and egg mixture  of the
Pharmacopoeia, frfeely administered.  In  all  this, however, the surgeon must be
guided by the patient's pulse, his previous habits, and the power of his constitu-
tion; and nothing requires greater judgment than the administration of stimu-
lants, according to these particulars.  The great importance of attending scrupu-
lously to the general  cleanliness of the patient, and to the ventilation of the ward
or room in which he  is lying,  as the best means of preventing the occurrence of
the lower  forms of inflammatory mischief need scarcely be insisted on, as these
hygienic precautions  are  universally recognised as being of the first importance
under such circumstances.
  The various special operations will be considered when  treating of the several
injuries and diseases for which they are  required; but as amputations do not
readily fall under any special head, being  required for a vast variety of different
conditions, I think it will be more convenient to consider them here.
                           CHAPTER  III.

             AMPUTATIONS AND DISARTICULATIONS.

  The term amputation properly means the separation of a limb from the body,
but it is sometimes applied to the removal of other parts, as the breast or penis.
The frequency of amputations of the limbs has  much lessened of late years;
other and less severe modes of treatment being now successfully had recourse to
in many cases of diseased joints,  of aneurism, and of compound fractures,  that
were formerly submitted to the knife.  But yet,  amputations  are  amongst the
most frequent operations in surgery, and will continue to be so as lon^as the
human body is liable to severe mutilations, to gangrene of the limbs, and to ma-
lignant and other incurable diseases of the bones and joints.   It has been some-
what the fashion to decry amputation; and to speak of this operation as an oppro-
brium to curative surgery.  But though no surgeon can deprecate unnecessary
amputations more strongly than I do, yet I cannot admit that the removal  of a
hmb differs from other operations,  which are only attempted when all other means
have failed in curing the diseased part, or saving the patient's life.  And surely
it is rather a subject of just pride than the reverse, for  the suro-eon  to be  able
with ease, and by a simple operation, to save the whole of the body though he
sacrifice a  limb that has been utterly and incurably disorganized or spoiled by dis-
ease or injury    Li the performance of an amputation also, much dexterity may
frequently be displayed, and there is commonly great scope for surreal skill in
the  constitutional treatment of the patient both before and after the operation
  An amputation may be done in  the  continuity of a bone;  or at a joint, when
it is called a disarticulation.  In  either case, hemorrhage during the operation
is a great  danger which must  be carefully guarded against.  As a o-eneral rule
it is better to prevent this by the application of a tourniquet than by trusting to
the  compression of the artery by an assistant; the tourniquet arrestino- the  flow 
MODE  OF  AMPUTATING.
83
of blood through the collateral vessels as well as the main trunk, whilst an assis-
tant can only stop the current of blood that passes through the latter.   When
the tourniquet is applied, the  pad should  be  carefully placed  over the  artery,
and the band buckled pretty tight, but  the instrument  should not  be screwed
up until the moment of  the operation, lest venous  congestion take place  in  the
limb, and  an inordinate  quantity of blood be lost.  So soon as the  main arteries
have been tied, after the removal of the  limb, the tourniquet may be unscrewed,
and the band taken off,  the assistant, however, keeping his finger on the artery,
lest a ligature slip; for  if it be only left half loosened, it will often happen that
venous hemorrhage continues abundantly from the stump, in consequence of the
pressure of the instrument being still sufficient to prevent the return of the blood
through the veins.   This will at once cease on taking the tourniquet completely
off, and elevating the cut surfaces.                                  t
   In amputations and disarticulations, the surgeon has the choice of three opera-
tive procedures:—by the circular method;—by flaps;—or, by a combination of
the two, the formation of skin-flaps with a circular cut through  the muscles.   It
is not my  intention to enter into a discussion as to the relative merit of these pro-
cedures, for which I would refer to the writings of Liston and  Velpeau.   I be-
lieve that  by either the  circular or the  flap method an equally  good  stump may
ultimately be formed; but that much will depend upon the special dexterity that
the surgeon may have acquired, by the  habitual performance of one  or other of
these operations.   Educated in the doctrines of Mr. Liston, who invariably am-
putated by the flap method, and who certainly did this with wonderful rapidity
and precision, I have been in the habit of performing this operation in preference
to the circular, over which it certainly possesses the special advantages of greater
celerity in performance,  more perfect coaptation and  smoothness of the opposite
sides of the wound, and a greater tendency to union of the stump by the  first in-
tention.
   The surgeon should always stand so that he may support and grasp the limb
to be removed, his left hand being placed on the outer side in amputations of the
left limbs, on the inner  side in those of the right.  [This rule is  not absolute,
as many surgeons prefer the reverse  position, and stand always  on the right side
of the limb to be operated upon, so that with their left hand they may grasp the
stump, whilst an assistant supports the portion to be removed.-—Ed.]
   The amputating instruments must be in proper order, and of good construction.
For the smaller amputations straight spring-backed bistouries,  in ivory handles,
will be  required, narrow or broad in  the blade, according to the size of the part
to be removed.  Scalpels also, not too  broad  in the blade, are useful in those
cases in which the bistoury, from  its length, might be inconvenient.  Cutting-
pliers, with long and strong handles  and short blades, either straight or  curved,
as may be most convenient,  are especially required in  amputations about  the
hands  and  feet.   The  knives for the  larger  amputations should  have  smooth
ebony handles, and be well balanced. The back of the blade should run straight
to the point and be well-rounded.  The edge should taper off towards the point,
with a good convexity.   The breadth of the blade should vary  from the  T^th to
the |th of an inch, and its length must be proportioned  to the thickness of the
limb to be removed.  As a general rule, in order to make a good  sweeping cut,
so as  to form a  well-rounded  and smooth  flap, the blade should  be in  length
equal to about double the thickness of the  limb.   The saw should be strong in
the blade  and back, so as not to bend in cutting.   The blade  must be of good
breadth, and, in order not to hang as it works  its way through the bone, must be
somewhat broader  at the cutting-edge than elsewhere.   The teeth  should not be
too fine, and must  be set crossways.  The artery forceps may either be of the
ordinary " bulldog"  make, or they  may be broad towards the point, so as to
allow the  knot more readily to be slipped over the point to be deligated. 
84
AMPUTATIONS.
   The flaps may be made either by cutting from without inwards, or by trans-
fixion—cutting from within outwards.   Transfixion should be preferred in fleshy
parts, as the thigh or arm;  but cutting from without inwards will be found  to
afford the best result, and is indeed the only mode of forming the flap in some
situations where the bones are thinly covered, as on the outer side of the fore-
arm, the  anterior  part  of the  leg, or just above the ankle-joint.   When the
patient is extremely muscular, and the amputation  has to be done in the arm,
thigh,  or leg, it will be found to be most convenient to have skin-flaps, made by
cutting from without inwards, dissecting up the integuments from the fascia to
a sufficient extent, and then making  a circular cut through the muscles down to
the bone, thus only leaving  a skin covering.   The  advantage of this  procedure
over the ordinary flap or circular operation is very  great  under certain circum-
stances.   In both cases, but more especially in flap operations on stout muscular
subjects, a large pad of muscle is apt to be left in the stump.   This, which at
first sight might appear an advantage, as an additional covering to the bone, is a
decided  disadvantage, inasmuch as  it usually projects  by the retraction of the
skin covering it, sloughs, and interferes with  the proper union of the  flaps.  If
the limb have been  the  seat of much suppurative action, the muscles become
softened, and do not retract, and are  apt afterwards  to project between the skin-
flaps, giving rise to much trouble and delay in the healing of the stump.
   So soon as  the  incisions  have been made through the soft parts, the  bones
must be cleared for the application of the saw.   This is best done, when there
is only a single bone, by a firm circular  sweep of the knife from  heel  to point
round the under segment of the bone, and then another  round the upper surface,
in the opposite direction.  If there be two bones, care must be taken in clearing
them  not to direct  the edge of the knife  upwards  into the interosseous  space
higher than the line to which the saw is to be applied, lest any artery be cut high
up in this situation, where it is always difficult to secure it, owing to its retrac-
tion above the membrane.
  The bone having been properly cleared,  the flaps must be forcibly retracted
by an assistant, in  order to  admit of the proper application  of  the  saw, which
should always be made opposite the highest point to which the incision is carried
through the soft parts.  For the purpose of retraction the assistant's  hands are
quite sufficient, though some surgeons are  still in the habit of using  retractors,
made of split pieces of linen cloth or of wash-leather.   In order  to saw the bone
quickly and steadily, there are several points deserving attention.  The first cut
should be made so as to form a deep  groove to receive the teeth, by pressing the
left thumb on the bone, and applying the heel of the  saw, held horizontally,
along this, by which it is steadied;  the instrument must  then be drawn  fairly
and sharply along  the whole line of its teeth from heel to point.  The «roove
thus formed receives the edge of the saw,  and the bone  may then be quickly
cut through by  long, light  and  sweeping movements  of the instrument  from
point to heel, the position being gradually changed from  the horizontal to the
vertical as progress is made.   The surgeon  must, with his left hand, support the
part to be removed;  and care must be taken not to bear upon this, so as to snap
the bone as it is  weakened by the action of the saw; nor should it be so much
raised as to run the risk of locking the saw.  When there are two bones in the
limb of equal strength, as in the forearm,  they should  be cut  through at the
same time;  but in the leg, the fibula, being the weakest, should always be first
divided.   Should the division  be  made irregularly, and splinters of bone project,
these must be snipped off with cutting pliers.
   [The circular operation is an old  one, and was performed, although rudely,
long prior to the invention of the flap method.  The object of the operation, as
effected at the present day, is, according  to the  definition of Alanson,  "the
shaping of the stump into a hollow  cone, of which the bone shall be the sum-
mit;"  and this  result is obtained by a series of circular divisions of the soft 
MODE  OF  AMPUTATING.
85
parts.  The first incision should be made at a distance below the point at which
it is proposed to saw the bone, equal to one-half of the diameter of the limb at
that  point,  and  should extend down to the  muscular aponeurosis, cutting
through the skin and superficial fascia; these are now to be  loosened from their
attachments, and reflected upwards like the sleeve of a coat;  and being held
in this position by an assistant, the second circular incision through the entire
muscular mass is effected.   The superficial layer  of  muscles having  less  firm
attachment than the deep, retract  more;  consequently, to avoid a ragged, pro-
jecting stump, a third circular incision is made through the deep muscles down
to the bone, at the line of  retraction  of  the superficial layer, and still further
to avoid undue protrusion  of the shaft, those  fibres of the muscles arising
immediately from it  may be divided according to the plan of Bell.  The parts
are then strongly retracted, and the bone sawn through.  The indications of the
operation will be thus fulfilled:  a hollow cone being formed, in which we have
muscle enough left to cover the bone, and  skin  enough to cover the  muscle.
Should the amputation  have been  performed in the  forearm or leg, the inter-
osseous muscular mass must be divided as in the corresponding flap operations.
In Fig. 10 the circular  amputation is  represented, the  terraced arrangement of
the wound in the amputated part is shown.  Fig. 11 illustrates the corresponding
conical stump.—Ed.]
Fig. 10.                               Fig. 11.
  After the limb has been removed, the ligature should be applied.  The main
and larger arteries must first be tied.   For this purpose, I think, fine compressed
whipcord is the best material.   The ends of these ligatures knotted  together
must be left long, so that they may be distinguished.   Usually from two to four
or six smaller vessels require to  be tied, and they should be secured with ordi-
nary ligature thread; but  sometimes,  when  extensive suppurative action has
been going on in the limb,  the stump is excessively vascular, and  a very  large
number of ligatures may be required.  I have more than once had occasion to
apply between twenty and thirty ligatures to vessels in the thigh under these cir-
cumstances.   As union always takes place by granulation in such cases as these,
it signifies little how many are put on, the smaller ones separating early.  Sutures
must then be introduced through the edges of the wound, but may be left loose;
and wet lint applied between the surfaces and  over the outside, the dressing of
the wound being deferred for a few hours until the surfaces are glazed.  At least
this is the plan, introduced by Mr. Liston, that I think should be generally fol- 
86
AMPUTATIONS.
 lowed, more  particularly  in  cases  of primary amputation, and in all  wounds
 where union  by adhesion may be  hoped  for.   But in amputation  for  disease,
 when patients arc in a low and irritable condition, I think it  is better to apply
 the dressings immediately after the  performance of the amputation, before the
 effects of the chloroform are recovered from.  Before doing this, it is desirable
 that all oozing should have ceased, and with this view, after the ligatures have
 all been applied, I commonly pour a jug or two full of cold water over the face
 of the stump, and then  proceed with the dressings, which must be conducted in
 accordance with the general principles to be laid  down when we come to  speak
 of wounds.   The stump should not be bandaged  until  the third or fourth day,
 unless it is very fleshy and heavy; and at first the roller should not be brought
 over its face, but merely by circular turns,  as far as the  line  of incision.
 When suppuration is subsiding, and cicatrization going on, the bandage may ad-
 vantageously be brought over the face of the stump.  As a  general  rule, it will
 be found that a narrow roller will adapt itself better than a broader one.    After
 cicatrization is completed, the patient should be allowed to go about on crutches,
 but must not wear an artificial limb for several months, until the parts have  become
 firmly consolidated; during the whole of  this  time the stump  should  be kept
 carefully bandaged, and  not be exposed to injury.
   On examining the structure of a stump, after a year or two have elapsed from
 the time of its formation, it will be found  to be composed of a mass  of fibro-cel-
 lular tissue, the muscular and tendinous structures that  enter into the formation
 having become transformed into this.   The ends of the bones will be found to
 be rounded, and the medullary canal filled up, the vessels being obliterated up to
 the nearest collateral branch (Fig.  12).   The ends of the nerves are thickened,
 and commonly assume  a bulbous appearance  (Fig. 13).  On examining these
                              rounded or oval tumors, they will be found to
                              be  fibro-cellular masses  having nervous  fibrillac
                              thinly scattered throughout.
                                The proper  adaptation of artificial limbs is  a
                              matter of considerable consequence, and  the in-
                              genious mechanical contrivances  that are at the
                              present day adapted to  stumps,  amongst  which
                              those introduced by Mr. Gray, of Cork  Street,
                              deserve especial mention, leave  little to  be de-
                              sired.   The surgeon had better leave the  details
                              of these mechanical contrivances to the  instru-
                              ment-maker; but he should  see that they are
                              made light consistently  with sufficient strength
                              and support, and  that the  end of the stump is
                              never pressed upon by them.1   Thus, after am-
                              putation of the thigh, the artificial limb  should
                              take its bearing-point from the lower part of the
                              pelvis and hip.  In amputation immediately be-
                              low the  knee, this joint should be bent  and re-
ceived into the socket of the instrument, and if the amputation be at a lower point
ihan this, and the stump be extended  in the artificial limb, its end must  be pro-
jected from injurious pressure.  It is only in  the case of disarticulation  at the
 ankle-joint, when the soft tissues of the heel are left, that pressure can be advan-
 tageously borne upon the end  of the stump.
   Morbid  condition of stumps.—It not unfrequently happens  that  the end of
 the bone in a stump necroses.  This occurs either  in consequence of the  iniury
Inflicted by the jarring of the saw, or happens  in those stumps that unite by the
  a [The most perfect of all the artificial limbs we now possess, is the one invented by Mr B F Palmer
 No. 376 Chestnut Street, Philadelphia.  This invention received  the prize-medal at the World's Fvhihi!
Uion 0/1851. It merits the entire confidence of the Burgeon.—Ed.]                     W s ^xmtn
Fig. 12.
 
STUMPS; DRESSING  AND  STRUCTURE  OF.           87
second intention, and where the bone consequently lies bathed in pus for a con-
siderable time, being exposed between the  flaps,  and  thus at last losing its
vitality.  This is especially apt to happen in cases in which the limb has, pre-
viously to the operation, been  the  seat of abscess  that  de-
nudes or otherwise injures the vitality of the bone.  In these
cases  a fistulous opening will be left leading  down to  the
necrosed bone, which usually separates three or four months
after the  operation in the shape of a complete ring, with irre-
gularly spiked prolongations stretching from its upper part
(Fig. 14); after this has been removed, the stump becomes
firmly consolidated.
   Conical  or sugar-loaf stumps, as they are  called, com-
monly form in consequence of the flaps having originally
been  cut too short,  but in  other  cases  they  may occur,
though  the stump may have been  skilfully fashioned, in
consequence of the soft  parts which have been the seat of
inflammatory action and suppuration before the  amputation,
retracting during the granulating process, so as to denude the
bone.  In  such cases as these, great retraction and contrac-
tion of the flaps are apt to go on during cicatrization, so that
the bone may never be covered at all, but be exposed at the
bottom of an irritable ulcer;  or if the soft parts do coalesce,
the cicatrix will be unable  to  support the slightest pressure
without  becoming ulcerated.   Under  these circumstances,
the only remedy consists in laying open the stump, and cut-
ting off about three inches  of the bone.
   If the stump be too long and projecting, so as constantly to be in the patient's
way, there is no remedy but to perform a second amputation higher up.  This
is especially required in badly fashioned stumps of  the leg where the limb has
been removed too far below the knee, so that it projects backwards in an awk-
ward manner, and  is constantly liable to accident when  the  patient uses a
wooden pin.
   Painful and spasmodic  stumps.—The  nerves in a stump naturally become
somewhat expanded  and bulbous;  and no material inconvenience results from
this condition.  But it  occasionally happens that  a distinct tuberose  enlarge-
ment forms in connexion with one of them, attaining the size of a cherry or a
walnut, and this being pressed against the end of the bone or implicated in the
cicatrix,  becomes the seat  of  intense pain of a  neuralgic character, more parti-
cularly  whenever  it  is  touched.   Under these circumstances  excision  of this
bulbous extremity  of the nerve is necessary, and will effect a cure.  But besides
this form of painful  stump, which  may happen in  the strongest and healthiest
subjects, and is entirely dependent on local causes, there is another condition in
which the stump becomes  not only the seat of intense pain, but usually of con-
vulsive twitchings.   This form of painful stump arises from constitutional causes,
and invariably occurs in females, more particularly in  those of the hysterical
temperament, and  who are  subject to neuralgic  pains elsewhere.   In these cases
the general cutaneous sensibility of  the stump is increased; it  is often the seat
of convulsive jerkings or twitchings, and the pain is of a more  or less intermit-
tent character, being increased under  the influence of various emotional  and
constitutional causes.  In cases such as these, the treatment should be conducted
on the general principles that will be fully discussed when we come to speak of
neuralgia.  No excision  of the nerves of  the stump or even amputation higher
up is of any avail: the disease being constitutional, will  certainly return in each
successive  stump, until  at last the  shoulder or hip may  be reached without any
permanent benefit  accruing to the patient.
 
88
AMPUTATIONS.
  Aneurismal enlargement of the arteries of a stump is of extremely rare occur-
rence.   The only case with which I am acquainted, is one recorded by Mr. Cadge,
late assistant-surgeon to University  College  Hospital, in which an aneurismal
varix formed in a stump after disarticulation at the ankle-joint (Fig. 15).
   Strumous  or  malignant degeneration may occur in a stump, presenting the
ordinary characters of these  affections met with elsewhere.  In  the  strumous
stump  secondary amputation may advantageously be  performed, but on the re-
currence of malignant disease,  it is seldom justifiable, as there  is probably de-
posit in internal organs or contamination of the lymphatics.
   The fatty  degeneration of the muscles of a  limb  arising from their disuse,
gives rise to a peculiar appearance in the stump.  During the amputation, the
muscles look  like pieces of yellow wax, and are  firm; no atrophy, so far as size
is  concerned, having  taken place; the degeneration appearing to  be that  form
described by Dr. Quain, in which fat is deposited between  the muscular fibres,
producing atrophy of them by its  pressure, but  occupying their place; the ge-
neral size of the limb and fulness of the stump being consequently preserved.
Union  takes place under these circumstances, though  somewhat  slowly; at least
in two  cases in which I have observed this condition it was so.   In one of these,
I amputated  the leg for disease of the foot of nine years' standing, and in the
other,  Liston amputated below the knee,  for congenital talipes with disuse of the
limb.
   Mortality  after amputation.—The general causes  of death after operations
have already been considered, but we must now consider some special points con-
nected with the  relative mortality after amputations of different kinds;  and the
cause of the difference that exists.  The principal causes of death after amputation
are the influence of shock, the occurrence of  secondary  hemorrhage, of erysipe-
las, phlebitis, pyemia, and congestive pneumonia; besides these, hospital gangrene
and sloughing of the stump, occasionally  carry off the  patient.
   The circumstances  which most influence the general result of amputation, as
well as the particular cause of death after the operation, are:—1st, the seat of
the amputation;  2d,  whether it has been performed  for injury or disease; 3d,
when for injury, the time that has elapsed between the  injury and the  amputa-
tion.
   With regard to the influence of the seat of amputation on the result of the ope-
ration,  it may be stated  as a  general rule, that the risk is greater in proportion
as the  size of the part that is amputated increases, and as the line of amputation
approaches the trunk.  It needs no formal argument to show, that the amputa-
tion of the toe,  or of the foot, is less hazardous  than  that of the leg, or of the
thigh.   The statistics collected by  Malgaigne of amputations of all kinds in the
Parisian hospitals, exhibit clearly  this increase in the ratio of mortality as the
operation approaches the trunk.  Thus, in 26 cases ef amputation of one of the
smaller toes, there was 1 death.  In 46 cases of amputation of the great toe,  there
were 7 deaths, or 1 in 6.  Of 38 partial  amputations of the  foot, 9 proved  fatal,
or about 1 in 4.   Of 192 cases of amputation of the leg, 106 died, about 56 per
cent.   And in 201 amputations of the  thigh, there were 126 deaths, or 62 per
cent.
♦ 
STATISTICS OF AMPUTATIONS.                 89
  Not only does the size of the part removed, and its proximity to the trunk, in-
fluence materially the general  mortality after amputation; but these conditions
also influence the particular cause of death.  Thus, after the smaller amputations,
as of a toe, for instance, death only occurs in unhealthy states of the constitution,
from the  occurrence of erysipelas, or of some of the various forms of diffuse in-
flammation.   Death after the larger  amputations more frequently results from
causes connected with the operation  itself, as,  for instance, secondary  hemor-
rhage, shock  or exhaustion from the abstraction of the large  quantity of blood
contained in the limb,  as well as by that lost during the operation.  After the
removal of the whole of a limb, as  in the case of amputation of the hip-joint, it
is possible that the cause suggested by Mr. Cox, viz., the removal of a  limb in
which the blood undergoes changes of importance to the rest of the economy, and
consequently causing a return of imperfectly altered blood to the heart, may ma-
terially affect the result.
  The mortality resulting from amputations is perhaps more directly influenced
by whether the operation is done for injury or disease, than by any other cause,
being far greater in corresponding limbs after injury than disease.  In the follow-
ing table  may be seen the results of  140 cases of amputation performed  at Uni-
versity College Hospital.

      Result of Amputations  in University College  Hospital.
No. I.—Injury.
SEAT OF AMPUTATION.	NO. OP CASES.	CURED.	DIED.	MORTALITY PER CENT.
Thigh,..... Leg and ankle, . . Arm and shoulder, . Forearm, ....	19 14 6 6	8 12 5 6	11 2 1 0	58 14 16J
Total, ....	45	31	14	31 .
No. II.—Disease.
SEAT OP AMPUTATION.	NO. OP CASES.	CURED.	DIED.	MORTALITY PER CENT.
Thigh,..... Leg and ankle, . . Forearm, ....	34 39 13 9	27 32 9 9	7 7 4 0	20} 18 303
Total.....	95	77	18	19
   Of these amputations, 66  occurred  in  the Hospital up  to  1841, and  are
reported by Mr. Potter in a paper published in the " Medico-Chirurgical Transac-
tions" for that year.   They were performed by the several surgeons of the  In-
stitution  at that time.   The remaining 74 cases occurred in the wards succes-
sively held by Mr.  Liston, Mr. Syme,  Mr. Arnott,  and  myself, and do  not
include any of Mr. Quain's cases.  Of these 74 amputations, 41 were performed
by Mr. Liston between  1841 and his  death, in  1847; 5  by  his immediate
successors ; and 28 by me.
  Malgaigne's statistics  from the  Parisian  hospitals  illustrate this matter in as
clear a point of view, as will be seen by reference to the following tables. 
AMPUTATIONS.
Amputations for Injury.
SEAT OF AMPUTATION.	CASES.	DIED.	MORTALITY PER CENT.
Thigh,...... Leg,....... Foot,.......	46 79 9 30	34 50 6 17	75 62 66 52
Amputations for Disease.
SEAT OF AMPUTATION.	CASES.	DIED.	MORTALITY PER CENT.
Thigh,...... Lea,.......	153 112 29 61	92 55 3 24	60 50 11 40
  The shock inflicted by the injury appears to be one of the principal reasons of
the greater frequency of the mortality after amputations for injury than of those
for  disease.   After amputation  for injury, also, there is a greater liability to the
occurrence of gangrene of the stump, and pyemia and its secondary effects, than
in the case of the removal of a limb for disease; in which  the principal causes
of death usually appear to be exhaustion, and the supervention of disease of the
lungs.  In amputation in cases of disease, it will, I think, be  found, that those
patients do best in whom the disease is most chronic.  This  is especially observa-
ble in cases of disease of bones and of the joints.
  In amputation in cases of injury an  important question has to be determined,
viz., the influence exercised by the time that  has  elapsed from the infliction of
the injury to the performance of the amputation, on its results.  Not only is the
rate of mortality very greatly influenced  by the period at which the operation is
performed, but the conditions that immediately occasion the fatal  event; as Mr.
James, of Exeter, has shown in a most excellent essay that he has published on
the causes of death after amputation.
  Amputations for injury are commonly  divided by surgeons into primary and
secondary ;  the primary being those that are performed during the first twenty-
four or thirty hours, before any  inflammatory action in the  part  injured  has
taken  place.  By secondary amputation,  many surgeons mean those operations
that are practised after the first twenty-four hours; whilst others again restrict
the term to those that are done  after suppuration has set up in the limb, calling
those amputations intermediate that are  performed  between these two periods,
viz., from the twenty-fourth hour to the occurrence of suppuration, and which
consequently occupy a very extensive range.  I think, however, that this  dis-
tinction is a somewhat trivial one, and  not very easily applied in  practice • and
it is better to include under the term secondary,  all amputations performed after
inflammatory action has  been set up in the injured  part.   The  mortality after
primary amputations, as will be seen by the annexed tables, greatly exceeds that
following secondary operations. _  It  is  more especially primary  amputations of
the lower extremities, and particularly  those of the thigh,  that are attended by
such fatal  results.   Of the 44 cases of primary  amputation of the  thigh re-
corded by Malgaigne, 34 perished.   And of 24 cases recorded by  South, Laurie,
and Peacock, as occurring at St. Thomas's Hospital, at the Glasgow  Infirmary,
and the Edinburgh Infirmary, every  one proved fatal.  This similarity of result 
statistics of amputations.
91
occurring in different institutions, shows clearly that this operation is one of the
most dangerous in surgery, and that the great mortality attending  it is inherent
to it, and not dependent upon local or accidental circumstances.
Primary Amputations.				Secondary Amputations.			
[	CASES.	DEATHS.	James.		CASES.	DEATHS.	
	13	8					
1	44	34	Malgaigne.	(	15	5	James.
Thigh, .J	5	5	South.	Thigh, . J	18	15	Steele.
1	11	11	Laurie.	1	24	16	Laurie.
I	32	21	Steele.				
\	18	7	James.				
	67	42	Malgaigne.	r	5	1	James.
Leg, . . -i	9	2	South.	Leg, . . 1	19	13	Steele.
	22	15	Laurie.		5	3	Laurie.
..	53	22	Steele.				
r	19	3	James.				
Shoulder J and arm, j	36 6 26	24 0 13	Malgaigne. South. Laurie.	Shoulder S and arm, J	4 16 14	1 9 7	James. Steele. Laurie.
I	49	15	Steele.				
r	18 10	0 2	James. Malgaigne.				
Forearm, <	1 15	0 0	South. Laurie.				
,	35	1	Steele.				
Results of Primary and Secondary Amputations in  Cases of  Injury
                  at University College Hospital.

                            No. I.—Primary.
SEAT OF OPERATION.	NO. OF CASES.	CURED.	DIED.	MORTALITY PER CENT.
Thigh,..... Leg and ankle, . . Shoulder and arm, . Forearm, ....	6 8 4 5	3 6 3 5	3 2 1 0	50 25 25
Total.....	23	17	6	26
No. II.—Secondary.
SEAT OF OPERATION.	NO. OF CASES.	CURED.	DIED.	MORTALITY PER CENT.
Thigh,..... Leg and ankle, . . Shoulder and arm, . Forearm, ....	13 6 2 1	5 6 2 1	8 . 0 0 0	61*
Total, ....	22	14 8		36
 »It is remarkable that, at the University College Hospital, secondary amputations of the thigh have
been more fatal than the primary ; but the number of cases (nineteen in all) is too small to vitiate the
general law. 
92
special  amputations.
   As has already been observed, not only does the rate  of mortality differ  in
primary and secondary amputations, but also the cause of death.   Primary am-
putations  are most  frequently fatal from shock or exhaustion, although  death
from secondary diseases of a low type, is by no means of unfrequent occurrence
in these cases.   Secondary amputations for injury most commonly carry off the
patient by the supervention of diseases of a low fype.  Amongst these secondary
affections  that are, according to my observation at the University College Hos-
pital, of most frequent occurrence, gangrene  of the stump stands in the first
place, especially after amputation of the thigh, and more particularly if the limb
has previously been  in a similar condition  before the  amputation.   Then again
phlebitis with pyemia, secondary hemorrhage, and some of the low forms  of
visceral  inflammation,  or  congestion, as pneumonia, pleurisy, and diarrhoea, are
of frequent occurrence.  Pyemia and congestive pneumonia are the most fre-
quent causes of death after secondary amputation of the leg and arm.   Secondary
hemorrhage to such an extent as to prove fatal is  not of common  occurrence;
when it does happen it is usually, I think, associated with some diseased state of
the blood that interferes with the formation of a plastic plug in the artery.
                            CHAPTER  IV.

                       SPECIAL AMPUTATIONS.

   Amputation of the Fingers is not unfrequently required for injury or disease
 more especially as the result of bad whitlow.   In many cases the ungual phalanx
 requires removal, having become necrosed.   This  may usually most readily be
 done by making an  incision through the pulp of the finger, and then extracting
 the diseased bone.  Yet, in  other  cases amputation will  be  required.   This is
                                      best done by cutting into the joint from
                                      its  dorsal aspect  with  a narrow-bladed
                                     bistoury, running  across it lightly, touch-
                                     ing the lateral ligaments, and making
                                     the flap from the palmar  aspect.   In
                                     many instances the flap may most con-
                                     veniently be made from the palmar sur-
                                     face  by transfixion,  and then cutting
                                     cross the joint (Fig. 16).  In doing this,
                                     care  must be  taken  not to  get too far
                                     backwards, and to mistake  the depres-
                                     sion above the head of  the second pha-
                                     lanx for the articulation, which  would
      ,    ,       L x.    ,   ,,      ,  lead  to  a little embarrassment.  As a
general  rule, amputation should  not be performed  between the proximal and
second phalanges; because as no flexor tendon is attached to  the proximal nha
lanx, it is  apt to remain  permanently extended, and a good deal in the  patient's
wy.m  In the case of the index  finger, however, it will  be better to leave the
proximal phalanx  the stump of which forms a useful opponent to the thumb
  Amputation is frequently required at  the metacarpophalangeal articulation.
Here it may be done in two ways; either by  lateral flaps, or  the oval  method.
If by lateral flaps, the adjoining fingers  should be well separated from the one
about to be removed, by an  assistant who grasps the hand, so as to  put the  in-
tegument of the dorsum upon the stretch.  The point of the  bistoury should
 
amputation of the fingers.
93
then be entered about three-quarters of an inch above the head of the metacar-
pal bone;  it is then carried forwards  to a point  opposite the interdigital web,
drawn across the side of the finger,  and  then carried a little way into the palm.
The same  process is performed upon the opposite  side, the flaps dissected down
by a few touches of the knife,  the extensor tendon divided,  the joint opened,
and disarticulation performed.   The oval method, which I think is  the best, as
it does not wound the palm, consists in entering the bistoury at the same point
as in the last case, carrying it as far as the  web, drawing it across the palmar
aspect of the finger, and then obliquely backwards to join the starting-point of
the incision.  By a few touches of the point of the knife the oval flap is  turned
back, and  the articulation opened.   As a general rule it is better to remove the
head of the metacarpal bone, together with the finger, as otherwise a  wide gap
will be  left, in the  situation of the finger that has been  amputated, and much
deformity of the hand result.   This may be done by cutting it across with bone-
forceps in  a transverse direction, if it be either the middle or ring-finger that is
removed.  If it  is  the index  or  little finger, it  should be cut obliquely from
without inwards, so as to shape the bone to the tapering form of the hand (Fig.
17).   If it be cut directly across, an ugly and inconvenient square protuberance
will always be left, which will be much in the way, and liable to constant injury.
In some employments, however, in which great strength and breadth of hand
are required, and where appearance  is  of little consequence, the head of the bone
may advantageously be left.
  The after-treatment of these  cases is extremely simple.  The hand should be
put upon  a splint,  the wound covered with a  piece of water-dressing, and  the
ends of  the fingers with a small piece of lint interposed, tied together by means
of a tape, care being taken, however, that they do  not overlap.  The shaft of the
metacarpal bone that is left  will gradually atrophy, and thus a very taper  and
shapely  hand eventually be left.

                     Fig. 17.                                  Fig. 18.
   Amputation of the Thumb.—In disease or injury of the thumb as little as
possible should be removed by amputation, for if even but a very short stump is
left, it will serve as a useful opponent  for the other fingers.   When the thumb
requires amputation, it may most conveniently be removed by Liston's  method.
The point of a long narrow bistoury should  be introduced well  on the  palmar
aspect  of  the carpo-metacarpal articulation  carried over this, which it opens
(Fig. 18), and the dorsum of the hand as far as the web; the point of the knife
should then be  pushed downwards through the ball  of the  thumb, transfixing
 
94
SPECIAL  AMPUTATIONS.
this and  issuing where the  incision commenced.   It  is next made to cut out-
wards, keeping close to  the  metacarpal bone, which is readily twisted out, the
remaining attachments being separated by a few touches of the knife.   An oval
incision will be left, which comes  together closely by a narrow line of cicatrix.
In amputating the right thumb, it will be necessary for the surgeon if he adopt
the method just described, either to use his left hand, or to cross his hands in
an awkward manner.  In order to avoid doing this, he may reverse the step of
the operation with advantage; first transfixing the ball, and making the anterior
flap, then cutting over the dorsum, opening the joint, and turning out the bone.
  The metacarpal bones of some of the other fingers occasionally require removal
for disease or injury.   For these operations, which  are  not of a  very  regular
kind, it is difficult to lay down definite rules; but  in performing them, care
should be taken to avoid cutting into the palm if possible; and it is well not to
disarticulate the lower end of the bone, so as to open  the wrist-joint, but  rather
to cut it off with bone-forceps a little above this.  In injuries from the explosion
of powder-flasks or gun-barrels, when the hand is much shattered, it is of great
consequence to avoid cutting up the palm to too great an  extent, and it  is well,
in these cases, to save  a finger if possible, which will be  more of use  to the
patient than any artificial limb, however ingeniously constructed.
Fig. 19.                         Fig. 20.
  Amputation at the wrist is not  very often  required.   In performing dis-
articulation at this joint, its peculiar  shape with  the convexity  looking  upwards
must  be borne in mind.   The integuments  being well retracted, an arched in-
cision should be  made from one styloid  process to the other, across the back of
the joint,  with its  convexity  looking  forwards (Fig.  20).   The  articulation
having been opened, and the lateral ligaments divided, the knife is carried for-
wards so as to make  a well-rounded flap from the palmar surface; in doing this,
care must be taken not to cut against the pisiform bone, which projects a good
deal beyond the other carpal bones.
  Amputation of the forearm is not unfrequently required for disease or injury
of the wrist or hand.  In performing  this operation, as long a stump should be
left as possible, so as to give the patient more power over any artificial  limb that
may be fitted to it.  The flaps should be about a couple of inches in length, and
well rounded, the hand  being placed in a midstate between pronation and supi-
nation.   The dorsal  flap is best made by cutting from without inwards; the line
of incision commencing just at the palmar aspect of  the under part of the ulna,
being carried forwards for a little distance parallel to this  bone, and then across
the arm in a slightly curved manner, until  it reaches the palmar aspect  of the
radius; it  must then  pass along  this, until it reach  a point opposite to that at 
               AMPUTATION  OF  FOREARM  AND  ARM.             95

which it commenced, and be dissected back.  The palmar flap is  next made by
transfixion (Fig. 21).   As soon as it is cut, the bones are cleared by a  couple

                                   Fig. 21.
of sweeps of the knife, and the interosseous  membrane divided; they are then
sawn together.   The vessels will be  found to be  cut  long  at  the end, and on
either side of the palmar flap.
  Amputation of the arm  is most readily performed  by lateral flaps made by
transfixion from before backwards;  the bone is then well cleared by a couple of
sweeps of the knife, and sawn across.   In clearing  the  bone, care must be taken
fairly to divide the musculo-spiral nerve by a firm sweep of the knife round the
back of the bone (Fig. 22), if the amputation is performed  in that part of the
                                   Fig. 22.
arm where this nerve winds round the humerus.   If the limb is very muscular,
skin flaps and the circular section of the muscles will probably give the best result.
  Amputation at the shoulder-joint may be required for injury of the arm or dis-
ease of the humerus;  in the first case it is best performed by transfixion; in the
other, by cutting from without inwards.   The  subclavian artery should be com-
pressed as it passes over the first rib, though, if the assistant be steady and well
up to his duties, this may be dispensed with.
  In operating by transfixion, a long  narrow-bladed  knife  should be used.  In
this operation, one  assistant must have charge of the limb;  another  should raise
the flap;  and to a third should be intrusted the important duty of following the 
96
SPECIAL  AMPUTATIONS.
Fig. 23.
knife as it cuts behind the  humerus, and grasping the posterior flap with the
axillary artery, so as to prevent hemorrhage from  this vessel.   The assistant
holding the arm away from the body, so  as to relax the deltoid somewhat, the
knife, instead  of being entered by a puncture, should  make  a smaH cross-cut
about an inch in extent, at the point at which transfixion is to be practised, so as
to prevent  that jagging of the integuments by the heel of the instrument which
                                 would otherwise  occur.   If the operation be
                                 on the right side,  the point of  the  knife
                                 should  be  entered about an  inch  below the
                                 acromion (Fig.  23); and being carried di-
                                 rectly across  the joint and  capsule, should
                                 pass out at the posterior border of the axilla;
                                 the  large flap containing  the deltoid muscle
                                 must then  be cut by a sweep of  the  knife
                                 downwards, and  as soon  as made  raised by
                                 another assistant.  The heel of the knife is
                                 now to be laid on the head of the  bone, the
                                 capsule of the joint cut across, and the attach-
                                 ments of the muscles to the tuberosity divided.
                                 In order to facilitate this part of the  operation,
                                 it is generally  recommended that  the  arm
                                 should be carried forcibly inwards across the
                                 chest.  This may readily be done in the dis-
                                 secting-room where the limb is entire; but in
the case of comminuted fracture of the humerus, with  extensive laceration of
soft  parts,  it  cannot be accomplished.   In such cases  as these, the  head and
upper end  of the humerus being broken off from the shaft, the lever-like action
of the bone cannot be  put in  force, and it  is sometimes  not such an easy matter
                                                    as  might at first appear
                                                    to detach its head from
                                                    the glenoid  cavity.  In
                                                    order  to  do this, I have
                                                    in  two cases of commi-
                                                    nuted  fracture  of the
                                                    humerus, in which  Iwas
                                                    amputating at the shoul-
                                                    der-joint, found it neces-
                                                    sary, after opening the
                                                    capsule to seize hold  of
                                                    the upper fragment and
                                                    to draw it forcibly down-
                                                    wards and inwards,  by
                                                    inserting the fingers be-
                                                    tween the head and the
                                                    glenoid cavity, in  order
                                                    to divide  the muscles in-
                                                    serted into it.   After the
                                                    head of  the  bone has
                                                    been  turned out of the
                                                    glenoid cavity, the  knife
                                                    must be  passed behind
                                                    it, and carried down  for
                                                    a distance of about three
                                                    inches close to the  bone
                                                    at its  inner side.  The
surgeon then cuts across the soft parts, so as to form the posterior flap.   In doinf
Fig. 24.
 
AMPUTATION  AT  THE  SHOULDER.
97
this, the assistant to whom this duty is  intrusted, must follow the knife with his
hands, grasping firmly the whole thickness of the posterior flap, so as to compress
the axillary artery,  and thus prevent the occurrence of hemorrhage (Fig. 24).
The surgeon should not  cut the flap across until
the assistant tells him that he holds  the vessel
firmly, and then he must be cautious not to injure
his assistant's fingers.   The artery will be found
to be cut long in the middle of the posterior flap,
and a few smaller branches may be required to be
tied at  its inner angle and in the deltoid.  The
stump, after it is healed, will present the appearance
in Fig.  25, taken from my last patient.
   In those cases in which this operation requires
to be performed for diseases, especially  for tumors
of the humerus, it may very conveniently be done
by making the anterior flap by cutting from without
inwards, using of course for this purpose, a shorter
knife than that which  is required for transfixion.
The joint is then  opened, and the posterior flap
formed  in the usual way.
   [The oval operation  of Baron Larrey has been
most frequently performed, and has been attended
with the best results.   It consists in making a ver-
tical incision of three  inches in length, from the
extremity of  the acromion directly  downwards  in the  axis of the humerus,
splitting the deltoid muscle into two portions.  From this vertical incision, about
one  inch  below  the acromion,  two oblique incisions  are carried,  the  anterior
of which shall divide  the tendon of insertion  of the pectoralis major, and the
posterior those of the  latissimus dorsi and teres  major.   The  soft parts  are
then  strongly retracted  by  an  assistant, so  as to  expose the  articulation;
the outer circumference of the capsule, with  its tendons, is divided, the arm
luxated outwards, and  the division of  the  inner portion effected, an assistant
compresses the axillary artery by grasping  it between his finger and thumb,  and
the surgeon finishes the operation,  by introducing  his catling  into the inferior
ends of the oblique incisions, and incising, in a somewhat downward direction,
the remaining soft parts and the skin.   In this process, the axillary artery is last
severed.—Ed.]
   Amputations of the foot.  The phalanges of the toes seldom require amputation;
when they do, they may be removed in  the same way as the corresponding parts
in the/ hand—by the formation of a flap  on  the plantar surface, either by cutting
from above downwards, or by transfixion.
   In removing a bone  at the metatarso-phalangeal  articulation  the oval method
should always be practised, so that the sole of the foot may not  be cut into.  In
doing this, it must be remembered that the articulation is situated at least three-
fourths  of an inch above the web of the  toes, and the incision must therefore be
commenced proportionately far backwards.
   The metatarsal bone of the great toe occasionally requires removal in whole or
in part.   If the  disease is limited to the  anterior part, the  shaft  of the bone
should be cut across with a pair of bone-nippers, and its  head left;  for as  this
gives insertion to the  peroneus  longus, its removal will  materially weaken  the
foot.  The whole of the bone may be readily removed in the  following way : the
point of a strong broad bistoury should  be  entered on the dorsum of  the foot in
the interspace between the first and second metatarsal bones, as far back as pos-
sible ; it should then be carried forwards upon the ball of the  great toe to a point
opposite to-the web  between the toes, and  thence made to sink into  the sole of
                                     7
 
98
SPECIAL  AMPUTATIONS.
the foot in a line parallel with the outer margin of the bone  (Fig. 28-1); the
flap thus formed should be dissected back, its plantar  aspect being kept as thick
                                       and  fleshy as possible.  The surgeon
                 Fig. 26.                 next passes the knife between the first
                                       and second metatarsal bones, and cuts
                                       directly forwards through the centre of
                                       the angle between the great and the
                                       second toes.   In doing this, care must
                                       be taken that the  edge of the knife is
                                       not directed too much towards the me-
                                       tatarsal bone of the  great toe,  lest it
                                       hitch against some  of the  sesamoid
                                       bones.   The surgeon next seizes the
                                       extremity of the toe, and, pressing it
                                       well inwards, passes  the point of the
                                       bistoury deeply into  the angle of the
                                       wound  (Fig. 26) where,  by the di-
                                       vision of some tendinous and  ligament-
                                       ous  fibres that constitute  the key of
                                       the joint,'he  opens the articulation and
                                       detaches the bones by lightly touching
                                       its ligamentous attachments.  By keep-
                                       ing the edge of the  knife well against
                                       the  side of  the bone, he may avoid
wounding the dorsal artery of the foot, the bleeding from which would be trou-
blesome.  When the bone is to be partially removed,  the operation requires to
be performed in the same way, the incisions, however, not  being  carried so far
backwards.
  The metatarsal bone of the little toe may conveniently be removed by an oval
incision, so as to avoid wounding the sole  of the  foot.   This is best done by en-
tering the point of the  knife just behind the tubercle of the bone, carrying it
forwards and inwards in the line of its articulation with the cuboid, to the  centre
of the fourth digital interspace, and thence forwards to the web of the toe; the
knife is next carried round  the  plantar surface  of this, the incision being con-
tinued obliquely into that which has been made  on the dorsum of the foot (Fig.
27).  The small flap thus formed is well dissected down, the knife passed round

                                   Fig. 27.
the under surface of the bone, and the joint opened by the toe being forcibly
drawn outwards, and its ligamentous connexions lightly divided.
  The whole of the metatarsal bones may be removed from the tarsal by the ope-
ration originally planned and executed by Mr. Hey.  This consists in, first of
all, making a large  convex flap in the sole of the foot, one horn of which com-
mences at the tubercle of the fifth metatarsal bone, whilst the other terminates at
that of the first, or rather opposite the projection of the scaphoid.   A small flap
is then made on the dorsum of the foot, and the articulations exposed.   These 
AMPUTATIONS  OF  THE  FOOT.
99
Fiar. 28.
must then  be opened with  some care, as  they are very irregular; the second
metatarsal  bone, especially,  being sunk into a kind  of pit in  the middle cunei-
form, and the articulation of the fifth with  the cuboid, being very oblique.  This
operation is seldom practised, disease being rarely limited to the metatarsal bones,
and their disarticulation from the tarsus being very troublesome.
   Amputation through the  tarsus may conveniently be performed by  Chopart's
operation, which consists in disarticulation in  the line be-
tween the os calcis and astragalus behind,  and the cuboid
and scaphoid in front.   This operation may be performed
either  by first  making the  flap from the sole  of  the foot,
and then disarticulating, or  the procedure may be  reversed,
and the  joints having  been cut through from the dorsum,
the flap may afterwards be made.  I prefer the first plan,
as it enables the surgeon to make a better and more correctly
fashioned flap.
   The knife should be entered just  behind the tubercle  of
the  scaphoid,  and carried  well forwards  for about two
inches and a half, then right across the sole, and be made
to terminate on the outer side,  behind the tubercle of the
fifth metatarsal bone (Fig. 28-2).  This flap should be made
broad, but well rounded at the  angles, and should  consist
of the whole thickness of parts in the sole  of the  foot.   A
convex incision is then made  along the dorsum  from one
horn to the other  of the plantar flap; the parts well re-
tracted, and the articulations opened by the surgeon bearing
firmly upon the anterior part of the foot, and lightly touch-
ing the ligamentous structures with the point of his bistoury.
The result of this  operation is extremely favorable, the pa-
tient by the aid of a properly constructed boot, being able
to walk, and  even dance, with  very little appearance  of
lameness.
   [The great  objection to the  performance of  amputation
through  the tarsal  joint, is the destruction of the antagonism naturally existing
between the flexor and extensor muscles of the foot, and it is  in  consequence of
this, that we so often see the stump left after such an operation, rendered  not
only useless, but painful, from the excessive contraction of those muscles which
go  to  form  the  tendo Achillis;  and  consequently the whole  weight of  the
body being thrown upon the tender cicatrix in walking, excoriation and sloughing
are apt to follow.   Hence it has been proposed by Dr. Pancoast, to divide  the
tendo Achillis subcutaneously, at the time of the performance of this amputation,
and by this means to prevent the unnatural extension of the stump.
   Indeed in the present state of perfection of surgical mechanism, it is question-
able whether it would not be better to amputate at once above the ankle joint, in
order to  allow the  patient to avail himself of those admirable  artificial limbs, by
which every appearance of deformity is removed, and  almost  every motion ren-
dered back;  especially should this point be well  considered,  when the surgeon
is called  to operate upon a patient whose avocation and support require constant
exercise  and locomotion.—Ed.]
   Disarticulation  of the foot at the ankle-joint was  first reduced by Mr.  Syme
to a regular operation, and certainly  constitutes one of the greatest improvements
of recent date in operative surgery,  as by its performance amputation of the leg
may often  be avoided,  and the patient being left with an exceedingly useful
stump, the covering of which being  ingeniously taken from the heel, constitutes
an excellent basis  of support (Fig. 32).   The operation is performed by making
an incision from  the anterior  part  of one malleolus downwards, and slightly
1. Line of amputation of
    great toe.
2. Line of Chopart's ope-
    ration.
3. Lines for excision of os
    calcis. 
100
SPECIAL  AMPUTATIONS.
backwards, across the plantar surface of the heel to a corresponding point in the
                                opposite malleolus.  This flap is well dissected
             Fig. 29.              back, the knife  being kept close against  the
                                bone, especially  when  it  passes towards  the
                                inner side of the os calcis, in the neighborhood
                                of the plantar arteries (Fig. 31).   An incision
                                is next  made across the dorsum of the foot,
                                from  the upper extremity of the sole flap on
                                one side to that on  the other, and the joint
                                opened  from the front.   The lateral ligaments
should now be  touched with the point of the bistoury, and  the  tendo Achillis
divided by pressing the foot forcibly downwards and cutting from  before back-
wards (Fig. 30) by some twisting and dissection, at the same time the os calcis
is completely separated from its soft attachments, and the foot removed;  the two
malleoli may then be sawn off, the plantar arteries tied, and the flap brought up.
A well-formed rounded stump will thus be left as represented in  Fig.  _2.
Fig. 30.
Fig. 31,
Fig. 32.
  In performing this operation, care must be taken that no button-hole apertures
are  made through the posterior part of the heel flap.   This may commonly be
avoided readily enough when the soft structures  in this situation are greatly
thickened and infiltrated by plastic  matter, as the result of chronic disease; but
if the operation be required for injury of the foot, great care is  required in dig-
ging out the heel, the  integuments at the posterior part  of the os  calcis  being
very thin and adherent to the bone.   The principal point, however, to be attended
to is, that the plantar arteries are cut long;  unless care be taken to do this, the
flap will be insufficiently supplied with blood, and sloughing, especially of its outer
angle, to which there is in all cases a tendency, will be particularly liable to occur.
As union  takes  place by granulation, there  will be  a tendency to bagging  in
the stump, but this may be  prevented  by  proper  bandaging.  The tendency
to sloughing and to undue suppuration  chiefly occurs  in those cases in which
the amputation has been performed as  a  primary operation for a crush of the
foot.  In  one case,  in which I  had occasion to perform it for an injury of this
kind, a good deal of trouble resulted from this cause, though eventually the case
did perfectly well, and the patient now walks with scarcely any  difficulty.
  Amputation of the leg may be  performed in two  situations, according to the
seat of the disease, and the  position of the patient in life.   In those individuals 
AMPUTATIONS  OF  THE  LEG.
101
who can afford the expense of a well-constructed artificial limb, and in whom the
disease will admit it, the amputation may be performed in  the lower part of the
leg.  In those on the other hand who will be obliged to wear a common wooden
pin, a long leg stump would be highly inconvenient and much in the way, and
here the operation usually  leaves the best result  if performed just below the
tuberosity of the tibia.   If, however, the disease be confined to the ankle, ampu-
tation, even  amongst the poorer clases, may advantageously be done below the
calf; the patient afterwards wearing a short wooden pin, in the socket of which
the stump is fixed in the extended position as recommended by Fergusson.
  The flap amputation of the  leg may be performed in  the following way.  The
tourniquet having been  applied to  the  artery in the popliteal space (Fig. 33),
the assistant, whose duty it is to  retract the flap, takes his stand in this, as in

                                   Fig. 33.
all amputations of the lower  extremities, opposite to the surgeon.  In the left
limb, the point of the knife is entered at the posterior edge of the tibia, carried
forwards for a  distance of one and a half inch, then  across the  anterior part of
the leg to the posterior border of the fibula, up which  the  incision is made to
extend to a  corresponding distance;  on the right leg, the incision commences
on the fibular side of the limb, and terminates  on the tibial.   The flap thus
formed, which should be broad  and well rounded, is next dissected up by a few
touches of the point of the  knife, and transfixion of the limb made by passing
the blade  across behind the bones, from one angle of the incision to the other. 
102
SPECIAL  AMPUTATIONS.
The posterior flap is then formed by cutting obliquely downwards and backwards,
and should be about three inches long.  The bones are next cleared by a double
sweep of the knife, and the  interosseous  soft parts  divided  by carrying the in-
strument in a figure of 8 way between the bones.   In doing  this, especial care
must be taken not to direct the edge upwards, so  as to split either of the tibial
arteries, more  particularly the anterior:  for  as this vessel retracts  above the
membrane, its ligature when divided too high, is no easy matter.  In sawing the
bones, the fibula should always be cut first, as otherwise it will be pretty sure to
be splintered.   This bone may be best divided on the left side, by sinking the
hand below its  level of the limb, and  using  the  heel  of the saw:  and on the
right, by holding the  hand above the limb, and cutting with  the  end of the
instrument.
  If the limb be very muscular,  a large pad of the muscles of the calf will be
left in  the posterior flap;  this will  usually be a good deal in the way during
treatment; may slough,  and thus interfere  with proper union.   In order to
avoid this,  the best  operation consists, in  such  cases as  these, in forming skin-
flaps on the anterior and posterior  aspects of the limb, and then making a cir-
cular cut through the  muscles.   In this way  the  ends of the bones receive but
a thin covering; but this matters little if the operation is performed just below
the knee, for the patient bearing upon the anterior face of the stump, exercises
no pressure upon its cicatrix when an artificial limb is adapted to it.
  Amputations of the thigh are commonly required, both for accident and for
disease;  they  may be performed in  three situations : immediately above  the
knee, in the middle of the limb,  or in its upper third.   In the amputations in
the lower and middle  third, a tourniquet  may be applied  high in the limb;  but
when the operation is done in the upper third there is  no space for the applica-
tion of this instrument, and the  surgeon  must then trust to an assistant com-
pressing the artery as  it passes over the brim of  the pelvis.  This is best done
by grasping the great  trochanter with the fingers of the  right  hand, and then
applying the thumb firmly over the artery; upon  this the other thumb  is  then
pressed as  firmly as possible, and thus all chance of letting the vessel slip is
prevented.
                                  Fig. 35.
  Amputation above the knee, or Vermale's  operation, is best done  by lateral
flaps.   In performing this operation, the outer flap should always be made first.
The point of the  knife  being  entered  in  the middle  of  the thio-h about three
inches above the  upper border of the patella, is  carried close round the bone
and brought out through the centre of the ham; the flap is then cut downwards
and outwards; the knife being entered again  in the upper angle of the incision
is carried close round the bone to  its  inner  side,  and the inner flap made by a
sweeping cut (Fig. 35).  Unless the blade be kept in contact with the bone in 
AMPUTATIONS  OF THE THIGH.
103
this situation the femoral  artery is  very apt to be split;  the flaps being then
retracted, the bone is cleared by two sweeps of the knife, and  sawn  about four
inches above its articular surface.
  In the mfiddle and upper third of the thigh, the antero-posterior flap operation
is to be preferred.   In ordinary cases the anterior flap may first be made, and the
posterior one  subsequently                      Fig. 37.
fashioned  by  transfixion
(Fig. 36).  If, however, the
patient be  very much ema-
ciated, it is difficult to get
a good cushion from the an-
terior part  of the  thigh in
this way, and it  is conse-
quently preferable to follow
the plan recommended  by
Mr. Luke, of making  the
posterior flap first  by trans-
fixion,  and  the anterior one
afterwards  by cutting from
without inwards (Fig.  37).
If the patient be excessively
muscular, and the amputation be a primary one, I think it is better to make skin-
flaps with a circular incision through the subjacent soft parts.   In this way the
large gaping fleshy stumps are avoided, which commonly run into unhealthy sup-
puration and sloughing, and lead to the death of the patient.
  Amputation at the hip-joint has been performed in a  variety of ways, which it
is not necessary to  detail.  The  simplest and  speediest is, I think, that recom-
mended by Mr. Liston, and figured in  his "Operative Surgery."  It consists in
making a large and thick anterior flap by transfixion, and a short posterior one
from the gluteal region and  back part  of the  thigh.  In  order  to perform this
operation properly, the patient's  body must be brought well forwards upon  the
edge of the table, so that the nates  project beyond it, with the sound  limb tied
to the leg of the table.   One assistant,  whose duty it is to compress the arteries
as they are cut and raise the anterior  flap,  should stand behind the  surgeon;
another must have charge of the limb and impress such movements  on it as to
bring the head of the femur  into the best position for the proper performance of
the operation.   The duties of both these assistants are of the utmost importance,
and should  only be intrusted to fully competent persons.  The  pelvis and body
must be well steadied by two or three others.  The knife, which must have a
blade fourteen inches long, requires to be  entered and the flap to be made  in
different ways, according to the side of the body on which the operation is per-
4869 
104
SPECIAL  AMPUTATIONS.
formed.  If it be on the left side, the knife should be entered about two fingers'
breadth below the  anterior  superior spine of the ilium,  and carried deeply in
the limb behind the vessels,  and directly across the joint; its point being made
to issue just above the  tuberosity of the  ischium (Fig. 38).  The anterior  flap
must then be rapidly cut downwards and forwards, about five inches in length.
The limb, which had, during this stage of the operation, been raised and slightly

                                   Fig. 38.
flexed upon the abdomen, must now be forcibly abducted and everted;  the cap-
sule of the joint is then to be opened by a firm cut with the point of the knife.
So soon as this is done, the head of the femur must be pushed up, so that it may
start out of the acetabulum; the heel of the knife is then passed behind it, the
remainder of the capsule cut across, and the posterior flap rapidly fashioned by
carrying the knife downwards and backwards through the thick  muscles in this
situation.   When the amputation is performed on  the right  side, the anterior
flap is made by entering the knife just above the tuberosity of the ischium, and
bringing it out two fingers' breadth below the anterior superior spine of the ilium
(Fig. 39); the remaining steps of the operation being performed as in the last case.
                                   Fig. 39.
  In amputation at the hip-joint, the great danger to be apprehended is excessive
hemorrhage, the incisions being made so high up  that  no tourniquet can be
applied, or pressure of the artery in  the groin trusted to.  It  is therefore  of
great importance to perform the operation with as  much rapidity  as possible, and
the disarticulation ought to be effected in, at most, thirty or forty seconds.   7he 
AMPUTATIONS AT  THE  HIP.
105
arrest of the hemorrhage during  the operation must be intrusted to an assistant
who can be fully relied on.   His business should be to  follow the knife in the
first incision, and, as the anterior flap is being made, slip his fingers under it and
grasp it firmly above and below, so as to compress the femoral artery in it, which
is divided as the knife cuts its way out (Fig. 40).  By grasping the flap tightly,
                                    Fig. 40.
there will be but little risk of undue  hemorrhage from  the femoral artery; but
lest it should slip, or the assistant whose duty it is to attend to it by any chance
fail in holding it properly, it may be well  to direct  one of the assistants, whose
business it is to steady the trunk, to have his thumb well pressed down into the
iliac fossa, so  as to compress the artery against the brim  of the pelvis.^  As the
posterior flap is being made, the bleeding from the gluteal and sciatic vessels,
which is often very free, may be arrested by covering them with the fingers  or
a sponge.   The arteries may then be ligatured one by one, as the assistant raises
his fingers from  them.   If he have good hold of the femoral, the vessels in the
posterior flap  may be tied first; but if the  femoral be insecurely held, it must
first be tied.   Another point of importance in  this operation in making the first
puncture across the thigh, is to avoid wounding the opposite limb, the scrotum,
or the obturator foramen; this may be done by keeping these parts out of the way
of the knife, and carefully guiding its course parallel to, but not against, the pelvis.
   The result of amputation  at the hip-joint has been investigated by Dr. Stephen
Smith of the United States; he has collected 98  cases  in which this operation
has been done, of which 56 died, and 42  were  cured.   With reference  to the
cause of amputation, it is stated that in 30  cases it was for injury;  of these 18
died, and 12 were cured; whilst in 32  cases in which  it was  done for  chronic
disease, 16 died and 16 were cured.  It is a remarkable  fact, according  to Dr.
Smith, that the mortality from this operation has been greatly less of late years
than formerly; this he attributes to the cases  having been better selected, the
operation more skilfully performed, and, above all, to the employment of anaes-
thetics ; indeed the employment of  chloroform must necessarily greatly diminish
the risks of an operation such as this, in which the effect of shock is much to be
dreaded. 
DIVISION    SECOND.
SURGICAL INJURIES.
                           CHAPTER  V.

                        EFFECTS  OF INJURY.

  The effects of an injury, if at all severe, are twofold, constitutional and local.
  The constitutional effects are immediate and remote.
  The immediate constitutional effects, or shock, as they are  termed, consist in
a disturbance of the functions of the circulatory, respiratory, and nervous systems,
the harmony of action of the  great organs of the  body becoming  disarranged.
On the receipt of a severe injury the sufferer becomes cold, faint, and trembling;
the pulse is small and  fluttering;  there is great mental depression  and disquie-
tude ; the disturbed state of mind revealing itself in the countenance, and in in-
coherence of speech and thought; the surface becomes covered by a cold sweat;
there  is nausea, perhaps vomiting, and relaxation of the sphincters.   This condi-
tion lasts for a variable period, its duration depending on  the  severity of the in-
jury, and on the nervous susceptibility of the patient.   In  extreme cases, the
depression of power characterizing shock may be so great as to terminate  in death.
In the great majority of instances, however, reaction comes on, and the disturbed
balance in the system is gradually restored.  Not unfrequently the reaction runs
beyond the limits necessary for this, and a febrile state is induced.
  Is this state the result of fear and  nervous susceptibility ?  or is  it occasioned
directly by the physical lesion ?  In many cases, doubtless, the effect is entirely
mental.  Thus persons have been frightened to death without  any local mischief.
That there is great difference in the mental fortitude of individuals is notorious;
some  suffering excessive  shock from the mere  apprehension of injury, whilst
others may be the  subjects of the  severest injury, and show  but  slight si^n of
suffering.  If the injury be sudden and unexpected, the shock is usually greater.
When the feelings  are roused, as in the heat of action, injuries often pass unno-
ticed by those who receive them.   Hence it is evident, that the state of mind at
the time of the receipt of the injury materially influences  its immediate effect on
the constitution.  There can be little doubt, however, that different individuals
manifest very different degrees of susceptibility to pain, independently of the
moral courage that enables them to support it unflinchingly.  Instances of this
kind must have fallen under the observation of every surgeon.
  The sudden occurrence of a severe injury will induce  all the signs  of shock,
independently of any mental  impression.  Thus it has been  found, that if the
limb of one of the  lower animals be suddenly crushed, the force and frequency
of the heart's action becomes suddenly considerably lessened.  Here  there can
be no mental impression.  So in man, it is found that the severity  and the  con- 
EFFECTS OF INJURY.
107
tinuance of the shock are usually proportionate  to the  severity of the injury.
The surgeon  not  unfrequently employs this fact as an accessory means of diag-
nosis.  Thus, if a man break  his leg, and at the same time strike his abdomen,
and the shock be very serious, and long continued, without sign of rallying, the
probability is that some severe injury has been inflicted upon an internal organ;
injury of the  viscera occasioning greater severity and longer continuance of shock
than a wound of a less vital part.
  The remote effects of shock give rise to serious constitutional disturbance,  as
has been pointed out by Hodgkin and James, which often do not manifest them-
selves for weeks or months after the infliction of the  injury.   Some change ap-
pears to be induced in the condition of the  blood, or in the action of the nervous
system, that is incompatible with health; severe febrile diseases, usually of a low
form, supervening.   Perhaps, as Hodgkin  supposes, the part locally injured be-
comes incapable of proper nutritive action, and thus  a morbid poison results,  in
consequence of the peculiar combination of the chemical  elements of the part, by
which the whole system is influenced.   Be this as it may, the fact remains cer-
tain, that constitutional disturbance  may continue for, or supervene, at a consi-
derable time  after the infliction of a local injury.
  The direct local effects of injury comprise  contusions,  wounds of all  kinds,
fractures and dislocations; these we shall immediately proceed to consider.
  The remote local consequences of injury are not so obvious.  But there can
be no doubt that  many structural diseases owe their  origin to this cause.   The
nutrition of a part may readily be modified to such an extent by a blow or  wound
inflicted upon it, as to occasion those  alterations in structure which constitute
true organic disease.   Thus we occasionally find on death resulting some months
after a  severe injury,  that extensive local  mischief, usually of an inflammatory
character, is disclosed, which has evidently been going on in an insidious manner
from the time of the accident.
  In other cases again, a  blow may give rise to severe and long-continued neu-
ralgic pains in a part, or it may be the  direct occasioning cause of structural dis-
ease in bones, joints, or blood-vessels;  and, lastly, the origin of many cases of
cancer can be distinctly referred to external violence.
   Treatment of Shock.—If the disturbance be chiefly of a mental character, the
patient will usually rally  speedily by being  spoken to in a kind and cheering
manner, or by having  a little  wine and water or  ammonia administered.  If the
shock be of a more severe character, and be the result of considerable injury, the
patient should be laid in  the recumbent position, and the injured part arranged
as comfortably as possible; he should be wrapt up in warm blankets, hot  bottles
should be applied to the  feet, and  friction  to the hands and surface; a  little
warm tea, wine, or spirit  and  water, may be  administered, provided the insensi-
bility be not complete; if so, it should not be given, as the fluid might then find
its  way into the larynx.   Under these circumstances  ammonia should be applied
to the nostrils, and a  stimulating enema administered.   When there is  much
pain associated with the shock, a few drops of laudanum may advantageously be
given.  By  treatment such  as  this,  the energies of the  nervous and vascular
systems are gradually restored, and then reaction speedily comes on.
   A question of considerable importance frequently occurs to the surgeon in these
cases, viz., whether an operation should be performed during the continuance of
shock.  As a general  rule, it certainly should be deferred until reaction comes
on, as the additional injury inflicted by the operation would increase the depres-
sion under which the patient is suffering.  In some cases, however, the presence
of a crushed limb appears to prolong the  shock, and thus prevents the  patient
rallying, notwithstanding the administration of stimulants.   Under these circum-
stances, the  surgeon would  be  justified in  operating before reaction come on.
Here the  administration  of chloroform is extremely beneficial by preventing the 
108
SHOCK — TRAUMATIC  DELIRIUM.
pain and dread of the operation from still  further depressing the vital energies.
In  these cases of long-continued shock, great care is required in ascertaining
that there is no internal injury giving rise to the depression, but that the shock
is really dependent upon the mangled limb.
  After the immediate effects of the shock  have entirely passed away, we must
adopt means to prevent the remote  consequences that  have been  alluded to.
With this view—if the patient can bear it—the old remedy of bloodletting is
of essential service, and, I think, far too much neglected at the present day.  In
addition to this the patient's diet and habits  of life should be carefully regulated
for  some time, especially with a view  of preventing over stimulation;  his bowels
should be kept freely opened, and  his general health attended to.   After the
immediate  effects of  shock  have gone off, the  reaction  which  ensues may hot
pass the limits  of health; but if the injury be severe  from its extent or the im-
plication of important parts, the local  inflammation, which is necessary for its re-
pair, gives rise  to a general febrile state.   This inflammatory fever assumes one
or other of the types  characterizing that which accompanies ordinary inflamma-
tion, and requires to be treated on  the principles  that guide us in  the manage-
ment of that affection.
  Traumatic delirium not unfrequently occurs in cases of severe injury in in-
dividuals with an irritable, nervous system;  particularly in  those who had been
drinking freely before, or were intoxicated at the time of the accident.   It usually
comes on about the third or fourth  day, but  not  unfrequently earlier than  this;
and most commonly declares itself  during the night.   This disease presents two
distinct types—the one inflammatory the other irritative.
  In inflammatory traumatic delirium there is a  quick  and bounding pulse;
hot skin and head, flushed cheeks,  glistening eyes, much thirst, and high febrile
action generally.   The delirium is usually furious;  the patient shouting, singing,
tossing himself about  the bed, and moving the injured  limb regardless of  pain.
The treatment  of this form of the  disease is strictly antiphlogistic.   Bleeding
from the arm, or leeches and ice to the head; purging, and low diet will subdue
it;  but in many cases it is speedily fatal.
  The irritative, or nervous delirium usually occurs in persons of a broken con-
stitution; and closely  resembles  ordinary delirium-tremens.  In this form of the
disease  the  pulse is  quick, small,  and irritable;  the pupil dilated;  the surface
cool; the countenance is pale, with  an anxious, haggard expression, and bedewed
with a clammy sweat.   The tongue is white, and there is sometimes tremor of it
and of the hands; but this by no means invariably occurs.   The  delirium  is
usually of a muttering and suspecting character; the patient is often  harassed
by spectral  illusions,  but will answer  rationally when spoken  to.  This form of
disease  is sometimes very rapidly fatal.  A strong, hale man, but an immoderate
spirit-drinker, admitted into University College Hospital with  a simple fracture
of the thigh, died of this form of delirium twelve hours after it first showed  itself.
  The treatment of irritative traumatic  delirium consists essentially in the ad-
ministration of opium until sleep is procured, or the  pupil  becomes contracted.
For this purpose  large quantities are frequently required;  and  the  drug should
be given in full doses; from twenty to thirty  minims of laudanum or half a  grain
of the muriate  of morphia being required every second or third hour.
  If there be much  depression, it  will usually be expedient to  administer the
opiate in porter, or in that stimulant  to which the patient—if a  drunkard—has
habituated himself.   The administration of the opiate should be preceded  by a
free purge and an aperient enema, so  that all source of irritation may be removed
from the intestinal canal.   A strait waistcoat is commonly necessary in all cases
of traumatic  delirium, in order to prevent the patient injuring the wounded part.
  After sleep has been induced, the  quantity of the  opiate' must be  lessened; 
CONTUSION.
109
but it will be  found necessary to continue it for some time, as there will be a
tendency to the recurrence of the delirium at night.
  These  two forms of traumatic delirium, the inflammatory and the irritative,
are  often found more or less conjoined; in practice a modification of the treatment
then becomes requisite,—the surgeon depleting with one hand, and allaying irri-
tation and giving support with the other.
                           CHAPTER  VI.

                     INJURIES  OF SOFT PARTS.

  Contusion.—In  a contusion  the  skin  is unbroken, but  there is always some
laceration of the subcutaneous structures.   Indeed, great disorganization of these
occasionally takes place, though the skin continues entire  owing to  its greater
elasticity and toughness.  Hence a contusion may be  loooked upon as being a
subcutaneous lacerated wound.
  Contusions may  result from direct  pressure—as, when  a part  is  forcibly
squeezed.   From a direct blow, usually by a hard blunt body;  or from an in-
direct blow, as when  the hip-joint is  contused by a person falling  on his feet
from a height.
  Compression of the  parts injured is  always  necessary for a contusion.  This
compression may occur between the force on one side, and a bone as the resisting
medium on  the  other; or the part injured  maybe compressed and  contused
between two forces in action—as when  the hand is caught between two wheels
revolving;  or between a force in action and a passive medium—as by a  wheel
passing over the limb and crushing it against the ground.
  Contusions are of various degrees; they may be arranged as follows :—1st, of
the skin simply;  2dly, with extravasation into the  cellular tissue; 3dly, with sub-
cutaneous laceration of the soft parts; 4thly,  with subcutaneous  disorganization
of the soft and hard parts.
  In all cases extravasation of blood is  the chief characteristic of contusion.   In
the first degree the blood is merely effused into the skin, producing ecchymosis
or bruise; the color of which varies from purplish-red to greenish-brown;  being
dependent upon changes that take place in the extravasated blood as it undergoes
absorption.
  In the second  degree, a bag of blood can often be felt  fluid  and fluctuating
under the skin, in which state it may remain for weeks  or even months without
undergoing any material change, provided it be excluded from the air.   In other
cases it gradually becomes absorbed; or, if it communicate with the air, the bag
being opened in any way, it may undergo  disintegration, suppuration taking-
place within  or around  it,  and the clots discharging through an abscess.   In
some cases it would appear from the observations  of P. Hewett  and  of Paget,
that the clot resulting from extravasated blood, may become organized and finally
penetrated  by bloodvessels.  The French pathologists have described the forma-
tion of a cyst containing serous fluid in the site of the extravasated blood; the
fibrine disappearing and the serum being left.  In other cases the  serous or fluid
parts are absorbed, and the fibrinous matters forming cheesy concretions are left
behind.   Lastly, extravasated blood may give rise to a  sanguineous tumor,
Hematoma, the blood—continuing for years fluid, but still not unchanged—be-
coming darker, treacly, and more or less disintegrated, being intermixed with
various products of inflammation. 
110
INJURIES OF  SOFT  PARTS.
   In the third and fourth degrees of contusion, the laceration and disorganiza-
 tion of structures  usually leads to fatal internal hemorrhage, to sloughing and
 suppuration, or to rapid gangrene  of the parts.
   The diagnosis of contusions is  not always easy.   The minor degrees may be
 mistaken for incipient gangrene;  the discoloration not being very dissimilar, but
 that the part when simply contused preserves its temperature and vitality.  In some
 cases the extravasated blood has a hard circumscribed border,  and is soft in the
 centre, thus resembling somewhat a depression in the subjacent bone.   This is
 especially the case in some bruises about the scalp.
   The diagnosis of old cases of extravasation, leading to Hematoma, from abscess
 or malignant disease, is not always easily made by tactile examination only;  but
 the history  of the case, exploration with a grooved needle, and examination of
 the contents of the tumor under the microscope, will always clear up any doubt
 that may exist.
   Treatment.—In the two first degrees of contusion our great object should be
 to  excite, as speedily as possible,  the absorption  of the extravasated blood.
 Here cold applications are of especial service;  lotions composed of one part of
 spirits of wine or of tincture of arnica to eight or ten of water should be constantly
 applied. Of the value of arnica in these cases I entertain no doubt; I have employed
 it largely in the most extensive extravasations, and have  rapidly promoted their
 absorption by its use.  Leeches—so commonly used in these  cases—should  not
 be applied to a bruised part; they cannot remove the blood that has already been
 extravasated, and  often set up great irritation that leads to its suppuration.  The
 bag of blood should never be opened, however soft  and fluctuating it may feel,
 so long as there  is any chance of procuring its absorption by discutient remedies;
 but if signs of inflammation occur around it, the parts  becoming  red, hot, and
 painfully throbbing, free incisions should at  once be made, the blood—already
 disorganized and  mixed  with pus—be  discharged,  and the  cavity allowed to
 granulate.   Purging and general antiphlogistic treatment will  often be found of
use in promoting absorption of the extravasation.
   In  the third and fourth  degrees of contusion it  is useless  to attempt to save
the life of the injured part.   Here poultices must be applied to hasten suppura-
tion and the separation of the sloughs;  the  ulcer that  results being treated on
general principles.  In the worst cases of contusion, where the structures of the
 limb are disorganized, amputation is the sole resource.
   Contusions of internal organs are always of a  very serious  character, and re-
quire special treatment, according  to the part that is affected, and  the extent of
 its injury.
                                 WOUNDS.

   A wound may be defined to be a solution of continuity suddenly produced by
 the incision, rupture, or fracture of a part.
   Surgeons universally divide wounds into incised, lacerated, and contused,punc-
 tured, and poisoned.
 ^ Incised wounds may vary in extent, from a simple superficial cut to the inci-
 sions required in the  amputation at the hip-joint.   Incised wounds are usually
 open, communicating freely with the air;  occasionally, however, when  made by
 the surgeon, they  are subcutaneous,  only communicating  externally by a small
 puncture; they may be simple, merely  implicating integument and muscle, or
 complicated with injury of the larger vessels and nerves, or of important organs.
 In all cases  they give rise to three symptoms; viz., pain, hemorrhage, and 'sepa-
 ration of their sides.
   The pain in an incised  wound is usually  of a burning, cutting 0r smarting
 character.   Dr.  J. Johnson compared his own sensations to the pa?n experienced
 by a stream of melted lead falling upon the part.  Much depends however  on 
UNION  OF  WOUNDS.
Ill
  the extent and the situation of the  wound;  and also whether  the cut is made
  from the  cutaneous surface,  inwards,  or from within outwards;  being much
  greater in the former than in the latter case, owing to the section of the  nerves
  being made from the branches towards the trunk.   When the cut is from  within
  outwards, the trunks being first divided, the branches are paralysed, and  do not
  feel the subsequent incisions.
     The  amount of hemorrhage necessarily depends upon  the vascularity  of the
  part, as well as on the size of  the wound.  The proximity of the part wounded
  to the centre of the circulation, or to a large vessel,  also influences this very  con-
  siderably—different parts of the same tissue bleeding with different  degrees of
  facility.  Thus the skin of the face pours out more blood when  cut than that of
  the leg.  The same parts will, under different states of irritation, pour out diffe-
  rent quantities of blood.  Thus the tonsils have bled, after their excision, to such
  an extent as to occasion death, although usually but a few drops are lost.
     The separation of the lips of the  wound depends  on their tension, and the po-
  sition of the part, as well as on the elasticity and vital contractility of the tissues.
  It is greatest in those  parts that are naturally most  elastic  or  that possess the
  greatest degree of tonicity; thus the muscles, when  cut, will retract to a distance
  of some inches; so also the arteries  and skin gape widely when divided; whereas
  in the ligaments, or bones, no  retraction takes place.
     Incised wounds  may unite  in the five following ways:—1st, by  the direct
  growing together of their opposed surfaces; 2dly, by scabbing; 3dly, by the oppo-
  site surfaces uniting through the medium  of coagulable lymph; 4thly, by granu-
  lations springing up from the  sides and bottom, and  thus filling up the wound;
  and 5thly, by the growing together of two granulating surfaces.
     The direct growing together of opposite  surfaces was termed by Hunter "union
  by the first intention/' though this  term is not  employed in this acceptation by
  all modern surgeons, some of whom extend it to the next process.   When wounds
  unite in this way it is by the simple and direct coalescence  of the opposed  sur-
  faces ;  and not, as Hunter had supposed, by the interposition of a layer of effused
  blood becoming the bond of union;  or, as  others have imagined,  by lymph being
'  poured out, which  united  the opposed surfaces.   Dr. Macartney, who pointed
  out the error of these doctrines, has shown that in this kind of union there is no
  intervention of blood or of lymph; the process consisting essentially in clean cut
  parts laid in apposition, uniting and growing together directly in the course of a
  few hours, without inflammation or any of its products being required to effect
  the union.   [He therefore termed it " immediate union/' which name has since
  been generally recognised.]
     The conditions necessary for the  direct union appear to be the perfect coap-
  tation of the cut surfaces;—a healthy constitution, and the absence of all inflam-
  matory action.  It is not often in surgical practice that such a simple and direct
  result can be obtained, though in some of the plastic operations about the, face,
  we not uncommonly succeed in securing it.  After some of the larger operations,
  also, this kind of union occasionally takes place.  Thus Paget records a case of
  amputation of the  breast, in which  the flaps contracted  immediate and  direct
  union with the  subjacent parts;  and on the patient dying at the end of three
  weeks, of erysipelas, the union was so perfect that it was impossible to discover
  by microscopical examination  that  any inflammation  had existed, or exudative
  matter been  poured out.  In some flap operations, the surgeon may be successful
  in attaining union by this  means.  Thus in amputations of the thigh  and arm,
  we occasionally find that nearly,the whole, or a considerable portion, of the flaps
  are united together at the expiration of about eight-and-forty hours.
     Healing by  scabbing consists in  the direct  adhesion of the lower part  and
  sides of a wound under a crust of dried  blood, hair, etc., which forms an air-
  tight covering.   The absence  of inflammation is necessary for healing by scab- 
112
INJURIES OF  SOFT PARTS.
 bing; if inflammatory effusion occur, the scab will be thrown off; and air getting
 admitted, an ulcer forms, upon which granulations will spring up.  This kind of
 union is extremely rare in man, owing to the  readiness with which inflammation
 is excited; but is  common in the lower animals, inflammation not being so readily
 induced in them.   This natural process is sometimes imitated by the surgeon
 closing a wound with a piece of lint steeped in blood or in collodion, under which
 union takes place.
   Analogous  to healing by  scabbing  is the process  of cure  in  subcutaneous
 wounds, as in tenotomy;  in these, union takes place without any inflammation,
 though this is sometimes excited by the injury.   The reparative material, "nu-
 cleated blastema/' not being an inflammatory  product.
    Union by the adhesive inflammation [the union by the first intention of modern
 surgeons], or, " primary adhesion/' as it is termed  by Paget, consisting in  the
 effusion of lymph between the opposed surfaces, is more frequently obtained than
 the direct union.  In order that it  should  take place, it is of great importance
 that no blood  be interposed between the sides of the incision; hence it is facili-
 tated by all oozing being allowed to cease, and by the surfaces being allowed to
 become glazed by  the exudation of lymph for some hours before  they are brought
 in contact.  If any blood be interposed, it acts as a barrier to the cohesion of the
 opposite layers  of plastic  matter, invariably  becoming disintegrated,  breaking
 down, and being washed away by the suppuration  excited by its  presence; hence
 in the dressing of surgical wounds, such as  stumps after amputation, in which it
 is desirable to procure union by adhesive inflammation, the cut surfaces should
 not be brought together for a few hours, until all oozing of blood has ceased, and
 the  fibrinous layer thrown out.
   The union by adhesive inflammation  in an  incised wound takes place in  the
 following manner.  After all  hemorrhage  has  ceased, the surface  becomes
 " glazed," being covered with a film of the  fibrine of the liquor sanguinis, with
 which a large quantity of white corpuscles are  found intermixed; a  sero-san-
 guinolent fluid draining away.   This layer of fibrine rapidly becomes thickened
 by the deposit of exudative matter,  and ultimately becomes vascular, undergoing
 development  into  fibro-cellular  tissue, which  constitutes the bond  of union, its
 exposed surface becoming gradually covered by an epithelial layer, as has al-
 ready been described in speaking of the development of lymph and its  cicatriza-
 tion. This adhesive layer forms with varying  rapidity on different surfaces; thus
 in a stump, after amputation, it will be  found  that the muscles,  fasciae, and cel-
 lular tissue are covered with fibrine in the course of a few hours; it is  not until
 about the third or fourth  day that the subcutaneous fat becomes coated in  the
 same way, and eight or ten days elapse  before the adhesive  lymph is thrown  out
 upon the cut surface of the bone; and here it shows itself first on the medullary
 canal, afterwards on the cancellous  texture,  and lastly upon the  hard bone.
   Fpr the production and organization of this  lymph a certain amount of in-
 flammation is absolutely necessary, but the inflammation must be confined within
 proper limits.   If too violent, the adhesive  may pass  into the suppurative inflam-
 mation ; and if  too long continued, its development  may be interfered with; for
 though inflammation be necessary for the formation  of the bond of union, none
 is required  for  its organization, or  its  ultimate development into  fibro-cellular
 tissue.
   In those cases, in which union by direct cohesion, or* by the adhesive inflam-
 mation, fails, either  by the interposition of blood, by the excitation of undue in-
 flammation, by the wound being left open  to  the air, or by  any  other disturbing
 cause, granulations are thrown out,  and union by " the second  intention/' as it
 is termed, occurs; and one may often see,  in  the same incised  wound, one por-
tion healed by direct union, another part by the adhesive inflammation, and  the
 remainder by granulation.  Union  by granulation, or  the second intention, has 
TREATMENT  OF  INCISED  "WOUNDS.
113
 already been  described when speaking of the repair of ulcers, with which it is
 identical.   A layer of plastic exudation is deposited, which gradually increases in
 thickness, becoming vascular:  accumulating  in  masses of pointed and  ruddy
 granulations, throwing off pus and effete corpuscles from its surfaces, and develop-
 ing in the deeper parts into fibro-cellular tissue, whilst the more superficial por-
 tion undergoes epithelial transformation.
   It not unfrequently happens that although granulations have sprung up, union
 between the opposed surfaces has not taken place.   We must endeavor to accom-
 plish this, by bringing the granulating sides of the wound together, when they
 cohere, thus constituting union  by "secondary adhesion."  In some amputations,
 and in many plastic operations, cases of hare-lip, cleft-palate, &c, this mode of
 union is occasionally established.
   Management of Incised Wowids.—In the treatment of an incised wound,  we
 must always endeavor  to procure direct union or adhesive inflammation between
 a portion if not the whole of the surfaces; if  union in this way be obtained,  we
 save the patient much time and trouble.
   The probability of procuring adhesive union depends  greatly upon  the consti-
 tution of the patient, as well as  on the management of the wound.  The sounder
 the constitution, the more readily will  union by the  first intention take place;
 and, in all cases, it is disposed  to it  by the removal of all sources of irritation
 from the system.  Thus in those operations, the plastic, for  instance, in which
 it is necessary that the union be as  direct as possible, the  constitution of the
 patient should be prepared, by his being  kept for  some days, or weeks, upon a
 nourishing, but  unstimulating diet, chiefly consisting of milk and light animal"
 food, having regular exercise, and  his  bowels acted on by saline aperients :  we
 should also look specially to  the state of the digestive and urinary organs, and
 remove any source of irritation in connexion with them.   In  cases of  accidental
 wound, if we wish to secure union by the first intention, we must purge the patient,
 keep him quiet, and employ a moderately antiphlogistic regimen, avoiding espe-
 cially all stimulants, which have a great tendency to interfere  with this desirable
 result.  It must be borne in mind, that the great object is to limit inflammation;
 if this be carried beyond what is necessary for plastic effusion,  suppurative action
 will certainly occur.  With regard to local antiphlogistic treatment, nothing is re-
 quired beyond simplicity of dressing, and keeping the part cool by means of wet
 lint, or, if the wound be very extensive, and inflammatory action threaten to run
 high, by irrigation (Fig. 3).
   There are three great indications in the local management of an incised wound.
   The first is  the arrest of hemorrhage.   If the bleeding be general from the
 surface,  it may be  stopped  by  position,  by  coaptation  of  the  sides of the
 wound, and by the application of cold and  styptics.  If it  be  of an arterial
 character, ligatures will be required to the bleeding points.
   The next indication consists  in the removal of foreign bodies of all kinds;
 such as dirt, pieces of stone, glass, &c, including coagulated blood from between
 the  lips of the wound.  In  doing this, care  should be taken not to wipe the
 wound too roughly;  a  piece of soft lint, a  triangular bit of sponge, or a stream
 of cold water poured over the surface, should be the means employed.
   The next and most important indication to  fulfil, is the coaptation  of the op-
posed surfaces as accurately as possible.  This  can only be obtained by attention
to position, and by the application of^sutures, plaster, and bandages.
  As a general rule, the sides should* not be brought  together until all hemor-
rhage has ceased.   If, however, there be but slight oozing, this may be arrested
by the approximation of the  surfaces.   If the wound be extensive, it  may  be
advantageous to wait for a few hours, until its  sides are glazed over  by a layer
of fibrine.   The parts  should now  be brought gently in contact,  due attention
being paid to relaxing  them as much as possible, by position,  so that there  may
                                      8 
114
INJURIES  OF  SOFT  PARTS.
Fig. 41.
be no gaping of the lips, or tension on  the sides of the wound.   They must be
kept in position by sutures, plasters, and bandages.
   Sutures are commonly employed when there is more tendency to gaping than
can be overcome by position or plasters.   The material that is used for this pur-
pose is well-waxed dentist's or twisted silk of various degrees of fineness, intro-
duced by means of a curved needle.  In wounds of the limbs, especially in those
cases in which some traction may be expected, the suture should be composed of
soft thick silk-twist; whilst in those cases in which it is of importance that as
little deformity as  possible be  left, it should consist of the finest  silk or thread
that is compatible  with the requisite strength.
   Sutures may be of various  kinds: the interrupted (Fig. 41) consisting of a
                            number of single stitches,  applied at  distances
                            varying from half an inch to an inch and a half, is
                            the  one  most  commonly had recourse to in all
                            cases involving the integument.   In applying this
                            suture the needle  should never be carried  deeper
                            than the fascia except in  some of the parts about
                            the face, such as the lips and eyelids.  The suture
                            should be tied by  means of the  reef-knot, and  the
                            ends be cut short.
                               The continuous suture, never used on the cuta-
                            neous  surface,  is  principally employed  in incised
                            wounds of the intestines.
                               The quilled suture (Fig. 42) is applied in cases,
                            as in rupture of the perineum, in which the sides
                            of a deep wound are required to be brought into
contact throughout.  It consists of a double interrupted suture  passed  deeply
                                           and  tied  tightly  over  pieces  of
                                           elastic bougie, laid parallel  to, and
                                           at the distance of half-an-inch from
                                           the edges of the wound.
                                              The beaded suture is  rarely em-
                                           ployed at the  present  day: in it
                                           the knot is made over a large bead,
                                           or a split shot,  strung upon either
                                           side of the suture, which thus dif-
fuses the pressure  over a greater extent of surface.
   The twisted or  figure of 8 suture (Fig. 43) is  very commonly employed  in
surgery; it consists in the introduction of a slender pin, made of soft iron, with
a steel point, across the lips of the wound, and the application  of  soft silk-twist
over this  in the manner of a figure of 8,  care  being taken not  to draw it too
tight, or to compress the soft parts between the needle and suture, lest slou^hin"
result.                                                        '         °    °
   Sutures, of whatever kind, act as irritants  along the tract through which they
                 are applied, hence they  should always  be withdrawn so soon
                 as they have accomplished their  object—that  of  procuring
                 union of the opposed surfaces.   Every minute that they are
                 left in beyond this is detrimental to adhesion, and is attended
                 with a  risk  of the excitation of undue action.  In general
                 they should not  be left in  beyond  eight-and-forty hours;  but
                 in some cases they may advantageously be  retained  for  a con-
                 siderably longer period, provided they do not excite irritation.
                 When they are withdrawn, care should be taken  not to disturb
                 the adhesion in their neighborhood by improper traction.
   Plasters serve to maintain the approximation of the opposed surfaces   They
Fig. 42.
Fig. 43.
 
CONTUSED  AND LACERATED WOUNDS.
115
are of various kinds;  but the resin,  soap, and isinglass  plasters  are  those that
are most commonly employed.   Each of these possesses  peculiar  properties that
fit it for particular cases.  The resin plaster has the advantage of being the
most adhesive, and of not being loosened by discharges,  but  is often irritating,
sticky, difficult to remove, and in consequence of the lead that it contains, leaves
a dirty-looking incrustation  on the part.
   The soap plaster is less irritating, but at the same time is less adhesive, and is
consequently seldom  employed in  the treatment of wounds.  The isinglass
plaster is doubtless the most cleanly and least  irritating of all, and  being trans-
parent, possesses  the advantage of enabling the surgeon to see what  is  passing
beneath it.   It has, however, the disadvantage of being  readily loosened by the
discharges of the part, or by the necessary  dressings.   The  plasters  should  be
cut into strips of sufficient length to support the sides as  well as to compress the
edges of the wound, and should be  applied between, but not upon, the  points
of suture, all hairs having been removed from  the part  on which they are laid
down, and the surface being thoroughly dried.   In removing them,  both" ends
should be loosened at the same  time, and the strip thus taken off without either
lip of the wound being unduly  dragged upon.
   After  coaptation  has been effected by position, aided by the application  of
sutures and plasters, a strip of  water-dressing may be laid along the line of the
wound, and a piece of wet  lint  over the whole surface, which should be  kept as
cool as possible.   If any ligatures have  been  applied  to bleeding  vessels, they
must  be left hanging out  at the most  dependent angle.  The first dressings
should be left unchanged for two or three days, the  sutures may then be removed,
and the plasters as they become loosened; care being taken to support the sides,
and after a time to  bandage  the part  properly by circular turns of a narrow
roller.
   Union may be readily accomplished in many slight incised  wounds by covering
the edges of the cut with a piece of soft lint soaked in  collodion. Direct cohesion,
by a process analogous to scabbing, taking place under this dressing.
   If union by the first intention fail, or if the wound occur in such a constitution
that it is useless to attempt it,  inflammation takes place, in  and  around it, the
lips swell and become red, a sero-sanguinolent  discharge, gradually assuming a
puriform character, exudes; and, at the same time, if the wound be an extensive
one, that form of constitutional fever which is indicative of suppurative action,
sets in, the pulse becoming quick  and the  skin hot, with derangement  of the
digestive functions.   Under these circumstances, the sutures  should be imme-
diately removed; the strips of  plaster,  if continued should be used  merely for
support and not for union; a large soft linseed-meal poultice, or a thick piece of
warm water-dressing, should be applied; and the  patient put upon a moderate
antiphlogistic regimen.   When suppuration has fairly set in, and granulations
have  sprung up, the treatment must be conducted  in  accordance with those
general principles that guide us in the management of ulcerated surfaces.  The
suppuration must be moderated, the  process of cicatrization facilitated  by the
application of a bandage, the general health attended to,  and  the strength of the
patient supported.
   Union by "secondary adhesion" may sometimes be accomplished,  after that
by the first intention has failed, by bringing the granulating surfaces together a
second time by means of sutures and plasters.   In this way I have often obtained
excellent union in plastic operations in  which the first attempt by adhesion had
failed.
                   CONTUSED AND LACERATED WOUNDS

   Comprise a great variety of injuries.   They may be defined to be wounds that
are conjoined with more or less bruising about the edges and sides;  presenting 
116
INJURIES OF  SOFT PARTS.
every possible variety in the  degree of contusion and of wound, from a cut on
the shin to a limb crushed and lacerated by a cannon-shot.   They are commonly
inflicted by blunt  cutting instruments, as in chops by a hatchet, or^ they are in-
flicted by stones, bludgeons, &c.  Lacerations  by machinery, in which  parts are
torn off or crushed;  the bites and gorings of animals, and gun-shot injuries of all
kinds, come under this  denomination.
   Whatever their mode of infliction, these wounds present certain characters in
common, by which they differ from  all  other injuries.   Their lips are  irregular
and torn, less  gaping than in incised  wounds, but surrounded by more  or less
ecchymosis and  contusion, with  a tendency to slough on their sides.   There is
usually but little  hemorrhage, and  the  pain is of an aching  or dull character.
In consequence of the sloughy state of the lips and  sides, these wounds always
unite by the second intention.
   Contused and lacerated wounds present peculiarities according to their mode of
infliction.
   When occasioned  by  the bite of a large animal, the part injured becomes very
painful and inflames extensively, the wound being lacerated, much contused, and
often penetrating deeply.  It slough sin consequence of the pressure to which it has
been subjected, and  of  the animal  shaking and tearing the part seized.   When
the wound is  inflicted  by the tusk  or horn of  an animal, it is extensively lace-
rated rather  than contused, and often partakes of the  nature of a punctured
wound.
  When a part of the body is torn  off the wound presents peculiar characters,
which differ, however, according  as the  separation is effected at the part struck
or seized, or at a distance from it.
  In the first  case, as when a cannon-ball carries off a limb, or an arm is caught
in a steam-mill or rag-tearing machine and crushed or torn off above the elbow, the
stump presents a very ragged surface, the skin being stripped away higher  than the
other parts, the tendons hanging out, and the bellies of the muscles that are torn
across being swollen, protruding, and apparently constricted by the lacerated integu-
ment.   A most important condition in these wounds is that of the vessels; these are
separated lower  down than the  other  parts, for being elastic they elongate and
pull out before they give way.  There  is  no hemorrhage, because the inner and
the middle coats of  the artery breaking off short, allow the external  one to be
dragged down and twisted over its  mouth in such a way as to offer a complete
barrier to the escape of blood.  The bone is crushed off at the end of the stump
of which it forms the conical apex.
  Occasionally when parts are pulled  off, they are separated  at a distance from
the point seized.   Thus fingers that  have been torn off by machinery, have their
extensor tendons separated higher  up, at their junction with the  belly of the
muscle, and not at the part  seized; the tendon being drawn out of its sheath,
and hanging on to the separated end in a ribbon-like manner.
  In the progress of a contused or lacerated wound there are two distinct periods:
1st, that of the separation of the slough produced by the contusion; and 2dly,
that of repair by granulations of the chasm left.
  The extent of the  slough depends not only upon the extent, but also upon the
situation of the injury.   If the parts around the wound be much bruised, then
superficial sloughing  to a great extent may occur;  if the wound be deep though
not extensive,  there will always be danger  of troublesome sloughing, leading to
suppuration, and burrowing of matter, and in some cases to secondary hemorrhage.
Those wounds that are  situated  immediately over bony points—as the shin and
elbow—are especially tedious, as the slough frequently implicates  the fasciae.
The  scalp, however,  has a less tendency to slough than any other  part of the
cutaneous surface.   This is owing to its  great vitality, and the large supply of
blood it receives from  closely subjacent arteries.   In all cases of contused and 
TRAUMATIC  GANGRENE.
117
lacerated wounds—but more especially in  those  of the scalp—there is great
danger of the supervention  of erysipelas.   But the chief danger to be appre-
hended in wounds of this description is the  supervention of gangrene.   In these
cases gangrene may occur in three ways:—
  1st, The contusion always kills a thin layer of tissue, which forms a slough on
the sides or lips  of the wound;  but in some cases the violence done to the part
is so great as directly to kill its whole  substance.  Thus if a finger is crushed to
a pulp by machinery, all circulation  is completely and  at once arrested, and the
vitality of the part destroyed outright.  If the violence be not quite so great as
this, the  vitality of the part may be  so lessened, and  its  resisting  power dimi-
nished to such an  extent, that the inflammation necessary for the repair of the
injury terminates in gangrene.   This is a local  traumatic gangrene, evincing no
disposition  to spread beyond the part injured, but being bounded by a line of
demarcation  along which it will  separate.  It is  not always very easy to distin-
guish this direct form of gangrene from such discoloration and disorganization of
a limb as is still  compatible with life.   In all cases of doubt the surgeon must
wait, and a very short time—a few hours—will be sufficient to declare whether
the life of the part can be maintained  or not.   In cases of much doubt there can
be no objection to make an incision into the part,  and thus ascertaining the true
state of things.  But this should not be done if it can possibly be avoided.
  2dly.  The injury may be chiefly inflicted upon the great vessels of  the limb,
damaging them to  such an extent as to interrupt  completely the  circulation;
gangrene being  thus induced  indirectly in the parts supplied by them.   This
form of gangrene we shall have occasion to  treat of fully when speaking of inju-
ries of the arteries.
  3dly.  The true  traumatic or "spreading gangrene," the most fatal variety of
mortification, may occur from  comparatively slight  wounds, in consequence of
some constitutional disorder; but most commonly it is the result of severe con-
tused and lacerated injuries and fractures.   It has a tendency to spread rapidly,
especially through the cellular planes of the limb,  often involving the whole
member in less than twelve hours after its invasion.  Its occurrence is indicated
by the injured limb  becoming cold, being  greatly swollen, with pitting of the
cellular  tissue, and  afterwards with  much  tension and oedema of the subcuta-
neous cellular tissue, causing the part to assume a brawny hardness;—there is
sometimes crackling from the generation of  gas.  The skin is at first of a dull or
tallowy-white or  bluish color, mottled or marbled by bluish-green streaks  in the
course of the veins, and speedily assumes a yellowish hue;  bullae containing dark
fluid often rising upon  it.   The constitutional  symptoms  set in very  early, are
for a short  time indicative of much febrile  action, but very speedily assume an
asthenic form.   Death usually occurs  in  the course of from  thirty-six hours to
four days;  and always very shortly after the gangrene has reached the trunk.
  The peculiarities of this form of gangrene consist  in the rapidity of its pro-
gress, its great fatality, and the tendency it  has to affect and  spread  along the
cellular tissue of the limb in preference to any other part.  It is truly a constitu-
tional affection, depending rather on the state of the blood than upon the local
injury.   Thus in  some  cases  we see it follow comparatively  slight contused
wounds, whilst in  others the most serious crushes and injuries  may  occur with-
out'it.   It appears to be closely associated in its occurrence with those conditions
of the system that dispose to the supervention of  erysipelas, phlebitis, and other
inflammatory diseases of a diffused or spreading character; and hence its great
fatality.   From  the other varieties of traumatic gangrene it differs remarkably,
not only in  the rapidity of its extension and  the  general  appearance  presented
by the parts affected, but more especially in the little disposition it  manifests to
limit itself by a line of demarcation or by any adhesive action.
   Treatment of  contused  and  lacerated  wounds.—In the  treatment of the 
118
INJURIES  OF  SOFT  PARTS.
 slighter forms of these injuries we must bear in mind the occurrence of the two
 periods; that of sloughing and of granulation.   There is  also  in  all injuries of
 this description a  special tendency  to  the occurrence  of erysipelas and  allied
 diseases.
   In these cases care must be taken  to clean the parts  thoroughly from foreign
 bodies that are frequently impacted  or  ground into  them.  However contused
 and torn a flap of skin may be, it should never be separated, provided  it main-
 tain any attachment to the neighboring  tissues, but always be replaced, on  the
 chance of its vitality being preserved.   If it live, as it will often do, especially
 about the  scalp, under apparently the  most discouraging circumstances, much
 will be gained;  if it slough, no harm can result from the attempt to preserve it.
 There are even cases on record in which  parts  that have been completely sepa-
 rated have become attached by being immediately reapplied to the surface from
 which they had been torn.   Whether this be actually the case or not, it is at all
 events certain that a very small  tongue of skin is sufficient to maintain the vita-
 lity of a part.   This we see exemplified in the operation for the restoration of a
 lost nose; and cases have occurred to me in which the nose, nearly cut off, being
 only retained by a  portion of one ala, has readily united on being replaced; so
 likewise  in bad cases of compound dislocation of the fingers, the part has been
 saved, though merely attached  by a  narrow bridge of skin.  After a  part has
 been replaced in this way, it should be retained in situ  by a few points of inter-
 rupted suture, with a piece of lint soaked in collodion applied to the line of wound.
 The sutures must  be left in for a somewhat longer time than usual, until good
 union has resulted.
   In ordinary cases of contused or lacerated wounds, whether  superficially ex-
 tensive or deep, we must facilitate the separation of the sloughs by the applica-
 tion of poultices,  which also serve to subdue  local inflammation.  About the
 period at which the slough  begins to be loosened, there is danger of the  occur-
 rence  of hemorrhage  if a large  artery have  been  implicated in the injury.
 When hemorrhage occurs in this way it usually sets in  from the sixth  to the
 twelfth day, and may, unless arrested, be speedily fatal.   After the slough have
 separated, an ulcer is left, which must be treated on general principles.
   In the more severe cases of contused or lacerated wounds any attempt at
 saving the part may be hopeless, and the patient's only chance lies in  amputa-
 tion.   In determining the expediency of operation, two questions present  them-
 selves; 1st.  The nature of the cases  in which amputation should be performed;
 and, 2dly.  The time at which it should be done, whether immediately after the
 infliction of the injury, or at a subsequent  period.  It  is difficult to lay down
 more than very general rules as to the kind of cases that require amputation, so
 much depending on the age, constitution, and previous habits of the patient.
 In all cases the surgeon should be careful not to condemn a limb that admits of
 a fair chance of being saved; and, if the patient  should happen to die, as  he
 often may, from the after-effects, such as erysipelas or phlebitis, of a contused
 wound that admitted of a fair prospect of recovery, the surgeon  may justly con-
 sole himself with the reflection,  that,  with the constitutional disposition leading
 to these diseases, the injury inflicted  by the amputation  would  in all probability
 have been equally fatal, and that thus the patient has been saved the  pain of an
 operation that would have been unsuccessful in its result.
   As a general rule, severe injuries are  more readily  recovered from in young
 than  in old patients, their vitality and elasticity of constitution beino-  greater"
 with less tendency to consecutive diseases.  Much will depend  upon  the habits
 of the patient, or upon the existence  of  visceral disease at the  time of the in-
jury.   In  persons  who have  been  free-livers,  and who have that  peculiar
irritability of system conjoined  with  deficient  power, so commonly observed in
such subjects; and more especially if there be already existing  disease of the 
AMPUTATION  IN  CONTUSED  WOUNDS.
119
liver or kidneys, contused and lacerated wounds are apt to be followed  by the
worst forms of erysipelas and traumatic gangrene, and thus to be speedily fatal.
Injuries of the upper extremity are less  serious than  those of the  lower;  its
supply of blood being  proportionably greater  and more uniformly distributed.
In some badly-contused wounds, also, of the arm and hand, as in bad lacerations
with fracture about the shoulder, elbow, or metacarpus, resection of the injured
part may be performed instead of amputation of the limb.
  Though there may always be this doubt as to the  cases that should not be
amputated, there are certain conditions  in which the surgeon need never hesitate
to perform this operation, as the only chance of saving  the patient's life.
  The following are the cases  of severe contusion and laceration  in which the
limb should be amputated; either with the view of preventing the occurrence of
gangrene, or in order to remove a mortified part from the body,  and thus to save
the life of the patient at the expense of the injured limb :—
  If  a limb has been torn off by machinery, carried away by a cannon-ball, or
cut off by the  passage of a railway train over it, the irregular and conical stump
should be amputated,  so as  to leave a  more  useful or healthy one  to the
patient;—
  If the whole thickness of a limb—the soft parts and the bones—be thoroughly
disorganized and crushed, it must be removed;—
  If  the  soft parts are extensively stripped away from the bones, though these
be entire, so much sloughing and suppuration would ensue as to leave a useless
limb, and amputation should be  performed.   It is in these cases that it is often
especially difficult to estimate the amount of injury that cannot be recovered from,
this depending so much upon the age and constitution of the sufferer.   I believe
that surgeons, in their  anxiety to save  a limb, often lose a patient under these
circumstances.  I  have more than  once had reason to regret having attempted
to save limbs  injured in this way, and believe that if  the  skin of the lower ex-
tremity be extensively  torn  down and the muscles lacerated, so as to slough
away, there is but  little chance for the patient—unless he be very young, and of
a remarkably sound constitution—except in amputation.
  If the bones are extensively comminuted and crushed at the same time that
the soft parts are  much lacerated, there can be no question about  the propriety
of removing the limb.
   So also if the  knee or ankle-joints  be  largely opened, with laceration of the
soft parts, and perhaps fracture of the contiguous bones, the limb must be am-
putated.   Corresponding injuries of the shoulder and elbow-joints, may, as has
already been stated, admit of resection  rather than of amputation.
   Bad crushes of the foot have a great  tendency to run into gangrene, and hence
require amputation.   In the hand,  on the  contrary, very extensive injuries are
often recovered from, without this operation being necessary; and in many cases
partial resection may be substituted for it.
   In those cases in which a large artery, as the femoral, is lacerated at the same
time  that the soft parts are extensively injured, and the bone fractured, amputa-
tion is required in order to prevent  the occurrence of  gangrene.   In the  more
local form of traumatic gangrene, in which the  disease is  confined to the part
directly crushed and injured, no good can come of delay, and amputation should
be performed so soon as mortification has  declared itself;  and the limb must be
removed at a sufficient distance from the seat of mischief.  Thus if gangrene of
the foot or ankle come  on  in consequence of a smash of these parts, the upper
part of the leg or thigh should be amputated.   When the mortification results
indirectly from injury of the vessels, the limb should also be immediately removed
in a line with the wound, unless  this be too high up; then the most favorable
point must be seized, as will hereafter be  explained.   Amputation under these
circumstances is by no means a very unfavorable  operation, and one that I have 
120
INJURIES OF  SOFT PARTS.
several times successfully performed, provided it be done sufficiently early before
the constitution becomes poisoned  by the absorption of morbid matters from the
gangrenous limb.   It is scarcely necessary to warn  the surgeon to be certain of
the existence of gangrene before he  operates; and also that  it be  not a mere
limited slough, but sufficiently extensive to jeopardize the patient's life.
  In all cases in which the true traumatic or rapidly spreading gangrene has set
in, the surgeon will be placed in a  great difficulty whichever way he act.   If
he leave the patient to nature, in the  hope of a line of demarcation forming, he
will almost  certainly be disappointed, the gangrene rapidly spreading up to the
trunk, and if he amputates, he will probably lose his  patient by the stump be-
coming affected.   Yet  amputation should, in my opinion, be performed at once.
For although this operation  is necessarily very unfavorable,  when practised in
these cases, in consequence of the gangrene not being a local affection, but depen-
dent on constitutional causes, yet it  must be remembered that if the surgeon
wait for the  line of  demarcation, or  trust to other means, such as  incisions or
general  treatment, the patient  will  almost to a  certainty die.   The patient's
safety in these cases  lies in amputating early, and removing the limb as high as
possible above the  parts affected; thus in spreading gangrene of the arm, at the
shoulder-joint, and of the  leg in the upper part of the  thigh.   The necessity for
high amputation in these cases  is owing to the gangrene spreading more  exten-
sively in the cellular tissue than  it does in the skin; and hence in reality in-
vading the limb to a higher point than it appears externally to do.   A principal
source of danger, and of death, after  amputation  in these cases, is the great dis-
position to the recurrence of the morbid condition in the stump.   Out of seven
cases in which I have seen or done amputation for this disease, this  recurrence
happened  in four instances.   This tendency will  be increased by the proximity
of the  line of amputation to the gangrenous limit.   But  even under the most
unfavorable circumstances  recovery will sometimes take  place.   Thus I have seen
the flaps in amputation for spreading gangrene infiltrated wTith  gelatinous-looking
fluid, and  yet recovery take place.   In  a man whose  arm  I  amputated at the
shoulder-joint for spreading gangrene  of  the  limb, the infiltration  had extended
as high as the scapula, but yet he made a very excellent recovery.
  Much of the success of the case will depend on the after treatment.   Light
dressings to the stump, the  administration of full doses of liquor opii, and the
early and free administration of nourishment and stimulants, are  the principal
points to be  attended  to; and attention to these will often  bring  the  patient
through,  though usually not without much difficulty  and  great  constitutional
disturbance.
  The next question, as to the period at which amputation should be performed
in contused wounds,  has already been considered at page 90.   It may be gene-
rally stated that the sooner a condemned limb is taken off,  the less is the  suffer-
ing, and the better the chance of recovery to the patient, and that, consequently,
primary amputation  should be practised in  these cases.   For notwithstanding
the higher rate of mortality in primary than in secondary amputations, it is abso-
lutely necessary to remove the injured limb within the  first twenty-four hours in
many cases.   This higher mortality may partly be dependent  on  the accidents
that require primary amputation being more severe  than those in which it has
been thought justifiable to attempt to save  the limb;  and certainly of the two
alternatives of leaving a badly crushed  and  mangled limb on until  suppuration
is set up, and thus exposing the patient to all the risks of gangrene, erysipelas,
pyemia, &c,  or removing  it at once,  the latter is  the one  attended with least
danger to the patient. 
GUN-SHOT  WOUNDS.
121
                           CHAPTER VII.

                         GUN-SHOT  WOUNDS.

  Amongst the special varieties of contused and lacerated wounds, none  are of
more interest than the different forms of gun-shot injury.  Though comparatively
and fortunately rare in  civil  practice in this country, yet  they are of sufficiently
frequent occurrence to render an acquaintance With  them indispensable  to the
general surgeon.  To the military surgeon their study is necessarily one of pecu-
liar interest and importance, and to  him I would  specially recommend the perusal
of the works of Hennen, of Guthrie, of Ballingall, and of other surgeons who
have had unusual opportunities of studying the nature of these injuries upon the
field of battle,  and by whom they have been treated with all the minuteness of a
specialty.  I  purpose in the following observations rather to confine myself to
such a general discussion of the subject as is required by the civil practitioner,
than to enter into it with all the minuteness of detail that may be thought  neces-
sary to the military surgeon.
  Gun-shot injuries constitute a species of contused and lacerated wounds cha-
racterized in some cases by the peculiar appearance presented by the color,  shape,
and size of the orifice;  and in others, by the extensive injury inflicted to parts,
both superficial and deep-seated, in consequence  of which they may prove  imme-
diately or rapidly fatal.  If the sufferer survive, high inflammatory action, with
much pain and tension, with  profuse  discharge, deep-seated suppuration, and
other after-consequences of a serious and very  protracted character, are apt to set
in.   These peculiarities were  at different times attributed to the parts  being
burnt by the  ball, to the poisonous nature  of projectiles, and to electricity, de-
veloped by the bullet in its passage through  the air, or by its friction against
the barrel.   All  these opinions, however,  have been  shown to be  erroneous,
and every peculiarity presented  by  these injuries can be  accounted  for by the
bluntness of the contusing body, the rapidity  of  its course, and the  force with
which it  is driven.  That the  sloughing which always occurs in the track of a
bullet-wound  is due to the injury being inflicted  by a blunt body is evident
from the fact,  that sharp splinters  of shell  have been known to inflict clean-cut
wounds.
  Gun-shot wounds vary greatly according to  the nature of the projectile,  to the
force  with which it is driven, and to the direction in  which it strikes.
  1st, As to the nature of the projectile:—Gun-shot injuries of a serious charac-
ter may be inflicted by weapons charged  only with  powder.   This may  injure
by the mere concussion of the  explosion; thus a pistol charged with powder,  and
discharged with the muzzle  resting against the chest  of a man, has been known
to kill by concussing the heart.   In  other  cases a portion of the powder unex-
ploded may be driven  into  or through the  skin  by that which is exploded be-
hind it.   In  this way very troublesome and disfiguring marks  are  not  unfre-
quently inflicted  on the  face  and other  parts  of the body,  by the charcoal
of the powder being driven into the skin.  That  a weapon so charged may actu-
ally kill,  appears  from a case related by Dupuytren, in which a  fowling-piece
charged with powder only, and fired at the distance of two or three feet from the
abdomen, pierced the belly with a round hole and killed the man.  The force of
the explosion only will sometimes  produce  serious  lacerations.   Suicides occa-
sionally forget to put a bullet in the pistol, and discharging it into their mouths,
blow open the cheeks and injure the pharynx  and glottis by the  explosive force.
Some years ago, a man was brought to University College Hospital, who had dis- 
122
GUN-SHOT wounds.
charged the tube of an Italian iron loaded with powder only, into  his mouth,
and died in consequence of the injuries he received.   In another case that oc-
curred in the same institution, a man died on the fifth day after  firing a pistol
into his mouth, from sloughing of the pharynx and inflammation of the glottis
and larynx, in consequence of the scorch of the explosion interfering with respira-
tion, and thus producing suffocation.
  Wadding and  soft  materials, as  pieces  of clothing, will  occasionally inflict
serious wounds by the force with which  they are driven.   These injuries often
happen on  the stage, at reviews, fairs, &c.   Taylor relates several  instances  of
the kind;—a girl killed by having a gun charged with  paper pellets discharged
at her; also, that of a man who was killed by a kid glove fired from a blunder-
buss.
  Small shot often inflict serious injuries, and these are most commonly met with
in civil practice.   If the person wounded be within a few feet  of the muzzle  of
the gun, a  terribly torn and lacerated wound, of a  very serious character, even
worse than that occasioned by a bullet, will be inflicted; for the  shot not being
scattered, is driven through the body in a solid compact mass, tearing the tissues
to a great  extent.
  The shot scattering  as it flies, produces at a greater distance a less serious in-
jury,  usually lodging in the subcutaneous cellular tissue, where  it may remain'for
years requiring to be picked out with a lancet,  or give rise to suppuration.  Oc-
casionally,  the shot, by penetrating an important part,  may  occasion serious or
fatal results; thus, a single shot penetrating  the eyeball will destroy vision, or,
lodging in  the heart, or the femoral  vein, has been known to give rise to rapidly
fatal results.   A patient was brought  to University College  Hospital, who com-
mitted suicide by firing a pocket-pistol loaded  with small shot into  the mouth;
after  death, the shots were found to be deeply lodged  in, and to have penetrated
the anterior portion of the vertebral column.
   Splinters of various kinds, of metal, wood, or stone, carried by the force of the
explosion,  as in blasting and mining operations, inflict perhaps the worst forms
of gun-shot injury that are met with in civil practice.   In naval actions the force
with  which splinters of wood  are driven, when struck and scattered by cannon-
shot,  is so  great as to inflict the most serious  and fatal mischief.   A particular
form  of  injury, not unfrequently met with in practice, and which belongs to this
class, is  the wound of the right eyeball, by the explosion and splintering of faulty
percussion-caps.
   Bullets,  slugs, and grape-shot occasion more serious wounds than any that have
yet been described; lacerating soft  parts, fracturing and crushing bones, tearing
asunder vessels  and nerves, perforating the viscera,  and occasionally cutting off
parts, as a finger,  the nose, or an ear,  and  thus  giving rise to every possible
variety of  injury.
   In the majority of cases, a bullet traverses,  and the wound has two apertures,
one of entry,  the other of exit; occasionally it happens, however, that in conse-
quenceof  the ball being spent, or of the piece not being efficiently  loaded, or of
the oblique direction with which it strikes the part, it merely leaves a contusion or
dent, rebounding or glancing off.  In  other cases, there is only one aperture, and
here the bullet has probably lodged  in the soft tissues, in a bone, or in the cavity
of a hollow organ, as the bladder.    It sometimes happens, however,  that the ball
drops out  through  the aperture at which it entered, as when a spent ball strikes
a rib; or that it carries a pouch of  clothing before it, which enables  the surgeon
to withdraw it.   One bullet may even make  more than two apertures : thus, a
ball has been known to split against the sharp  edge of the tibia, and to have one
aperture of entry and two of exit:  or it may pass through both thighs,  or both
 calves, and thus occasion four apertures,  and cases have been recorded 'in which
five wounds even have been made in the same person by one bullet. 
APERTURES  OF  ENTRY  AND  EXIT.
123
  The direction of these openings is often of importance,  in a medico-legal, as
well as in a surgical point of view.  Thus, Sir Astley Cooper, by attending to
this circumstance  in a case of murder,  ascertained that the fatal shot must have
been fired by a left-handed man,  and thus led to the detection of the criminal.
These apertures, though usually opposite  to one another, when a ball  traverses,
will sometimes take a very remarkable course, the bullet being deflected by meet-
ing with obstacles from bones,  or by the elasticity of the skin.  Thus, a bullet
has been known to strike a rib and to be deflected, running under the skin to the
opposite side of the body; so again striking one temple, it has been carried under
the scalp to the other side of the head, where it has passed out; thus giving the
appearance of having penetrated important cavities,  which in reality were not
wounded.
   The apertures of entry and of
exit, made  by  a  bullet, deserve
attentive  consideration.   Much
discussion has arisen as to whether
there is any difference  between
these apertures,  and if so,  to
what it is owing.  That there is a
difference in the great majority of
cases there can be no doubt.  The
hole made by the entrance of the
ball being  small,  depressed, and
circular  (Fig. 44, b), whilst that
made by its exit,  is larger, some-
what everted, and more irregular
(Fig. 44, a). In some cases, how-
ever, it  is  equally certain  that
there is no appreciable difference between the two, and in others  that the aper-
ture of entry is larger than that of exit.
   I think there can be no doubt that Mr.  Guthrie has given the correct explana-
tion  of these discrepancies when  he states, that the amount of the difference in
the two apertures will depend partly on the momentum of the ball, and partly on
the resistance it meets with.   If the ball  strikes shortly after its discharge, when
at the maximum of its velocity, it will make but a small round hole;  not so much
shattering the parts as separating them.   If it traverse a part  composed of soft
tissue, meeting with but little resistance  in its passage, it loses but little of _its
momentum, and passing out of the body with nearly  the same  force with which
it entered, it makes an aperture of exit that differs  but slightly, if  at all, from
that of entry.   If the ball strike a bone on its passage through a limb or body,
and  thus, by meeting with much resistance,  have its momentum  materially les-
sened, the aperture of exit  will be torn, large, and ragged,  differing  materially
from that of entry.  So also we  find in all bullet-wounds the entrance aperture
is actually less in  diameter than the  bullet  itself, provided it  be made whilst
the ball is moving with its full velocity; if it have nearly lost its momentum be-
fore  it strikes,  then the  entrance-wound  will always be large and ragged.  In
this  there is nothing peculiar to the tissue of the living body, the same happens
when any elastic material, as a piece of green timber,  is struck.  Much, however,
will  also depend on the  period at which the  wound is examined.  In the early
stages, for the reason mentioned,  the wound of entry is smaller than  that of exit,
 but  as the eschar which forms in the  wound of entry is larger than that at the
exit  aperture, the  former may,  in a later stage, appear larger than the latter.   This
difference in the size of the two wounds I saw well exemplified in the case of  a
young man, shot  through the neck in a duel.   The aperture of entry,  which was
at first the  smallest, appeared on the second day the largest, in consequence of
 
124
GUN-SHOT  WOUNDS.
 the extrusion of a black eschar; though it continued more regular in shape than
 that of exit.
   Cannon-balls inflict two kinds of injuries.   They may contuse a part without
 destroying  the integrity of the skin, the ball striking obliquely, or rolling over
 the surface of the body.   The elasticity of the skin prevents this from injury,
 though all the subjacent textures, bones, muscles, and vessels, may be totally dis-
 organized and crushed into a pulp if a limb be struck; if the trunk itself be in-
 jured, the vertebral column and lumbar muscles, may be disorganized, and the
 liver, kidneys, spleen, stomach, and intestines ruptured,  without any breach of
 surface.  These injuries,  formerly erroneously attributed to the action of the
 current of air set in motion by the ball, go by the name of wind contusions.  In
 some of these contusions gangrene of the limb sets in, apparently, as Mr. Guthrie
 has pointed out, from  the rupture of  the principal vessels.
   Cannon-shot more commonly carry away the whole thickness of a part, tearing
 and shattering a limb, carrying off the thick and fleshy parts of the thigh, calf,
 or shoulder; or they may inflict the most fearful injuries, by smashing the trunk
 and head.
   In gun-shot injuries, the shock to  the  nervous system  is usually very great;
 and the severity of the shock is usually indicative of" the amount of mischief in-
 flicted.   Thus, if a bullet appear to have traversed the chest, but in reality have
 been deflected  under the skin,  the comparative absence of shock will serve to a
 certain extent, to prove  the absence of visceral mischief.  In some cases  the
 shock alone  appears to be sufficient to  kill; thus a man shot by a pistol-bullet,
 which traversed the distended stomach, died in a few seconds from shock, there
 being no bleeding of importance, or other cause of immediate death discernible
 (Taylor).  In  some cases, however, that are mortal,  the symptoms of shock are
 but slight.
   Gun-shot wounds being contused, do not in general bleed much, when merely
 fleshy or _ muscular parts are perforated  or even carried away.  But in many
 cases, patients  lose their lives from immediate hemorrhage ; the larger arteries
 when cut across by a bullet, bleeding as freely as if divided with a knife,  the
 contusion not giving rise to sufficient  slough to cause their occlusion.   Gun-shot
 wounds always inflame with much swelling and tension of the part.  The pain
 which, at the moment  of infliction, may not have been severe, becomes extremely
 acute when inflammation has set in, owing principally to  the great tension that
 takes  place.  This, indeed, is one of the most remarkable phenomena of gun-
 shot injury, and, by giving rise to strangulation of the tissues, is often the cause
 of serious mischief  The inflammation  speedily terminates in suppuration,  not
 only in the track of the ball, but in the neighboring parts.  A period  of great
 danger in gun-shot wounds is that about which the sloughs begin to separate,
 usually from the twelfth to the twentieth days; and up to this time, it is often
 impossible to know the precise  extent  of  the  disorganization.  At this  period
 also, "consecutive hemorrhage"  is very apt to come on, after verv sli-ht exer-
 tion, without any warning.   This may be suddenly fatal, and is  always more
 dangerous than the primary hemorrhage, not only on account of the difficulty of
arresting it, but likewise from the patient being already weakened by inflamma-
 tory and suppurative action.  At a still  later period than this the patient if  his
 limb be saved,  may have to  undergo  long  and tedious  processes  of exfoliation
 of dead bone and to run the  risk  of intercurrent attacks  of erysipelas, hospital
 gangrene, and visceral  mischief.                                    '    r
   Treatment-Some of the slighter forms  of gun-shot injuries, those of a purely
 superficial character, require  to be treated on the ordinary  principles that euide
 us in  the management of contusions and  lacerations.  When they affect  the
 head, chest, and abdomen they  present so  many circumstances of special impor-
 tance that we must defer their consideration until we come to treat of injuries 
SYMPTOMS--TREATMENT.
125
of those regions.   Gun-shot wounds of the soft parts, and  of the extremities,
may be divided into two great classes in reference  to treatment.  1st.  Those in
which amputation is necessary.  2d. Those that do not require amputation.
  1st.  The cases of gun-shot injury that require amputation are of a very simi-
lar kind to those of contused wounds  generally, in which the  same operation is
necessary, and  the surgeon must  exercise the same amount of caution not to
condemn a part too hastily; for a  part that looks much  shattered  and injured
when covered with coagulated  blood and dirt, before being cleaned and put up,
presents a very different appearance after the fracture has been reduced, splin-
ters of bone removed, and the soft parts brought properly together.
  Amputation, however, is required when  the whole limb is  carried off, a rag-
ged stump merely being left; so likewise, if the limb is completely crushed and
disorganized, whether by direct blow or by  a wind-contusion, though still left
adherent.   Again, if the principal vessels and soft parts be carried  away, though
the bone be uninjured, the limb cannot be preserved.   Amputation is especially
necessary in some of the more  serious injuries of the lower extremity; thus, if
a bullet divide  the femoral vessels, or the  sciatic nerve, and splinter the thigh
bone, or if the sciatic nerve and  soft part  at  the back of the thigh be carried
away, although the vessels  and bone be left uninjured, the case is one for ampu-
tation; and, indeed, it  may be stated generally, that compound fractures of the
thigh, occasioned by gun-shot, require amputation.   In gun-shot wounds of the
joints of the lower extremity, also, removal  of the limb becomes necessary ; thus,
if the head, neck, or trochanters of the femur  are broken by a bullet, it is gene-
rally considered necessary  to remove the limb at the hip-joint.   But of late Mr.
Guthrie has recommended excision of the injured head and  neck of  the bone
instead.  In those cases in which  the  knee or ankle-joints are perforated and
smashed by balls, or in which longitudinal fractures of the tibia or femur extend
into them, amputation is imperative.  In some cases of gun-shot wounds, impli-
cating the shoulder and elbow-joints, removal  of splinters and
excision of the injured portions of bone may be advantageously
substituted for  amputation, the injury in the soft part being
treated on ordinary principles, as in the case represented in Fig.
45, of a bullet lodged in  the head  of the humerus.   Gun-
shot wounds of the foot, if serious, require  its removal, either
at or above the ankle.   Those of the hand are of special in-
terest from their frequency, in consequence of the bursting of
guns, or of powder-flask explosions.   In these cases, however
extensive the injury may be that is inflicted  upon the hand,
fingers being blown away,  the thumb thrown back, and the
metacarpal bones splintered, we must endeavor, if possible, to
save a portion of it, if it be only one  or two fingers;  and,
owing to the great reparative power possessed by the hand, we
shall often, in the worst-looking cases, be able to accomplish this.  If the thumb,
with one finger as an  opponent, can be preserved, it will be of more service to
the patient  than any artificial contrivance, however ingeniously made.  It not
unfrequently happens that amputation may be required in the more  advanced
stages  of gun-shot injury, in consequence of  mortification supervening. ^ Under
these circumstances, it must be practised without delay, and without waiting for
a line of separation.   If,  in consequence  of long-continued suffering and  dis-
charge, the  patient's health becomes  worn out, and the  limb remains  a useless
appendage, amputation will at last be  imperative.
   The question as to the period at which amputation ought to be performed after
the infliction of these wounds is one of great importance, and has given rise to a
corresponding amount of discussion among surgeons.  The older military sur-
geons,  Wiseman, Ledran, Ranby, &c, taking a common-sense  view of  the ques-
 
 126                      GUN-SHOT  WOUNDS.

 tion, advocated the removal of the hopelessly injured limb so soon as the shock
 to the system had subsided, the pulse had regained its  volume, and the warmth
 of surface had returned.  After the battle of Fontenoy, in the middle of the last
 century, professional opinion underwent a change upon this subject, and Faure
 wrote a thesis, which obtained the prize of the French  Academy of Surgery, re-
 commending  delay in  amputating in certain cases.   Hunter, Percy,  and  other
 surgeons of repute, promulgated similar views, until Bilguer, the surgeon-in-chief
 to Frederic the Great's armies, went to the absurd and dangerous extent of con-
 demning amputation entirely.  These extreme opinions necessarily occasioned a
 reaction, and the experience gained in the wars of the French Revolution and
 Empire, has finally enabled surgeons to settle this question definitely.   It is more
 particularly by the labors and observations of John  Bell, Larrey,  Thomson,
 Guthrie, S.  Cooper, and Hennen, that the necessity of having recourse to imme-
 diate amputation in all cases of gun-shot injury, requiring  this operation, has
 been established.
   In determining this point we must be guided,  partly by surgical  experience
 on the result of such cases left to nature, and partly by  an appeal to facts.   In
 appealing to experience we  must, to  use the forcible language  of Sir Charles
 Bell, contemplate what shall  be the condition of  the parts  in twelve hours, in
 six days, and in  three months:  " In  twelve hours the inflammation, pain, and
 tension of the whole limb, the inflamed countenance, the brilliant eye, the sleep-
 less and restless condition, declare  the impression the  injury is making on the
 limb and on the constitutional powers.  In six days, the limb, from the groin to
 the toe, orfrom the shoulder to the finger, is swollen and half the size of the
 body; a violent phlegmonous inflammation pervades  the whole;  serous effusion
 has taken place in the whole limb, abscesses are forming in the  great beds of
 cellular texture throughout the whole extent of the extremity.  In three months,
 if the patient has labored through the agony, the bones are carious; the abscesses
 are interminable sinuses;  the limb is undermined and everywhere unsound, and
 the constitutional strength ebbs to the lowest degree."
  If we appeal to facts, we shall find that of 300 secondary amputations reported
 by Monsieur Faure, after the battle of Fontenoy, only 30 were successful; whereas
 Larrey saved three-fourths of his primary amputations.  In  the Peninsular War
 the comparative loss after  secondary amputations of the  upper extremity was, to
 that following the primary, as twelve to one;  and of the lower extremity, the
 loss after secondary amputation was three times as great as after primary.  Pri-
 mary amputation, therefore, should always be performed.   But if an unsuccessful
 attempt at the preservation of the limb be made, and  if occasion for its subse-
 quent removal should arise, the surgeon must wait until  suppuration has set in
before he operates, the period of acute inflammatory action being allowed to pass
by.   The cases that  most commonly require secondary  amputation, are those in
 which traumatic gangrene has set  in;  here the limb must always be removed
without delay, in  accordance with the principles laid down in speaking of  this
subject in reference to  contused wounds.   If profuse hemorrhage occur from the
wound, that does not admit of suppression by the ordinary means" secondary ampu-
tation may become necessary.   So, also,  when  the  bones  do  not unite,  the
patient being worn out by discharges and  the irritation of  necrosis and caries,
and left with a wasted, shattered, and useless limb, its removal is the only means
of saving life.
  2d. Those cases of gun-shot injury that  do not  require amputation, must be
treated on the principles that guide us in the management of all  contused  and
lacerated wounds, the  surgeon, however, bearing  in  mind  that these injuries
are especially apt  to be followed  by extensive and intense inflammatory action,
and that sloughing will inevitably result in every part that has been touched by
the ball. 
AMPUTATION  IN  GUN-SHOT  WOUNDS.            127
  The first point to be attended to in these cases is  the  arrest of hemorrhage.
In o-eneral this may not give much trouble;  but if a  large vessel be injured, the
loss&of blood will rapidly prove  fatal,  unless  stopped.   This is done in the first
instance by the application of the tourniquet, or if this instrument be not at hand
by some simple substitute, such as rolling a pebble, about the size of an egg, iii
the middle of a pocket-handkerchief,  laying this over the  artery, knotting the
ends of the handkerchief round the limb, and then twisting it up tightly with a
piece of stick passed under it (Fig. 46).   The  wound in the artery may  be  of
such a kind as to require amputation, if  not, hemorrhage must  be permanently
arrested by an incision being made down to the bleeding vessel, and a ligature
applied on either side of the wound in it.
   The next point to be attended to is the extraction of foreign bodies, such as splin-
ters of bone, shot, slugs  or bullets, wadding, pieces of clothing  that have been
¥\s. 46.
Fig 47.
Fig. 48.
carried in with the ball, and other  matters
of a like kind.   Splinters of bone  require
special attention.  Those that are quite loose
and  carried away  from  the  shaft must be
taken away, as they will necrose and produce
the same irritation that other foreign bodies
would.   If splinters are still attached to soft
parts, though carried considerably away from
the portion of bone to which  they  are at-
tached, they must also be taken out: but if  u       ^
they continue attached in the vicinity of the fracture, they must be left, becoming
enveloped in, and  tending to consolidate the  callus that is thrown out for its
repair, and thus adding eventually to the strength of the limb.
   If the bullet lodge, it, together with  foreign bodies accompanying it, such as
pieces of clothing, must be cut out by a counter opening.   If anything is very
tightly fixed, so that it cannot readily be removed, it must be left  till  loosened
by suppuration.  In searching for bullets and  other foreign bodies, care should
be taken not to probe the wound unnecessarily from mere  curiosity, or so as to
excite irritation; in many cases, the introduction of the finger is far more useful 
128
PUNCTURED  WOUNDS.
 than  that  of the probe.   Various instruments are used  for  the removal  of
 bullets and other foreign bodies.  The accompanying woodcuts (Figs. 47 and 48)
 represent the best form of bullet-screws and forceps.   The probes are  usually
 made much larger and stronger than those in ordinary use.
   In those cases in which small shot are lodged under the skin, they may be turned
 out by being cut down upon with a fine scalpel.
   Our next object should be the treatment of the wound itself.   This, as has already
 been  stated, will always inflame violently and slough along the whole track of the
 ball.   The principal points to be attended to  are, consequently, to limit the in-
 flammation, and to facilitate and watch the suppuration of the sloughs.
   In order to limit the  inflammation, it was a  common practice with military
 surgeons, and still is so with the French,  to dilate, by incision, the wound made
 by the ball,  with the view of preventing  tension and  strangulation of parts.
 Since  the  time, however, that  John Hunter pointed out that an incision could
 not alter the  nature of a contused wound, and only superadded another injury
 to the one  already inflicted by the bullet,  British surgeons have  only employed
 the knife in the early stages of gun-shot wounds, for the purpose  of securing
 bleeding vessels, or to facilitate the extraction of foreign  bodies.   In the more
 advanced stages, however, incisions are commonly required, in  order to lessen
 inflammatory  tension,  to  prevent the extension of sloughing, and  to favor the
 escape of matter.
   The best mode of lessening inflammation in a gun-shot wound  is by cold irri-
 gation (Fig. 3), conjoined with position  and rest; to which  water-dressing and
 poultices, useful as they may be, are far inferior.  As suppuration comes  on, we
 must  substitute warm applications  for  the cold, so as to  hasten  the fornaation
 of matter  and the separation of the sloughs.    Free incisions will also now be
 required, for the purposes already indicated.   At the period of the  loosening
 and separation of the sloughs there is always especial danger of the supervention
 of consecutive hemorrhage.   The patient, consequently, at this time requires to
 be carefully watched; if the wound be in the vicinity of large vessels, he  should
 have a tourniquet  placed  loosely round  the limb, so  as to be screwed up at a
 moment's notice;  and must, on the  supervention of bleeding,  have the  arteiy
 ligatured, if possible at the seat of the wound; if this be not practicable, in the
 most convenient situation above it; and if  this do not arrest the bleeding, ampu-
 tation should be had recourse to.
   After-consequences of a serious character, such as abscesses, profuse discharges,
 necrosis,  and the separation of splinters of bone, must be looked for  in many
 cases; and these consequences maybe prolonged for a considerable  series of
years, at  last perhaps wearing out the patient if the cause of irritation be not
removed.   Thus General Bern  required  to have  a bullet  removed by  Liston
from the  external condyle of his femur nineteen years after it first lodged there;
and Marshal Moncey died forty years after the receipt of a gun-shot wound from
its effects.
                          CHAPTER VIII.

              PUNCTURED  AND POISONED  WOUNDS.

  Punctured wounds, made by narrow sharp-pointed instruments vary greatly
in extent, from the prick of a needle in the finger, to a sword-thrust through the
body.   Not  unfrequently  punctured wounds  are  somewhat  contused °bein<>
made by a triangular or wedge-like weapon, as a bayonet or lance blade  ' Hence 
PUNCTURED  WOUNDS.
129
they partake of the general character of contused wounds having  a tendency to
unite by granulations from the bottom, and to be accompanied by much inflam-
matory  fever.   When  deep, they are of the most dangerous  character—wound-
ing bloodvessels, traversing the great cavities, and injuring the contained viscera.
  In the treatment of  punctured wounds, the principal points are to arrest the
hemorrhage, and to facilitate union.
  The hemorrhage must  be  arrested by pressure  properly applied by means of
compresses or pads, so  as to approximate the sides of the puncture ; by the appli-
cation of cold; or by cutting down on the injured vessel if it be a large one, and
ligaturing it above and below the perforation in it.
  In the  majority of cases, unless the injury be a  slight  one, suppuration and
union by  the  second  intention  will take place.  This  must be  promoted by
poulticing;  and undue inflammation must be guarded against by local antiphlo-
gistic remedies.  In many cases  union by adhesion is attained; and in others that
are allowed to suppurate, there can be little doubt that the same favorable termina-
tion might be secured if  proper  attention were paid  to the injury.  In former
days when duels with the small sword were of frequent occurrence,  persons called
" suckers," who were often drummers of a  regiment, were employed to  attend
the wounded combatant.   Their treatment, which  was conducted  with a certain
degree of  mystery, consisted in sucking the wound till all blood  ceased to  flow;
then applying a pellet  of chewed paper or a piece of wet  linen to the  orifice;
and in  this way it would appear that  many sword-thrusts  traversing the  limbs
were healed in a few hours or days.   The process of suction cleared the wound
thoroughly of all blood, and, drawing the sides into  close apposition, placed the
parts in the most favorable  condition  possible for  union by  adhesion.   This
practice might, perhaps, in many cases, be advantageously imitated at the present
day with a cupping-glass and syringe.
   Amongst the varieties  of punctured wounds that are most commonly met with
in surgical practice  are those  that  are  occasioned by needles penetrating into,
and breaking off in the body.  These accidents chiefly occur  in the fingers and
about the nates, and though of a  trivial character, are  often extremely troublesome
both to surgeon and patient.   When  the  surgeon is called shortly after the oc-
currence of the accident, he must endeavor to  remove the fragment left behind
by cutting down  upon it.  In  doing  this he will be guided by the situation of
the puncture, and  by the seat of the pain, and  sometimes by feeling the  point
projecting under the skin.  In many cases this is a sufficiently simple     Fi- 49
proceeding; in others, however, a  deep and troublesome dissection    g\
may be required, especially when the  fragment of needle gets into or   fj
under the sheaths of a tendon.   I  have had occasion to  undertake   |\
somewhat troublesome  dissections between the biceps tendon and the   i\
brachial artery, or in the close  proximity of the ulnar artery, for the   I \
removal of fragments of  needles lodged in the  bend of the arm and   Mjjk
the wrist.  For the purpose of extracting needles, thorns,  splinters of  M\mk
wood, and other foreign bodies of small size and pointed shape lying  ||  B|
in  narrow wounds, the forceps  shown in the  annexed woodcut (Fig.   }|/ |H
49) will be found most serviceable, as they have very fine, but strong  i  3 |B
and well-serrated points.                                            m fff*
   In many cases, if the  needle  have been lodged for some days, the |  f / \
surgeon will fail in  his endeavors to extract it; and unless the indi- 1   /  \\
cations  of its presence  be very clear, I think the wisest course is to I      II
leave it undisturbed, and to trust to nature  for its elimination  from j      \|
the body, as it will seldom be found when  sought  for, and, indeed,    j    V
may not exist, although supposed to be present.  The following plan
of ascertaining whether a portion of needle be really impacted has been suggested
by Mr.  Marshall.   A powerful magnet is to be held upon the part for a quarter
                                     9 
130
POISONED  WOUNDS.
of an hour, so  as to influence the fragment; a finely-hung polarised needle
should then be suspended over it, when if any iron  be present,  deflection of it
will ensue.
                            POISONED WOUNDS.
  A very important variety of punctured wound is that in which a poison is
introduced into the puncture.  The most important of these poisoned wounds are
those inflicted by the stings of insects, the bites of snakes or of rabid animals,
and injuries received in dissection.
  The stings of insects, as of bees, wasps, &c, though painful, seldom produce
any serious inconvenience; yet occasionally they may do so, and even prove fatal,
by inducing erysipelas in some unhealthy constitutions, or by giving rise to in-
tense irritation by the multiplicity of the stings; as by bees swarming upon and
stinging a person in great numbers; or they may be dangerous in consequence of
an important part being stung, as the eye, or the interior of the mouth or pharynx,
as has happened by swallowing a bee in a piece of honeycomb.   Some insects,
as scorpions or the tarantula in Italy, give rise to serious and even fatal disturbance
by their bite.   A peculiar train of nervous phenomena is said to follow the bite
of the tarantula, hence called " tarentismus," a disease that is generally stated to
be peculiarly influenced by music, though this has recently been  denied by M.
Gozzo.
  In  the treatment of stings of insects the application  of cooling lotions, of a
cold  poultice,  or rubbing the part with olive oil, will be  found the most useful
means of allaying irritation.  In some cases, touching the part stung with ammo-
nia, gives immediate relief.
  Snake-bites are seldom fatal in this country, venomous reptiles, such as the
viper and adder, not possessing a sufficiently energetic poison to destroy a healthy
adult, though they might possibly kill  a child or a very  delicate and weakly
person. They are said to be most active in warm weather and during the season
of procreation, and their bites are most dangerous if inflicted through a vein or
glandular part, or  near the centre of  the  circulation or about the neck and face.
In some countries the bite of the rattlesnake, of the Cobra  di Capella, the puff-
adder, or the  tobacco-pipe snake, is often fatal;  and it  occasionally happens in
this country that the surgeon has an  opportunity of seeing  wounds  inflicted by
these fearful reptiles in menageries.  Thus Sir E. Home has recorded a fatal case
of rattlesnake bite occurring  in this country.  A similar instance lately occurred
at St. George's Hospital,  and another in Paris, to showmen.   The  most remark-
able  case of this kind with which I am acquainted occurred  recently  at the Uni-
versity College Hospital,  affording an  opportunity,  rare in this country, of wit-
nessing the effects of the bite of a Cobra di Capella.  The patient,  a keeper at
the Zoological Gardens, was bitten in the bridge of the nose, the poison fang
having apparently penetrated the angular vein.  When brought to the hospital,
about half an hour after the accident, he was apparently dying, being unable to
speak, swallow,  or support himself; the pupils were  dilated, face  livid,  heart's
action feeble,  and he was scarcely conscious.  After death, which occurred in
little more than an hour from the  time of the infliction of the wound, the veins
of the brain and the cerebral sinuses were found congested  with blood, as were
also the lungs to an immense extent, and the solid abdominal viscera.  The right
cavities of the heart were loaded with dark blood, the left being empty; indeed
the phenomena of asphyxia were strikingly marked.  In this case  death would
appear to have resulted from the  poison paralysing the  medulla oblongata, and
those portions of the nervous system  that are instrumental in carrying on respi-
ration, at the  same  time that the  blood was disorganized by the  action of the
virus.
  Snake-poison when introduced into the system may kill in two ways;  either 
POISONED  WOUNDS.
131
by its direct depressing influence,  somewhat resembling that  produced by some
narcotic  poison;  or by  exciting a kind of diffuse inflammation of the  cellular
tissue of the limb or part.
  The first mode of death only occurs when the poison is either very powerful,
or the animal bitten, small.  Thus the poison of the tobacco-pipe snake is said
to be so virulent  that it will kill a full-grown man in less than a quarter of an
hour.   The rattlesnake,  or  Cobra di Capella,  will  kill a small animal in the
course of a few minutes, and a man lately bitten by a rattlesnake, in  Paris, died
in nine hours; and the Cobra bite just related was fatal in one hour.
  In other cases again,  the poison acts by exciting diffuse inflammation, suppu-
ration, &c, of the cellular tissue.   Thus in the case which  occurred in  St.
George's, the patient died  on the eighteenth day after the bite of a rattlesnake,
with large abscesses in the arm and in the axilla, and with sloughing of the cel-
lular tissue of the limb.
  The symptoms  occurring after a poisonous snake-bite, consist in great depres-
sion and prostration of the system, a feeble and intermittent pulse,  dilated pupils,
usually slight delirium,  speedy stupor, insensibility, and death.  The part bitten
swells and becomes livid in a few hours; and, if the patient survive  sufficiently
long, diffuse inflammation and gangrene occur in its neighborhood : involuntary
evacuations take place;  asthenic symptoms set in, which may eventually termi-
nate fatally in the way that has already been mentioned, or end slowly, and after
a lapse of time in the recovery of the patient, whose  health may long suffer seri-
ously from the  effects of the accident.
   The treatment  of these injuries is local and general.
   The local treatment presents two great indications : 1st, to prevent the absorp-
tion of the poison into  the system;  and 2dly, to treat  the diffuse inflammation
and sloughing that may subsequently occur.  The first indication may be fulfilled
by  tying a ligature so tightly around the limb at a little  distance above the in-
jured part as to arrest all circulation through it.   In this way the absorption of
the poison may be prevented ; the wound should then be freely cauterized with a
red-hot iron or cinder,  or better still, be  excised, and a cupping-glass applied
over the cut surface, so as to withdraw the blood in the  neighborhood which may
have become contaminated by the poison.   If a cupping-glass be not at hand, or
if the part bitten  be  so situated as not to admit of its application, there can be
no  objection to the employment of suction by the mouth after free excision; the
poison not being absorbed by an unbroken mucous membrane.  In using suction,
the mouth should be rinsed with brandy.   With the  view of lessening the swell-
ing, tension, and pain of the limb, frictions with olive  oil are said to be advan-
tageous.   After diffuse inflammation has set in this  must be treated on general
principles—by fomentations and free incision.
   The constitutional  treatment  consists in the early and free administration of
the most powerful  stimulants, with  the view of combating the depression  that
exists.   For this purpose, brandy,  ammonia,  and ether may be freely given,
either alone or in combination with olive oil.  The eau de luce—which  enjoys a
high reputation in some tropical countries—owes its  efficacy to the ammonia
which it contains.   Should drowsiness come on, the patient must be walked about,
and artificial respiration with galvanism may be resorted to  as a last means of
maintaining life until the effects of  the stimulants  may overcome those of the
poison.   Large doses of arsenic have been recommended as  a  kind of  specific,
and the  " Tanjore  pill," a celebrated  Indian remedy, owes  its activity to this
mineral; but care must, of course, be  taken in administering this, lest the remedy
prove as fatal as the injury for which it is administered.
   The bite of rabid animals gives rise to  the disease so much  dreaded and so
often spoken of, but fortunately so seldom seen  in man in this country, termed
hydrophobia. 
132
POISONED  WOUNDS.
   This disease invariably occurs in man, and, most commonly, in the  lower ani-
mals as the result of contagion.  The wolf, the fox, the jackal,  and the cat, are
most  liable to it.  When originating de novo, its causes are excessively obscure.
It has been attributed to the influence of season; thus Eckel finds it most com-
mon in the months of February and May; but want of  water, sudden changes
from  heat to cold, bad food, and unsatisfied sexual desires, have all been assigned
as causes of its  occurrence in animals.  Dogs more frequently  become  rabid
than  bitches; thus,  of a  hundred  and forty-one cases collected by Eckel, only
fifteen occurred in bitches; and amongst dogs it is most common  in  those of a
mongrel breed, seldom occurring  in those  that are of pure blood;  or  that have
been  castrated.   In  the human subject it never occurs except  as  the result of
contagion either by a bite, or  by the  rabid animal  licking a  raw surface, as an
abrasion on the hand or lip.  The bite of a rabid animal is most dangerous when
inflicted on a naked part, as  on the hand or face.  A  person bitten through
clothing often escapes any ill  effects, in consequence of the teeth  being wiped,
and the poisonous saliya arrested by the clothes.   Hence a number of persons
may be  bitten by the same rabid animal, and but a very few take the disease;
not more, perhaps, than one in ten,  or one in twenty.
   The period that intervenes between the bite and the occurrence of the disease
is  usually  considerable.   Meade has related  the  case of a  lady who got the
disease fifteen months after the bite.   Elliotson says that the average time that
elapses between the injury and the symptoms is from six weeks to three months.
The Duke of Richmond,  who was bitten by a tame fox, took the disease between
six and seven weeks after the injury.  Writers, however, in stating that six,
seven, twelve, and even fifteen years have intervened between  the  infliction of
the wound and the manifestation  of the symptoms, have evidently committed an
exaggeration or fallen into error, having very probably confounded other nervous
affections that closely resemble hydrophobia with it.
   Symptoms.—The  wound has generally cicatrized long before any symptoms of
hydrophobia declare themselves, and no peculiar appearance is presented by the
scar.   Shooting pains, twitching and itching sensations have, however, occasion-
ally been experienced in  the  site of the wound before the supervention of the
attack; and it is probable that in  all cases some process  analogous to a zymotic
action takes place within  it before the disease comes on.   The precise nature of
this, however, requires to  be elucidated by further observation.
   The general symptoms are usually ushered in by some antecedent phenomena
for two or three days; according to Perry, for five or six.   These  initiatory symp-
toms consist of giddiness, chills, and  heats, and a general feeling of discomfort.
The more special symptoms never manifest themselves until the  disease becomes
fairly  established; they consist of extreme nervous irritability  and apprehension,
with convulsions, induced by various external  influences, whether acting on the
surface of the body,  or on the  fauces, or may be occasioned by  mental impres-
sions, and speedily end in exhaustion and death.   These more special  symptoms
may be arranged under three heads :  consisting of a spasmodic affection of the
muscles of deglutition and respiration;  of extreme sensibility of the surface and
of the senses;  and of excessive mental terror and agitation.
   In  consequence of the  spasmodic affection of the& muscles  of deglutition, the
act of swallowing commonly excites convulsions;  hence the patient*5 experiences
a horror of all liquids; and, in attempting to drink gulps  down  the fluid with a
strong  mental effort.  In some cases, solids  give  rise to the same difficulty  in
deglutition as liquids; but occasionally, though rarely, patients have been known
to swallow perfectly  well  throughout the disease.   This difficulty in swallowing
is certainly owing to an  excessive  sensibility about the  pharynx  and throat,
in consequence of which every effort at deglutition  induces violent reflex move-
ments. 
HYDROPHOBIA.
133
  A catch in the breathing, resembling what occurs when a  person  goes into a
cold bath, is met with as one of the earlier symptoms, taking place in the midst
of conversation, and before the patient's mind is directed to the nature of the
disease.  This catch is due to  the spasmodic descent of the diaphragm, and gives
rise to severe pain at  the  pit  of the  stomach, or a feeling of suffocation, and a
return of the convulsions.
  An extreme degree of sensibility of the surface, and of some of the senses, is
characteristic of hydrophobia.   The cutaneous nerves become so sensitive that a
blast of cold air, the rustling of the bed-clothes, the slightest touch of or move-
ment on the skin  will  bring on convulsions.  The nerves of sense become equally
excitable, so that  a sudden flash of light before the eyes, as the reflection of the
sun from a looking-glass, or a sudden  noise, as the slamming  of a door, will pro-
duce the same effect.'   The noise produced by liquids being poured from  one
vessel to another is peculiarly distressing to the patient;  and Dr. Elliotson men-
tions a patient with hydrophobia being thrown into violent agitation, by hearing
the dresser, who sat up with him, make water.
   The sufferings  and  convulsions that patients experience when they attempt
to drink appear to be owing to  this excessive sensibility of  the  nerves  of the
mouth and pharynx, and the  recollection  of these sufferings makes them afraid
to repeat the attempt; hence the fear of liquids, from which the disease derives
its name.
   One of the earliest symptoms of hydrophobia and one of the most persistent
is an extreme degree of mental agitation and terror, a vague  sense of dread, and
horror at the impending fate.  Delusion  sometimes occurs of a spectral  charac-
ter, the patient supposing himself to be surrounded by animals, by horrid forms,
or by  gaping, ghastly, and grinning countenances.   The first symptom  in the
Duke of Richmond's case was  that he fancied some poplar trees opposite his bed-
room window were men looking in.  These delusions may alternate with fits of
delirium and frenzy.   In these it is said  that the patient barks like a dog, and
endeavors to bite; but this is  a popular error—the pretended bark is merely the
catch in breathing, and the attempt  to bite is  nothing but movements of the
tongue and mouth induced by the clamminess of the viscid  and ropy  mucous
saliva.  Occasionally  the  symptoms subside completely before death; the sensi-
bility of the surface  disappearing,  the  mental agitation or  delusion being  re-
moved, and  deglutition and  respiration  being quietly performed.  Thus Dr.
Latham relates the case of a man laboring under this disease, who sat up quietly
in bed and drank a pint of porter half an  hour before he died.
   I am not acquainted  with any authentic case of recovery from hydrophobia,
after the disease  has  fairly set in.   The  disease may prove fatal in four-and-
twenty hours, or life may  be prolonged for six or  seven days;  death generally
occurring from the second to  the  fourth  day, and being apparently induced by
exhaustion.
   The appearances found  after death  throw no light whatever upon  the disease,
and indeed may often be supposed to  be the effects rather than the causes of the
spasmodic irritation.   The tongue, the fauces, the throat, the glottis, and the
larynx, the stomach and oesophagus, the brain, the medulla oblongata, and spinal
cord, have all been found congested and inflamed; there is nothing, however, in
the appearances presented  by  these parts that affords a  clue  to the  true nature
of this inscrutable and terrible malady.
   The treatment must principally  be  of a preventive and palliative character;
we cannot speak of curative  treatment in hydrophobia; for after  the disease
has once set in, the utmost that  can be  done will not accomplish more than to
lessen the sufferings  of the patient, and stay for a few hours the fatal termina-
tion.
   When a person is bitten by a dog that  is mad, or even by one that is supposed 
134
POISONED  WOUNDS.
to be so, the surgeon should always adopt energetic means  to  save  the patient
from the invasion of a disease that is  necessarily fatal.  In having recourse  to
preventive treatment it should be borne  in mind that the  larger proportion  of
persons actually bitten by rabid animals do not fall  victims to hydrophobia; the
probability of  the occurrence of the disease depending partly  upon the animal
that bites, and partly  upon whether the bite is inflicted  upon  the naked  or
clothed parts of the body.  Thus Watson states, that of 114  persons bitten by
mad wolves, 67 died of hydrophobia; whilst, according to Hunter and Vaughan,
only one out of twenty or thirty bitten  by mad  dogs take the disease.  This
latter estimate may probably be somewhat lower than the truth, but yet the fact
remains certain that wolf-bites are far more dangerous than  dog-bites, and this is
probably owing to the  circumstance of wolves always flying at the face and naked
parts.   It is in consequence of this small proportion of persons taking the dis-
ease out of the total number bitten, that so many popular  remedies and super-
stitions have obtained an unmerited reputation for preventing the disease.   The
only preventive means that can be trusted to by  a surgeon,  are excision and
caustic.
  Excision of the part bitten  should be carefully and freely performed, no half
measures being had recourse to.   Hence it  is better to remove too much of a
comparatively  unimportant tissue or part, than to allow the sufferer to  run any
risk of falling a victim to this fatal disease.    In  order to excise every part that
has been touched by the  tooth, the  surgeon, after washing the  wound and con-
tiguous surface, should make a circle with ink, or tincture of iodine, completely
round the injured part. He must then pass a probe to the bottom  of the wound,
and excise the whole by scooping out a conical piece of the tissues, taking care
to go beyond the furthest limit to which the probe  is passed.   If there  be any
doubt  of the  whole of the injured parts  having  been removed, potassa fusa
should be applied.  If the lip is bitten  through, a portion should be cut out, and
the wound brought together, as in hare-lip operations; if it be a finger that  is
injured, amputation of it should  be performed.  In those  cases  in which the
wound is so situated that  excision cannot readily be performed, potassa fusa, or
strong  nitric acid, or nitrate of silver, as recommended by Mr. Youatt, should be
freely applied  to every corner of it.
  If the bite  have already cicatrized,  the place  should be  excised  at any time
after the injury, provided the dog is known to have been, or to have become mad,
for  it is not improbable that the occurrence of some of the  remoter cases of the
disease is dependent upon, or connected with, some  peculiar action set up in the
wound, which might possibly be averted  by the removal of  the cicatrix.  I for-
bear to speak of any other means of preventive treatment than  excision and
caustic, as I consider them utterly undeserving of confidence.
  After the disease has once set in, nothing can be done but to palliate symptoms
and to  prolong life.  Every possible remedy that the ingenuity  of man could de-
vise, from warm water to  viper and ticuna-poison,  has been tried, and been found
utterly useless.  The  only plan  of treatment  that holds out a  hope of eventual
success, and which, whether it succeed or not in curing the  patient, at all events
mitigates his  sufferings,  is that which has been recommended  by Dr. Marshall
Hall and Dr. Todd.   It consists, in the first place, in removing all external irri-
tation,  whether mental or bodily;  putting the  patient in a darkened  room,  as
much removed as possible from all noise and the intrusive curiosity of strangers,
and surrounding his bed with gauze curtains or screens, so as to prevent the&dis-
turbing influence  even of a draught of cold air.  Measures must then be adopted
to lessen the excitability of the spinal cord.  This may be done most efficiently,
as Dr.  Todd suggests, by the application  of  ice in a piece of gut laid along the
whole  length  of the  spine, and lastly, the  surgeon must bear in mind that he 
DISSECTION  WOUNDS.
135
has to treat an exhausting disease, and that he must  consequently support the
patient by wine, beef-tea,  and such nourishment as can be taken.
  Dissection  Wounds.—The majority of wounds received  in dissection are not
dangerous.  Every student in anatomy frequently punctures and cuts himself in
dissecting in  the  course  of his studies, and  it is but rarely that we see any  ill
consequences following these injuries.   In some cases, however, the most serious
results, terminating in permanently impaired  health, or even in death, ensue.
The result depends partly on the state of health of the person punctured, and
partly on the  condition of the body from which the puncture is received.   If
the health be broken by any cause, whether excess of study or dissipation, very
serious effects  may follow  that would not occur if the patient had more resisting
power; hence it is of much importance to those engaged in the practical study
of anatomy not to allow the health to become  impaired to too great an extent.
  The deleterious influence exercised  by the  dead body  may  be attributed  to
three different causes.  Thus it may be supposed to  result from the  mere
mechanical irritation  of the wound;  or, it may arise from the inoculation  of
putrid matter; or, lastly,  be dependent upon the introduction of a specific virus
into the system.  I think it is probable that each of these  causes may exercise
an influence, but that the worst effects of dissection wounds are  dependent on
the inoculation of a peculiar virus.
  That ill effects sometimes result from the simple mechanical irritation of the
puncture is evident from the fact that  we see  mere scratches or punctures with
splinters of wood, or other harmless substances, give rise to considerable local
disturbance in certain states of the constitution; so we also find that those dis-
section wounds that are ragged and  torn, such as are made by spiculae of bone
or the tooth of a saw, are attended by peculiarly troublesome consequences.
  Putrescent matter must always  be injurious when introduced into the economy,
but at the same time,  it is a remarkable fact,  that the worst dissection wounds
have been received before putrefaction had set in, and that they more commonly
occur in post-mortem inspections than in the dissecting-room investigations.
  That the worst forms of dissection wounds are dependent upon a specific virus
is evident from the fact,  that it is especially after  death  from certain  diseases,
especially of an erysipelatous type, that these consequences ensue.   Most danger
is to be apprehended from punctures received  from the bodies of those who die
of erysipelas, phlebitis, and the diffuse forms of peritonitis following parturition
or the operation for hernia.   The mere contact of  such a  body is  occasionally
dangerous.  Thus,  I have known a  subject in the  dissecting-room seriously in-
fect  in different ways six students who were working at it.   Two had  suppura-
tion of the cellular tissue,  under the pectorals and in  the axilla; one was seized
with a kind of maniacal delirium; a fourth had typhoid fever; and the  remain-
ing two were seriously  though not dangerously  indisposed.
  From all this it would appear that there are  two distinct kinds of mischief re-
sulting from these injuries.
  The  milder  form is not of a specific character, but proceeds from the simple
irritation of a  scratch  in a broken constitution, or from the inoculation of putre-
scent matter.   In these cases the part punctured becomes painful, hot, and throb-
bing, in from twelve to twenty-four hours after the injury, the  finger swells and
inflames,  the absorbents of  the arm are perhaps affected, and  the glands in the
axilla become  enlarged.   There  is general febrile disturbance of an inflamma-
tory  character, ushered in by rigors, and a feeling of depression; suppuration
takes place about the puncture, and  also, perhaps, in the  inflamed glands, the
case  presenting the ordinary character of whitlow with inflammation of the ab-
sorbents.
  In the more severe  form  of dissection wounds,  the patient is seized, about
twelve or eighteen hours after the puncture, with rigors, anxiety of countenance, 
136
POISONED  WOUNDS.
and  depression of the  nervous system; with a  quick pulse,  and with  febrile
reaction of an  inflammatory character; on examining the finger,  a pustule or
vesicle, with an inflamed areola will be observed in the situation of the puncture;
from this a few red lines  may be  observed stretching up towards the  arm-pits,
with a swelling and tension in this region.   Diffuse inflammation of the cellular
tissue  of the limb  sets in  about  the fifth or sixth day,  extending up  to the
shoulder,  and down the side of the chest to the  flank.   Abscesses, usually of a
somewhat diffuse character, the pus being mixed with shreds and sloughs, form,
often with much  pain, in  these situations.    The general symptoms  gradually
assume an asthenic type; the tongue becomes brown, sordes accumulate about the
lips  and gums, low delirium sets in with a rapid feeble pulse,  and death occurs
in from ten days to  three weeks.   When  incisions are made  into  the brawny
tissue,  it is found infiltrated with sero-pus, and in a sloughy state.   If the patient
live, large circumscribed abscesses form under the pectorals, in  the axilla, and
above  the clavicle, with much exhaustion and depression of the system,  conva-
lescence being tedious and prolonged, and the constitution being  often shattered
for life.
   It is this form of the disease that  resembles diffuse inflammation  of the cel-
lular tissue arising from other causes; and  indeed there can be little doubt that
it  is  a  cellular erysipelas dependent on a toxic agency.   That  this form of dis-
section wounds  is of a truly erysipelatous character, is evident from the fact that
patients laboring  under it will  communicate fatal erysipelas to their nurses and
attendants; as happened in the case of the  late Mr.  Potter, whose early death is
so much to be lamented.   It is also this kind of dissection wound that is espe-
cially apt to occur after punctures received from patients who have died of diffuse
inflammation of the serous membranes.    '
   Treatment.—On the receipt of a puncture in dissection, the  best mode to pre-
vent injurious consequences, is  to tie  a string tightly round the finger above the
injury, thus causing the' blood to flow, and perhaps to wash out the virus with it.
The  part should  then be well washed  in a stream of cold  water at a  tap, and
sucked for some minutes;  in this way any  poisonous matter that  has been intro-
duced  may usually be got rid of.   I  think that  in  general, it is better  not to
apply caustics in these cases; they only irritate and  inflame the finger, and can
do but  little good.  If any caustic be employed, it should be a drop of nitric acid
let fall into the wound.   The nitrate of silver, which is commonly employed, can
never do much good, as  it does not penetrate to a sufficient depth to be of service.
Dissectors should bear in mind the influence  that the  state of the  constitution
exercises upon the effects of the puncture,  and that in proportion as the health
is sound there is  less likelihood of any injurious consequences ensuing.
   In the slighter forms of  dissection wound,  attended by a moderate amount of
inflammation, the part must be poulticed,  leeches should be  applied, and the
arm  put in a sling.  If the absorbents become  inflamed, chamomile and poppy
fomentations  must be diligently used,  and the  early opening of abscesses had
recourse to, and free incisions should be practised wherever there is much tension,
even though matter have not already formed, with a view to prevent suppuration.
The  general treatment must consist of moderate antiphlogistics in the early stages,
but support will soon be required;  and if there be much constitutional irritation,
opiates may advantageously be administered.
   The treatment of the more severe forms of dissection injury consists  princi-
pally in fomentations, and in early and very free incisions into the finger or other
parts that become tense and brawny.   In the  constitutional treatment, our great
reliance, after clearing  out the intestinal canal with a  free  purge, such  as five
grains  of  calomel and fifteen grains of jalap, consists in the  administration  of
bark,  ammonia,  camphor,  wine, and  brandy, with such  nourishment  as the 
INJURIES OF NERVES.
137
patient can take;  the case being treated as one of the lowest forms of asthenic
inflammation.  If the patient survive, he must be sent as soon as possible into
the country, and must devote some months perhaps to the re-establishment of his
health.  The part that has been punctured often continues irritable for a great
length of time, even for many years, remaining red, inflamed, and desquamating,
with perhaps the  occasional formation of pustules  upon it.   This  condition is
best remedied by the occasional application of the nitrate of silver.
                           CHAPTER IX.

               INJURIES OF  TISSUES AND ORGANS.

   We next proceed to the consideration of injuries  of particular tissues and
organs, and we shall take these in the following order : 1st.  Injuries of nerves.
2dly.   Of bloodvessels.   3dly. Of the organs of locomotion, including  those of
bones, joints, muscles, and tendons; and 4thly. Injuries as they affect particular
regions of the body.

                          INJURIES OF NERVES.

   Nerves are often contused, the injury producing a  tingling sensation at their
extremities, and pain at the part struck, which usually pass off in the course of
a few minutes or hours; but in certain conditions of the system, more especially
in the hysterical temperament, this  may last for a considerable period, and even
give rise to neuralgia of a more or less permanent character.
   If  a nerve  be  punctured, unpleasant consequences sometimes result, more
particularly in delicate women.  Thus, I have more than once seen a puncture
of one of the digital branches of  the  ulnar nerve produce a kind of painful
paralysis in its trunk, rendering the arm nearly useless.   I have seen the same
effects happen in  the median nerve from so slight a cause as the puncture of
a finger with a needle.   It occasionally happens in venesection  at the bend of
the arm, that a branch  of the internal cutaneous is pricked with the lancet, and
that very persistent neuralgia occurs in consequence.
   When a nerve is completely cut across, immediate  paralysis  of sense and
motion occurs in all the parts supplied by it.   Consequently if the  integrity of
the nerve be essential to life, as in the pneumogastric,  death must ensue.   There
is  well-marked loss in temperature and modification of nutrition in  some cases of
cut nerve.  Thus in  a  patient who applied at the University College Hospital
twenty-one weeks  after  the ulnar nerve had been accidentally divided, and who
had paralysis of the parts supplied by it, I  found the temperature between the
ring and little fingers of the injured side to be 9° Fahr. below that of the same
spot on the other hand.
   If a cut nerve be examined shortly after  the  injury, it will be found to have
become slightly bulbous at the  extremity, nervous matter having  escaped from
the neurilemma, and fibrine being thrown out around and between the two ends.
Restoration of the continuity of the nerve evidently takes place, however, as is
shown by the fact, that in the course of  a few months its functions  become re-
established in its lower  part, the paralysis slowly disappearing.   If, however, a
portion of the nerve have been actually excised, there is no restoration of function
as  was shown  long  ago by Haighton.   Schwann and  Ilasse have found the 
138
INJURIES  OF  TISSUES  AND  ORGANS.
return of sensibility and  motion in the lower part of the nerve  to be owing to
nerve-tubes forming in the uniting  medium, and thus serving to establish the
continuity of the nerve.

        CUTS AND WOUNDS OF BLOODVESSELS AND HEMORRHAGE.

  The characters of the bleeding or hemorrhage differ according to the nature
of the vessel  from which the blood escapes.   When a vein  is wounded, the
blood that is poured out is of a dark color, and  flows  in a uniform stream; the
force with which it  is projected  depending  on the conditions  in which the
wounded vein is placed.   If there be any pressure, as of a ligature upon the
vessel between the wound and the  heart; or if the position of the part be such
as to favor the gravitation of the blood  towards the wound, or if the  muscles
of the limb be made to contract, the force of the flow of blood will be increased.
  When an artery is wounded, the blood that  escapes  is of a  bright vermilion
or scarlet color.   It flows by jets, synchronous with the  contractions of the left
ventricle;  and between each jet the flow does not cease, but the stream becomes
continuous.  In the great majority of cases the jet only comes from the proximal
aperture, dark blood issuing from the distal opening in a continuous and trick-
ling stream; but in some  situations a jet of blood, of an arterial character, may
issue from the distal as well as the proximal end of the cut vessel, as in wounds
of the palmar and plantar arches, or of the arteries of the forearm.   As the
blood flows, the  jet lessens in height,  in consequence of  the weakening of the
heart's action.   The  height  and force of the jet in all cases depend greatly on
the size of the vessel; thus the jet from the  femoral artery is stronger than that
from the muscular branch  of the thigh.   When a small arterial branch is wounded
near to its origin from the main trunk, the jet  will always be forcible and free;
so also the proximity to the centre of  the circulation will influence materially
the force with which the blood is propelled from the wound in the vessel.
  When the blood is not  poured out on the surface, but escapes from a wounded
vessel  into the  cellular tissue of a part, the  substance  of  organs,  or  internal
cavities, it is termed an extravasation.    In these cases there are not the ordinary
local signs of hemorrhage, but we judge of the escape of blood  by the  general
effect produced upon  the system by its loss.
  The constitutional effects of hemorrhage depend upon the  quantity of blood
lost, on the rapidity with which it is poured out, and on the state of the patient's
constitution.
  When a large quantity  of blood is suddenly lost, as when a main artery is cut
across or  an aneurism bursts, the patient may die forthwith ; falling down in a
state of syncope, with a pale cold surface, lividity about the lips and eyes, and a
few gasps, sighs, great restlessness  and  convulsive movements of the limbs be-
fore he expires.   If the quantity lost  be not so  great  as to produce death, but
is yet very considerable, the patient  becomes faint  and  sick,  with  coldness
and pallor of  the surface, great restlessness  and agitation, thirst,  noises in the
ears, and failure or complete  loss of sight.  If the  quantity lost, though con-
siderable, be not so great  as this, or be spread over a greater interval  of time,
so that the patient is enabled to rally between the recurrences of the hemorrhage,
a state of  anemia will be  induced, characterized by pallor of the skin and of the
mucous membranes, palpitation of the heart, rushing noises in the head, amaurosis,
a tendency to syncope when in the  erect position, oedema of the extremities, and
general debility  of the system.
  After excessive loss of blood the  patient may gradually rally, and  as the vital
fluid is reproduced in his  system, he may recover without any bad effects;  or he
may fall into  a  state  of anemia, which may  perhaps never  be  completely re-
covered from, and be associated with various forms of local  debility and  distur- 
EFFECTS AND  TREATMENT  OF LOSS  OF BLOOD.
139
bance of functions.  After very abundant loss of  blood, " hemorrhagic fever,"
is apt to set in, characterized by a tendency to  reaction in the system^ with ex-
treme irritability of the heart and arteries.  It is irritative fever conjoined with
anemia.   There is but a small quantity of blood  in  the system, and the heart
and arteries make  violent efforts to  drive it forwards.   This condition is marked
by the symptoms of extreme loss of blood, alternating with periods  of  intermit-
tent reaction, the pulse becoming much hurried, fluttering, jerking, and  irregular
in force and  frequency; slight  flushing of the face and brilliancy of  the eyes,
rapidly passing again into pallor and syncope ;  and if the hemorrhage eventually
prove fatal, delirium and convulsions, with excessive restlessness, usually precede
death.  The body of a person who has died from the  effects of hemorrhage
presents a  peculiarly blanched, semi-transparent,  waxen  look;  the lips, alse of
the  nose,  and finger-nails,  having a somewhat livid appearance,  contrasting
 strongly with  the  clear yellowish-white hue of the general surface.
   The general treatment of hemorrhage is sufficiently simple.  After the flow
 of blood  has  been arrested by proper local  means, such  as will  hereafter be
 described, the effects of its loss are usually speedily recovered from  by rest and
 good nourishment.  In some cases, however, the nutrition of the system becomes
 permanently impaired, and  a state of chronic  anemia is induced ^ which, not-
 withstanding  the administration of  chalybeate preparations, may continue through
 life, and terminate in cachexia, phthisis, or diarrhoea.
   When the  loss  of blood is considerable, and is attended by symptoms of much
 prostration, it may be necessary to  have recourse to immediate measures in order
 to prevent the syncope being fatal.   With this view  the patient should be laid
 recumbent, with the head low, and pressure may be exercised upon  the abdomi-
 nal aorta or the main arteries of the limbs, so as to confine the blood as much as
 possible to the nervous and circulatory centres.  If death appear imminent from
 the effects of the hemorrhage, as  happens in some cases of flooding, transfusion
 of blood may be had recourse to;  the influence of which, in restoring the  failing
 powers of the heart  and nervous  system, is immediate  and most  striking, and
 has been unquestionably determined by the observations of Dr. Blundell and
 other obstetricians.                                              .        .
    The operation  of transfusion is one of some delicacy, and requires care lest
 mischief is occasioned by the injection of air together with the transfused blood,
 an accident  that would probably prove fatal to the  patient.   If the  proper
 transfusing apparatus, by which the blood  may be injected without the risk of
  admixture of air, and of a proper temperature, be not at hand, an  ordinary hy-
  drocele syringe, capable  of  holding about six ounces, and fitted with a stop-cock
  and canula, may  be used.   An opening of  sufficient size having been made in
  one of the larger veins at  the bend of the arm or about the instep, and the
  canula having been introduced to  a sufficient extent to insure the proper entrance
  of the blood, the syringe, previously warmed, should be filled, and about twelve
  ounces of freshly-drawn  human  blood  slowly but  steadily injected  the limb
  being placed in  such  a position  as to favor its  transmission  to the heart.  In
  performing this operation the  principal points to be attended to are  the proper
  introduction  of the canula  into the  vein with as little  injury  as possible to its
  coats, the perfect freedom of the  whole apparatus from bubbles of  air and the
  steady  but rapid performance of the operation, so as to avoid coagulation  and
  deterioration of the blood.  If transfusion  be determined on it  should  not be
  delayed until the last moment, when  the agony of death  has already commenced;
  as then  the  actions  of the nervous and circulatory systems may be so impaired
  that  the patient is no longer recoverable, or if temporarily  so,  will speedily
  relapse into a state of fatal  disease. 
140
WOUNDS  OF  VEINS.
                            CHAPTER  X.

                          WOUNDS OF VEINS.

  Veins  are  very commonly wounded suicidally,  accidentally,  or in surgical
operations, but unless they are deeply seated, their  injuries are seldom attended
by any serious  consequences.   There are, however,  three sources of danger
in wounds of veins:  1st, from loss  of blood; 2dly, from the occurrence of
diffuse inflammation of the vessel; and 3dly, from the entrance of air into the
circulation.
  A vein  is known to be wounded when dark blood flows in a rapid and uniform
stream from the seat of injury.   If the  vessel wounded be one of considerable
magnitude, or be  in  close proximity  to  the centre of circulation, the flow of
blood may be rapidly fatal, more especially if its escape is favored by the depen-
dent position of the part.
  The hemorrhage from a wounded  vein may, if the vessel  is superficial, be
arrested by position, and the  pressure of a compress, by means of a few turns
of a roller.  If the vein be one of considerable magnitude, as the internal jugu-
lar, for instance; or if it be so situated that pressure cannot be brought to bear
upon  it, it may require the application of a  ligature: this, however, should, if
possible, always  be avoided, inasmuch as  it is apt to occasion dangerous inflam-
mation of the  vessel.
  Th'e wound in a vein is healed by slight inflammation taking place about the
lips of the incision, and giving  rise to the formation of a distinct cicatrix.   In
some  cases, from the irritation of the simple wound,  and in others from the appli-
cation of the ligature,  a diffuse form of inflammation  of the vein  takes  place,
which usually proves fatal.  This variety of phlebitis will be described when we
come to speak of the different kinds of venous inflammation.
  The entrance of air into a  wounded vein, though an  accident of rare occur-
rence, is one that occasions such peculiar and alarming symptoms, that it becomes
necessary  to be acquainted with the circumstances attending it; and  its study is
the more interesting  to the  practical surgeon, as  it is chiefly in  the course of
operations that this condition occurs.
  It has long been known to physiologists that the forcible introduction of air
into the circulation would  kill an animal;  and Morgagni, Valsalva, Bichat, and
Nysten, have  made this a subject of observation and experiment.   The death of
the animal in these cases would  appear to be dependent partly upon the quantity
of air injected, and partly on the rapidity with which  it is thrown in.  Bichat
supposed that a single  bubble  injected into the circulation killed the animal with
the rapidity of lightning, but this  is  erroneous, as shown by  Nysten.  And I
have  on several  occasions injected two  or three cubic inches of air into the jugu-
lar vein of a dog without producing death, though much distress resulted.   The
rapidity with which the air is thrown in exercises a considerable  influence upon
the result.  If blown  in quickly, a small quantity may kill;  if thrown in slowly
and gradually, a large quantity may be  injected without destroying • life, the
blood appearing to dissolve and carry away the gaseous fluid.
  In surgical practice, we do  not meet with the forcible introduction of air, but
have  only to  do with  its spontaneous admission into the circulation. This was
first observed in the year 1818,  in a case in which  the internal jugular vein was 
ENTRY  OF  AIR INTO VEINS.
141
opened during the  removal of a large tumor from the right shoulder by M.
Beauchesne.   The investigation of  this subject is consequently a comparatively
recent matter, in which the labors of the Commissioners of the French Academy
are conspicuous,  and the names of Magendie, Amussat, Cormack, and Wattmann,
are distinguished.   As cases of the  entry of air into the veins comparatively sel-
dom occur  in  man, it is  necessary to study the phenomena accompanying it, on
the lower animals.   In experiments which I have made on this  subject, I have
observed the following phenomena:—On exposing the internal jugular vein low
in the neck, and puncturing it at a  place where the flux and reflux of the blood
are plainly discernible, there is perceived in the first inspiratory effort made by
the animal  after  the wound, a peculiar lapping or gurgling liquid hissing sound;
the nature  of the sound  depending partly on  the size and  the situation of the
opening in  the vessel.  At the same time, a few bubbles of air are seen to be
mixed with blood at the orifice in the vein.  The entrance of the air is imme-
diately followed  by a struggle during  the  deeper inspirations, in which fresh
quantities of air gain admittance, the entrance of each portion being attended
by the peculiar sound, above described.   On listening now to the action of the
heart, a loud churning noise  will be heard, synchronous with  the ventricular
systole, and the  hand will, if  applied to  the parietes of the chest, perceive at
the same time a  peculiar bubbling,  thrilling, or rasping sensation,  occasioned by
the  air  and blood being, as it were, whipped together between  the columnas
carneae and chordas tendineae.   As  the introduction of air continues, the circula-
tion becomes  gradually more feeble and  languid; the  heart's action, however,
being fully as forcible, if not more  so, than natural.   The  animal soon becomes
unable to stand: if placed upon its  feet, rolls over  on one  side, utters a few
plaintive cries, is  convulsed,  extrudes  the faeces  and urine, and  dies.   If the
thorax be immediately opened, it will be seen  that the heart's action is continu-
ing  regularly and forcibly, and that the pulmonic cavities, though filled, do not
appear distended beyond their ordinary  size.
   Death occurs,  as  I  have shown, in a  paper on this subject, published in the
158th  number of the " Edinburgh Medical and Surgical Journal," in  conse-
quence of the air and blood being beaten up together in the right cavities of the
heart into  a spumous  froth, which cannot be propelled through the pulmonary
vessels; hence there  is a  deficient supply of blood to the  brain  and  nervous
centres, and fatal syncope conies on, attended usually by convulsions.
   The spontaneous entry of air into the veins of man is attended by two distinct
sets of phenomena,  one of a local, the other of a constitutional character.
   The local phenomena consist in a peculiar sound, produced  by the entrance
of the air,  and in the appearance of bubbles about the wound in the vein.  ^ The
sound is of a hissing, sucking, gurgling, or lapping character, and never fails to
indicate the dangerous accident that has occurred.   When once heard,  whether
in man or the lower animals, it can never be mistaken.  It has  fortunately only
fallen  to my lot to hear this sound  in the human  subject on one occasion;  that
of a patient who  had attempted suicide by  cutting his throat. _  The internal
jugular being wounded, was being  raised for the  purpose  of having a ligature
passed under it; at this moment a  loud hissing and gurgling sound was  heard,
some bubbles of air  appeared about the wound, the patient became faint, and
greatly oppressed in  his breathing.  The ligature was immediately tightened,
the faintness gradually passed off, and no bad consequences ensued.
   The effects produced upon the constitution are usually very marked.   At the
moment of the entry of the air, the patient is seized with extreme faintness, and
a sudden oppression about the chest;  he usually screams out, or exclaims that
he is dead or dying, and continues moaning or  whining; the  pulse  becomes
nearly imperceptible, and the heart's action laboring, rapid and  feeble; death 
142
WOUNDS  OF  VEINS.
commonly results, but not instantaneously, in many cases at least.  Thus Beau-
chesne's patient lived a quarter of an hour after the occurrence of the accident;
Mirault's between three and four hours; and Clemot's several hours.   Amongst
the other recorded fatal cases I have  not been able to find any but vague state-
ments as to the length of time the patients survived.
  If the patient survive the immediate effects of the accident, he may probably
recover without any  bad symptoms, as happened  in  the  case to which  I  have
referred, as occurring at the University College  Hospital,  and  in an instance
recorded by B.  Cooper.  The presence of the air in the pulmonic capillaries
would  appear in some cases to act as an irritant, and induce fatal pneumonia or
bronchitis, as  happened to the patients of Roux and Malgaigne.
  The cause of the spontaneous entiy of air into the veins has been very com-
pletely investigated and determined by the French Commission.   If we  open a
large  vein at the root  of a dog's neck, near the thorax, in which the venous
pulse, or flux  and reflux of the blood is perceptible, we  shall see that  the air
rushes in at each inspiration—but only at this time—never gaining entry during
expiration.  This is owing to the tendency to the formation of a  vacuum within
the thorax, more particularly in the pericardium, during inspiration.   This suc-
tion action, or " venous inspiration," is confined  to the large vessels in and neai
the thoracic cavity, being limited,  by the collapse of the coats of  the veins, at a
little'distance  from this.   If the veins  were rigid tubes, it would extend through-
out the body, but as they are  not, it ceases where their coats collapse.   It is
indeed  limited to that part of the root of the neck and  the axilla, where the
venous  flux and  reflux are perceptible, and  the space in which it occurs has
been termed  the  " dangerous  region."  But under  certain  circumstances air
may spontaneously gain admission beyond this.
  It is well known that what is called by the French writers the  " canalization"
of a vein, or its conversion into a rigid uncollapsing tube, is the condition of all
others which is  most favorable  to the introduction of the air  into it.   Indeed,
except in those situations in which there  is a natural movement of flux and
reflux of the blood in the veins, this accident cannot occur unless these vessels
be canalized, or, in other words, prevented from collapsing.  This canalization of
the vessel may be occasioned in  a  variety of ways.   Either the cut vein  may be
surrounded by indurated cellular tissue, which will not  allow it to retract upon
itself, but keeps  it open like the  hepatic veins; or the coats of  the vessel may
have acquired, as  a consequence of inflammation or hypertrophy, such a degree
of thickness as to prevent their falling together when divided.   There again, the
principal veins at the root of the neck have, as Berard has pointed out, such in-
timate connexions with  the neighboring aponeurotic structures, that they are
constantly kept in a state of tension, so that their sides are held apart when they
are cut across.   The  contractions of the platysma and other muscles  of the neck
may likewise,  as  Mr. Shaw has shown, have a similar effect.  In removing a
tumor also, that is situated about the neck, the traction exercised upon its  pedicle
may, if this contain  a vein, cause it to become  temporarily canalized;  and the
incomplete section of the vessel, especially in a transverse direction, must  prevent
the approximation of  the sides of the incision in it, which will be rendered open
and gaping by the retraction of the surrounding  tissues.   This  patency in the
incision in the vein  is  apt to be  increased by the position that is necessarily
given to the head and arm in all operations of any magnitude about the shoulders
and neck.  Lastly, the introduction of air into a vein will be favored by the vessel
being divided in the angle of a  wound, the vein being, when the  flaps that form
that angle are lifted up, rendered open-mouthed and gaping.
  On looking over the reports of  cases in which air gained admittance into the
veins during operations, it will be  found that these vessels were always in one or 
CAUSES  OF  ENTRY  OF AIR  INTO  VEINS.
143
other  of the  above-mentioned conditions.  Thus, in Beauchesne's case, air was
introduced in consequence of incomplete division of the external jugular, imme-
diately above the right subclavian, whilst in a state of tension, during the re-
moval of a portion of the clavicle.  In a case that occurred to Dupuytren, a large
vein connected with the tumor, and communicating with the jugular, was  cut at
the last stroke of the scalpel, whilst the tumor was being  forcibly drawn up.
The vein was found to be adherent to the sides  of a sulcus, so that it remained
gaping when  cut.  In a case by Delpech, there was hypertrophy of the axillary
vein, causing it to gape like an artery.   In Castara's case there was incomplete
section of a vein, which opened into the subscapular, whilst the tumor was  being
raised up.  In Roux's case, a vein  in  the neck was opened, whilst a tumor,
which was being removed from  that region,  was being forcibly raised, in order
to dissect under it.   Ulrick saw the accident occur in consequence of the incom-
plete division of the internal  jugular vein, which was  implicated in a tumor in
the neck.   A similar case happened  to  Mirault  of Angers, the internal jugular
being divided to half its extent.   A case occurred to Warren, in which the air
entered by the subscapular vein, the coats of which were healthy, but in a state
of tension, in consequence of the position of the  arm; and another, in which the
same accident happened from the division of a small transverse branch  of com-
munication between  the external and internal jugular, whilst in a state of ten-
sion.   Mott,  whilst removing a tumor  of the parotid gland, opened the  facial
vein, which was in a state of tension in consequence of the position of the patient's
head, when air was  introduced.   A  case is related  by Malgaigne in which the
accident happened in consequence of  the incomplete  section of the external
jugular vein, which was enveloped in  a tumor that was being removed.  M.
Begin also relates a case in which the accident happened, in consequence  of the
puncture of the internal jugular whilst he was removing a tumor from the neck.
   These cases, which are  all that I have been able to meet  with, in  which the
condition of the wounded vein was particularized, show clearly what is the state
of the vessel and of the surrounding parts that is most likely to favor the  occur-
rence of the accident, and consequently what the surgeon should peculiarly  guard
against in the removal of tumors about the neck and shoulders; viz., incomplete
division of the veins, and  the employment of forcible  traction on  the diseased
mass at the moment of using the scalpel.  In removing tumors from the neck
and shoulder, it  is in many cases impossible to avoid drawing them forcibly up-
wards or forwards, in order to get at their deeper attachments; but if this be ne-
cessary the chest should, for reasons that  will immediately  be pointed out, be
tightly  compressed, so that  no deep inspirations may be made at the moment that
the knife is being used, or  before a divided or wounded vein can be  effectually
secured.
   Preventive Treatment.—When a patient is under the knife, the respirations
are generally shallow and  restrained, the breath being  held, whilst  every now
and then there is a deep gasping inspiration, at which moment, if a vein be opened
in  which the pulse  is perceptible, or that is canalized, air  must necessarily be
sucked in;  and, as has already been said, in quantity and force proportioned
to the depth of the inspiration.   This, then,  being the case,  the mode of guard-
ing against the introduction of air into the veins is obvious.   The chest and ab-
domen  should be so tightly bandaged with broad flannel rollers or laced napkins,
as to prevent the deep gasping inspirations, and to keep the breathing as shallow
as  possible, consistently with the comfort of the patient.  I have  often found,
that the entrance of air into the veins of a dog could  be arrested by forcibly com-
pressing the chest of the animal, so as to confine the respiratory movements, but
that as  soon as a deep inspiratory effort  was made, the compression having been
removed, a rush of air took place into the vessel.  If, therefore, during an ope- 
144
WOUNDS  OF  VEINS.
ration about the  root of the neck or summit of the thorax, the chest be ban-
daged, as here recommended, the  surgeon must  be  careful not to remove the
compression until  the operation is completed, and the wound dressed; for if this
precaution be not attended to, the patient will most probably, on the bandage
being loosened, make a deep inspiration, and air  may be sucked in at the very
moment that all appeared safe.
   Curative Treatment.—Different plans have been recommended by surgeons for
the treatment of those cases in which air  has  already gained admittance into a
vein; but, from the very fatal  nature of this accident, it does not appear that
much benefit has  resulted  from any of them.  The  recovery of the patient, in
some of the cases,  appearing  to be rather due to the quantity of air that was in-
troduced being insufficient to cause death, than to any effort on  the part of the
surgeon.  The two principal  modes of treatment that have  been recommended,
consists in the suction of the air from the  right auricle, and the employment of
compression of the chest.   Thus, Amussat  and Blandin advise  us to  introduce
the pipe of a syringe, a female catheter, or a flexible  tube, into the wounded
vein, if it be large enough  to admit the instrument, and if not, to open the right
jugular, and pass  it down  into the  auricle, and then to employ suction, so as to
empty the heart of the mixture of blood and air.  At the same time that this is
being done we are, say they,  to compress the  chest as forcibly as possible, so as
to squeeze more of the air out of  the  heart.  Magendie and Rochoux advise
suction alone; and Gerdy recommends us to be content with compression of the
chest.   Warren (of Boston) directs us, according to the condition of the patient,
to have  recourse to bleeding in the temporal artery, to  tracheotomy, or stimulants.
   The indications  that present themselves in the treatment appear to me to be
threefold:—
   1st. To keep up a due supply of blood to the brain.
   2d.  To maintain the powers of the heart until the  obstruction in the pul-
monic capillaries can be overcome or removed.
   3d. To remove,  if possible, the obstruction in the capillaries of the lungs.
   We shall now see how far  the means already  mentioned, viz., suction, com-
pression, &c, can  fulfil these indications.  And, first, with regard to suction, it
would no doubt be highly advantageous if we could, by this  or any other means,
remove the air that has gained access to the heart, and thus prevent the pulmo-
nic capillaries from being still farther obstructed.   But, putting out of considera-
tion the difficulty of finding the wounded vein,  the still  greater difficulty of
introducing a suitable tube a  sufficient distance into it,—the danger of allowing
the ingress of a fresh quantity of air whilst opening the sides of the incision in
the vein, so as to introduce the tube, and the risk there would be, if the patient
recovered from the effects of the accident, of having phlebitis induced;—putting
all  these circumstances aside, which appear to me  to be most serious objections,
it becomes a question, according  to  Amussat, who is one of the strongest advo-
cates of this mode of practice, whether  by suction with a syringe or the mouth,
even, any material quantity of air can be removed.   He says that  even when
the tube is introduced into the right auricle, much more blood  than air is con-
stantly withdrawn.   These  considerations, then, should,  I  think  make the
surgeon hesitate before having recourse  to such a hazardous  mode of procedure.
   The next plan, that of circular compression of the chest,  however valuable it
may be in  preventing the ingress of air, can, when that fluid has once been in-
troduced into the veins, have no effect  in removing it from the circulatory system.
We cannot by any compression that we may  employ, squeeze the air out of the
heart.   But compression  may not only  be productive of no positive  good, but
may even occasion much mischief, by  embarrassing still   farther the  already
weakened respiratory movements, and thus interfering with the due aeration of
the small quantity  of blood  that may yet be traversing the lun°-s. 
TREATMENT OF AIR  IN  VEINS.
145
  Bleeding from the temporal artery can by no possibility  be productive of any
but an injurious effect, by diminishing the already too small quantity of blood in
the arterial system.  Opening the right jugular vein may, perhaps, to a certain
extent, be serviceable, by unloading the right cavities of the  heart, as Dr. Reid
has shown it to be capable of doing, and it has been recommended by Dr.  Cor-
inack on this account.   Lastly, tracheotomy cannot be of any particular service,
as the arrest of the respiratory function is secondary and not primary.
   What, then, are the measures that a surgeon should adopt in order to prevent
the occurrence of a fatal termination in those cases in which air has accidentally
been introduced into  the veins during an operation ?  Beyond a doubt, the first
thing to be done  is to prevent the further ingress  of air, by compressing  the
wounded vein  with the  finger, and, if practicable, securing it by a ligature.   At
all events, compression  with the finger should never be omitted, as  it has been
shown by Nysten,  Amussat, Magendie, and others, that it is only when  the air
that  is introduced exceeds a certain   quantity that death ensues.  All further
 entry of air having thus been prevented,  our next object should be to keep up a
 due supply of blood  to the brain and nervous centres, and  thus maintain the
 integrity of their actions.  The most  efficient means  of accomplishing this would •
 probably be the plan recommended by Mercier, who believing that  death ensues
 in these cases, as  in  prolonged syncope, from a deficient supply of blood to the
 brain, recommends us  to employ compression  of  the aorta and axillary arteries,
 so as to divert the whole of the blood  that may be circulating in the arterial sys-
 tem to the encephalon.  This appears to me to be  a very valuable piece of advice,
 and to be the  most effectual way of carrying out the first indication, that of keep-
 ing up a due  supply of blood  to  the  brain and nervous  centres.  The  patient
 should, at the same time that the compression is being exercised  on his axillary
 arteries and aorta, or, if it be preferred, as more convenient and  easier than the
 last, on his  femorals, be placed in a  recumbent position as in ordinary fainting,
 so as to facilitate the afflux of blood  to the head.  The compression of the  axil-
 lary and femoral arteries may readily  be  made by the  fingers of  two  of  those
 assistants that are present at every operation.
    For the fulfilment of the second indication, that of maintaining the action of
 the heart until the obstruction in the  capillaries of the lungs can be overcome or
 removed, artificial respiration should be resorted to, as the  most effectual means
 of keeping  up the action of that organ.
    For the  purpose of  keeping up  artificial  respiration, the  Humane  Society's
 bellows, if  they  be at  hand/might be used, or, if they cannot readily  be pro-
 cured, the surgeon must inflate with  his mouth.   Before inflating the lungs it
 will be necessary to remove everything that can compress  the chest, or  interfere
 in any way with the free exercise of  the respiratory  movements.   Friction with
 the hand over the precordial region, and the stimulus of ammonia to the nostrils,
 may at the same time be resorted to.
    The third  indication—that of overcoming the obstruction in the  pulmonic
 capillaries—would probably be best fulfilled by the means adopted for the accom-
 plishment  of the second, viz., artificial inflation of the lungs.   That the action
 of respiration, if kept up sufficiently long, will enable the capillaries of the lungs
 to  get rid of the air contained  in  them, appears to be  the case; for I  have
 several times observed that, if a certain  quantity of air be spontaneously  intro-
 duced into the jugular vein of a dog, and artificial respiration be then established,
 and be maintained for half or three-quarters of an hour, but  a very small quan-
 tity indeed, if any, will be found, on  killing the  animal, in the cavities of the
 heart, or in  the branches of the pulmonary vessels.  I am aware that this is
 not altogether conclusive of the fact, as  the air might be  dissolved in the blood,
 or might  still exist  in the capillaries  of the lungs, although  none  might  be
 found in the larger branches of the pulmonary artery;  but  still it seems to  me
                                      10 
146
INJURIES OF  ARTERIES.
that we can hardly account for the large quantity of air that will disappear when
artificial respiration is kept up, in any other way than that,  some, if not all, of it
passes out of the capillary vessels into the air-cells of the lungs.
                           CHAPTER  XI.

                       INJURIES OF  ARTERIES.

  An  artery may be bruised, torn, punctured, or cut.   A  slight bruise of an
artery is not attended by any bad consequences, but if the contusion be severe,
obliteration of the vessel may ensue from  adhesive inflammation some days after
the accident.  Thus, a  patient was admitted into University College Hospital,
under Mr. Quain, with a contused wound  in the axilla, received by falling upon
some iron railings;  no change took  place  in  the  circulation of the arm for two
days, when pulsation in the radial artery ceased, the injured vessel having evi-
dently become obliterated by adhesive inflammation.
  An artery may be torn either partially or completely across.  When partial
rupture occurs, the internal and middle coats only give  way, the toughness of
the external coat preventing  its laceration.   This  accident is especially apt to
occur, as a consequence of blows or strains upon diseased or weakened vessels, and
thus may possibly lay the foundation for aneurism.  In some cases, the partially
ruptured vessel becomes blocked by plastic matter occluding its interior.
  The complete rupture of an artery may occur either in an open wound or under
the integuments. When an artery is torn across in an open wound, as by the avulsion
of a limb by machinery, or by a cannon-shot carrying it off,  there  is  usually but
little hemorrhage, even from  the  arteries of the magnitude  of the axillary or
femoral; and though the vessel hang out of the  wound, pulsating to its very end.
This absence of bleeding is owing to the  internal and middle coats, which  are
fragile, breaking off short and contracting somewhat; whilst the external coat and
the sheath of  the vessel, being  elastic,  are  dragged down and twisted over the
torn end of the artery, so as completely to prevent the escape  of blood.
  When the laceration of the artery is subcutaneous,  as occasionally happens in
the attempted reduction of an old dislocation of the shoulder, either extensive
extravasation,  or one or other of the  varieties of traumatic  aneurism may be
produced.
   Wounds of  arteries may be  divided  into those  that  do not  penetrate into  the
interior of the vessel, and those by which  it is laid completely open.
  Non-penetrating  wounds of arteries are  very  rare.  Mr.  Guthrie  however,
relates  the case of a gentleman who cut his throat,  and in  whom  the carotid
artery was exposed and notched through the external and middle coats only; the
vessel  finally gave way on  the  eighth day, fatal hemorrhage  ensuing.   A case
also lately occurred  at the London Hospital, in which a suicidal wound of the
throat had exposed the carotid artery.  After death it was found  that the inner
and middle  coats of the vessel  had been  divided by the  pressure of the knife,
which was blunt, but the external coat had been left entire, and under this a dis-
secting aneurism was found.
  In penetrating wounds of an artery we  have always hemorrhage of an arterial
character, unless the puncture be made with so  fine an instrument as  to be closed
by the mere elasticity of the coats of the vessel.   Thus, Maisonneuve has shown
that an artery may be punctured with a fine needle without  any hemorrhage or
other unfavorable result occurring.  If,  however,  the puncture be  larger than 
TEMPORARY  ARREST  OF  HEMORRHAGE.            147
this, being made by a tenaculum or hook, it does not commonly close in this way;
and if hemorrhage do  not take place  immediately, it will probably come on in
the course of a few hours or days, from ulceration of the  vessel.  If  the wound
be larger than this, there is always  an amount of hemorrhage proportionate to
its size, and to that of  the vessel.
   The direction of the wound in  the artery influences materially its  characters.
If the cut be parallel  to the axis of the vessel,  there is less tendency to gaping
of the edges than  if it be  oblique.   In transverse wounds of  arteries, the re-
traction of the coats is so great as to cause the wound to  assume somewhat of a
circular  appearance.   If the artery be cut completely across,  there is  always a
less degree of hemorrhage than when it is partially divided, for the retraction and
contraction of the  cut  ends  may then be sufficient to close  the vessel, which is
not the case when it is merely wounded.  When the wound in the artery is  sub-
cutaneous, communicating only by an  oblique and narrow aperture with the sur-
face, but little, if any, external  hemorrhage takes place, but  extravasation of
blood occurs.   The extravasation may either be poured  into one of  the  serous
cavities, or it may be diffused in the.cellular tissue of the limb or part, infiltrating it
deeply and extensively; and perhaps by its pressure giving rise ultimately to  gan-
grene ;  or it may be effused  in a more circumscribed manner,  giving rise to one
or other of the forms of traumatic aneurism.

                          ARREST OF  HEMORRHAGE."

   The  arrest of  arterial hemorrhage is perhaps the most important topic  that
can engage  the surgeon's attention, as on the  safe accomplishment of this the
success of every operation is necessarily dependent.   In studying this subject we
must first investigate the means that are adopted by nature for the suppression of
the  hemorrhage; and secondly, how these may be imitated by art.
   The natural arrest of arterial hemorrhage  is effected by means that are in the
first instance  of  a  temporary, but  afterwards of a permanent character.   The
means which secure temporarily the flow of  blood from an artery,  and which, if
the  vessel be  of a small size, as the facial or radial, are sufficient in  many cases
to stay  the  hemorrhage without the  interference of the surgeon ; and by which,
whatever be its size, his operations  are materially assisted, and nature makes an
effort, though it may be an unsuccessful one, to prevent a fatal escape of blood, are
threefold.   They consist,
   1st. In an alteration in the constitution of the blood.
   2d. In a  diminution of the force of the heart's action, and consequently  of
the  pressure on the inner coat of the vessel.

  a The history of the investigations into the means adopted by nature for the arrest of hemorrhage is
full of interest to the surgeon, and is excellently  given in Jones's work on hemorrhage.  No subject in
surgery affords a stronger evidence of the advantage of the application of "Experimental Pathology"
to practice than this, as our knowledge of it has been wholly sained by experiments on the lower animals.
  Petit, who published several  memoirs on this subject in 1731 and following years, states that hemor-
rhage is arrested by the formation of two clots—one outside the vessel which he calls the " Couvercle;"
the other inside, the  "Bouchon;:'—the first being formed by the last  drops of  blood that issue, the
second by the few drops that are retained. These clots by their adhesion stop the bleeding.  AVheu a
ligature is  applied, a similar clot forms above and below it.  He recommends  compression  and the
support of the clot.                                                       ...    ,
  Morand. in 1736, added much of interest.  He  admitted the formation of coagula, but insisted on the
change in the artery  itself; which he showed became corrugated, contracted, and retracted.  Morand
entertained erroneous views as to the structure and functions of arteries, but he established the great fact
that changes occur in the artery itself.
  Kirkland, in 1763, wrote an excellent treatise on the subject, and his views were adopted and supported
by White, Gooch. Aikin, and other  surgeons of his day.  He showed  that hemorrhage was lessened by
swooning; and, that an  artery contracted up to its nearest collateral branch, and was of opinion that co-
agulum did not arrest the bleeding.
  J. Bell took  a retrograde step on this subject, by denying the retraction and contraction of the artery,
and the importance of the internal coagulum, and by attributing the arrest of hemorrhage solely to the
injection of the surrounding cellular tissues with blood.                               c  n a
  It was not until 1805  that Mr. Jones, by a series of admirably conducted investigations, nnally'de-
termined  the mode in which the arrest of hemorrhage takes place.  Since his time but little has been
added to the subject, so complete has been his examination of it. 
148
INJURIES  OF  ARTERIES.
   And 3d. In certain changes effected in the artery itself.
   The alteration that takes place in the blood consists in an increase of its plas-
 ticity as it flows.   The blood that escapes from a wounded artery has from the
 first a tendency to  glaze and coagulate about the cut vessel, so as to offer a me-
 chanical obstacle to the  further escape of blood from it.  This of itself is suffi-
 cient in the  smaller vessels  to arrest  the hemorrhage, the more so,  as has been
 pointed out by Hewson,  in  consequence of  the last  flowing blood  being  more
 coagulable than the first.
   The diminution in the force of the  heart's  action exercises a very material in-
 fluence in arresting the  flow of blood from an artery.  The forcible manner in
 which the jet of blood is propelled at each systole of the ventricle is the principal
 obstacle to the coagulation of blood around  and within the cut vessel; for not
 only does the movement of the blood prevent coagulation, but so long as the jet
 is more powerful than the cohesion of the clot, it will certainly wash the coagulum
 away.   As the blood flows, and the heart's impulse becomes gradually lessened
 in force, the jet becomes lower and lower, until at last, when faintness comes on,
 it is almost entirely arrested, and  time is afforded for  the formation and the de-
 posit of a coagulum in the vicinity of the wound.
   The changes that take place in and around the vessel itself axe those upon which
 the final arrest of the bleeding is  dependent.    They consist in the retraction of
 the artery within its sheath,  in the  contraction of the cut ends, and in the for-
 mation of a coagulum around its  exterior, and of another in its interior.
   When an artery is  cut across,  it immediately retracts  within its sheath, the
 interior of which is left  rough and  uneven.  Through this uneven channel the
 blood is projected,  either flowing freely externally, or being extravasated into the
 neighboring  cellular tissue, according to the direction and state of the wound.
 As the blood flows over the roughened surface of the sheath, it becomes entangled
 in the fibres, and tends to coagulate  upon them; this  tendency to coagulation is
 favored by the increased plasticity of the blood a's it  flows, and  by the  diminu-
 tion of the propulsive  force with which it is carried on.   By the conjoined ope-
 ration of  these causes a coagulum  is formed, which, though lying in  the sheath,
 is outside of, and extends beyond the artery; and hence it is termed the  external
 coagulum.  It is usually of a somewhat cylindrical shape, and often looks like a
 continuation of the vessel, being  at first perforated by a  hollow track,  through
 which the stream of blood continues to flow.  As it increases, the hollow  becomes
 closed by the concentric  deposit of  coagulum.  The  hollow track leading  from
 the surface of the coagulum  to the  wound in the artery has been  especially de-
 scribed and dwelt upon by Amussat.  This coagulum acts mechanically by block-
 ing up  the end of the artery, and  also by compressing the vessel within the
 sheath; thus  constituting the first barrier to the hemorrhage.  The formation of
 the external coagulum is thus in a great measure dependent on the retraction of
 the artery within its sheath.
   The  next changes that take place in the artery, and, indeed, that are to a
certain extent simultaneous with those that have just been described are its con-
 traction and the formation of the internal coagulum.
   The  contraction  of the  cut artery commences immediately after its  division,
.and may  of itself be sufficient to  close  the smaller  arteries.   Thus, during an
 operation, we may  often  see  an artery which, when first cut, jetted a stream of
 blood as large as a  straw, gradually contract in size until it cease to bleed, owing
 simply to this contraction.  In the larger arteries this process is not sufficient to
 close completely the vessel, but merely gives its cut end a conical shape, diminish-
 ing greatly the aperture, and converting it into a kind of pin-hole at the end of
 the .artery.
   In proportion as the  open end of the artery is obstructed by the  external
 coagulum, and contracts  in diameter, the blood is propelled with more and more 
PERMANENT ARREST  OF  HEMORRHAGE.           149
difficulty through it, until at last it escapes in but a small and feeble  stream, or
even becomes completely at rest, allowing its fibrine to be deposited in a slender
coagulum, which plays a more important part in the permanent than in the tem-
porary arrest of the bleeding.   To the formation of this internal coagulum the
contraction of the vessel  is subservient.   This coagulum is slender, and of a
conical shape, the base being attached  to  the margins of the aperture  in the
vessel, and the apex extending upwards.   It has no point of attachment except
by its base, the apex and  sides  being perfectly free; it is at first composed en-
tirely of coagulum, though of a firm fibrinous character,  no exudative  matter
entering into its composition at this period, though after-changes of an important
character occur within it.   The importance of the  internal coagulum, as  a tem-
porary means of arresting hemorrhage, though great, has, I think, been over-
estimated.  In many cases it is not formed at all;  this happens in certain states
of the blood when that fluid is devoid of plasticity, and in some cases the proxi-
mity of a collateral  branch to the cut end of the  vessel appears, by preventing
the stasis of the blood within it, to interfere with its coagulation; even when it is
formed, it is of but little service, so far as the primary arrest of the hemorrhage
is concerned, not being deposited until after the flow of blood has been checked
by other means, such as the deposit of the external coagulum, and the contraction
of the vessel.  After it is formed, it is useful in acting as a damper, and  in
breaking the force of the wave of blood against the cut end of the vessel.   It is
in the permanent arrest  of hemorrhage  that the  internal coagulum is of great
importance.  After the hemorrhage from the cut artery has been arrested tempo-
rarily by the means that have been indicated, nature proceeds to secure the vessel
by permanently occluding it.
  The permanent closure of a cut artery is effected by two processes:
  1st. By the adhesive inflammation set up in the vessel and  the  surrounding
parts.
  2d. By the continued contraction of the artery.
  A few hours after the  division of the  artery, lymph is found to have been
poured out both within and on the outside of the injured vessel. The lymph that
is thrown out within the vessel forms the  most important part of  the internal
coagulum, and tends materially to the permanent  closure of the wound.  It is
effused from the  cut surface of the internal and middle coats around and imme-
diately within  the contracted orifice of the vessel, forming a small nodule pro-
jecting into  its interior.   If an  internal clot have already formed, this  plastic
nodule is deposited underneath it, or is effused into its base; if no temporary clot
have formed, a conical mass of coagulum will be deposited upon this nodule, in obe-
dience to that law of pathology by which blood tends to  coagulate upon inflamed
points. When fully formed, this coagulum differs materially in structure at different
points.  At its base it is firm, of a brownish or buff color, and is composed prin-
cipally of  fibrine; above  this it  becomes  dark, maroon-colored, and  ends in a
long tail-like projection  of simple clot, which extends  up to the nearest large
collateral branch. The  important part of this coagulum,  pathologically speaking,
is its plastic base; the rest, however long  it may be, is of no use in the perma-
nent closure of the vessel;  but, like  the internal clot already described, merely
serves to break the shock of the blood.
  Coincident with these changes in the interior of the vessel, important  pheno-
mena occur on its exterior.  Inflammation  takes place in the sheath and in the
surrounding parts, a round or ovoid mass of fibrine being here effused, which is
at first mixed up with the external coagulum ; the coloring matter of this, how-
ever, gradually becomes  absorbed, leaving the plastic matter accumulated in a
mass, and  completely blocking up the end of the vessel from the outside.
  Under the influence of the inflammation set up within and around  it, the
artery goes on contracting, until it  embraces the  included  coagulum so  firmly 
150
INJURIES OF  ARTERIES.
that it would appear as if it were adherent to every part of it, and some difficulty
is experienced in separating them.   That they  are not adherent I have ascer-
tained by finding, on careful dissection, that the transverse stria? of the lining
membrane of the artery are always visible, although the coats of the vessel are
often stained nearly black by the imbibition of the coloring matter of the blood.
The contracted vessel usually assumes a conical shape, but in some  cases I have
seen the contraction commence suddenly, and the narrowed part to  be perfectly
cylindrical for the distance of about an inch.  ,
   The changes that have just been described are those that take  place in the
proximal end  of the artery.  In  the  distal or inferior end, occlusion is  effected
by the  same  processes  essentially, but the retraction  and contraction of  the
vessel are not so complete  and extensive, and the coagulum is usually smaller
both inside and out;  in  some cases, indeed,  the  internal coagulum is deficient.
The less perfect closure  of the distal  end may, as Mr.  Guthrie suggests, be the
cause of the more frequent occurrence of hemorrhage from it.
   The ultimate change  that takes place in the divided artery is the transforma-
tion of its cut extremity up to the first collateral branch into a dense fibro-cellular
cord. This is effected by the plastic effusion inside and outside the  artery, with
the cut and contracted vessel in the centre, developing into fibro-cellular tissue.
   The arrest  of hemorrhage from a punctured  or partially divided artery, is
effected in a  somewhat different  manner to what has been  just  now described;
the difference consisting in the  changes that go  on in the neighborhood of  the
wound.   If the wound in the soft parts covering the artery be of small size and
oblique in direction, so that the blood does not escape with too great  facility, it
will be found  that the temporary arrest of the hemorrhage takes place by an ex-
travasation of blood occurring between the artery and  its sheath, by which the
vessel is not only compressed, but the relation between the wound and the aper-
ture in the sheath  are altered.   This stratum of coagulated blood extends  for
some distance within the sheath, above and below the wound, opposite to which
it is thicker than elsewhere.  Coagulum  may likewise  be formed in the tissues
of the part outside the sheath, by which the vessel is  still  further compressed,
and the tendency to the  escape of blood proportionately lessened.
   The permanent closure of the puncture is effected by the adhesive inflamma-
tion.  Lymph may be effused  in such a way as to be sufficient merely to plug
the wound in  the coats, or  else it may be in  sufficient  quantity to obliterate the
whole of the interior of the artery, producing complete occlusion of it.   In order
that the wound in the artery should unite without obliterating the cavity of  the
vessel, but simply by the formation of a cicatrix in the coats, it is necessary that
it be below a certain size;  but this size will vary according  to its direction.   If
the wound be longitudinal or slightly oblique, it  will be more  likely to  unite in
this way than  if transverse.   Mr. Guthrie states  that in an artery of the size of
the temporal a small longitudinal  wound may sometimes heal without obliteration
of the vessel,  though this  very rarely happens in arteries  of larger size.  If a
vessel the size of the femoral be opened to the extent of one-fourth of its circum-
ference, there is no  proof that the  wound can heal  without obliteration of the
cavity of the artery; but when the longitudinal  wound is  very small in a large
artery, little more than a puncture, closure may possibly take place simply by its
cicatrization.   The plastic matter forming the cicatrix is thrown  out by the ex-
ternal coat of  the artery.   The internal and middle do not unite strongly, the
aperture in them being merely filled up by a  plug of lymph; hence the artery
always continues weak at this point, and may eventually become  aneurismal.
   If an artery of the second or third magnitude, as the axillary or femoral, be
divided to  one-fourth or more of its  circumference, either fatal hemorrhage or
the formation  of a traumatic aneurism  will usually take place.   Tn those com-
paratively rare cases, however, in which the hemorrhage is arrested without these 
SURGICAL  ARREST  OF  HEMORRHAGE.
151
consequences ensuing, it will be found that it is so by the vessel becoming obli-
terated by a plug of lymph, which is poured out at the wounded part and gra-
dually encroaches on the cavity of the artery, until complete obliteration is pro-
duced, and the  vessel at the seat of obstruction becomes converted  into a fibro-
cellular cord.

THE SURGICAL TREATMENT OF HEMORRHAGE FROM WOUNDED ARTERIES.
  The object of the surgeon, in  any means that he adopts for the suppression
of arterial hemorrhage, is to imitate, hasten,  or assist the natural processes, or to
excite analogous ones.   All his  means act by increasing the retraction and con-
traction of the arterial coats in forming an  artificial coagulum or in exciting ad-
hesive inflammation in and around the vessel.
  The danger from arterial hemorrhage, and the measures that must be adopted
to meet it, vary according to the size of the vessel.   Under all circumstances the
surgeon should  bear in mind the  excellent advice given by Mr. Guthrie, never
to fear bleeding from any artery on which he can lay his finger; the pressure of
this readily controlling the bleeding from the largest vessels provided it  can be
fairly applied, or the cut end of the artery seized between the finger and thumb.
Thus, in  amputation at the hip and shoulder joints, the assistant readily controls
the rush  of blood from the femoral and  axillary arteries by grasping  them be-
tween  his fingers; above  all, the surgeon should nlver dread  hemorrhage, or
lose his presence of mind  by its occurrence.  If effectual means for its suppres-
sion are had recourse  to, it can  always be at  least temporarily arrested.  And
least of all should any surgeon have recourse to inefficient means to stop it,  and
endeavor by covering up the wound with  rags, handkerchiefs, &c, to prevent the
escape of blood.  These means  only hide the loss that  is going on, and by in-
creasing  the warmth  of the parts  prevent  the contraction  of the  vessels,  and
favor the continuance  of the bleeding.  Under all circumstances therefore, bleed-
ing wounds should be  opened up,  the coagula gently removed from their surface,
by means of a piece of soft sponge  or a  stream of cold water,  and the part well
cleaned.   In this way  "you look your enemy in the face," and can adopt efficient
means for the permanent arrest of the hemorrhage.
  The flow of blood through a limb may be controlled for a temporary purpose,
as during an operation, by the compression  of the main artery by the hands of
an assistant.  This may be done in the lower extremity by pressing the femoral
artery against the brim of the pubes, and  in the upper extremity by compressing
the subclavian  against the first  rib or  the brachial against  the  shaft  of  the
humerus.   The pressure should be made by grasping the limb with  one hand
in such a way that the index  and middle fingers bear upon the artery, and press
it directly against the  subjacent bone.   If the limb be large, or if long-continued
pressure be required, the same fingers of the other hand should be firmly applied
upon those that are already compressing the vessel.  In  some cases, especially
when the subclavian or external  iliac requires to be compressed, the handle  of a
large key, or the end  of a desk seal covered with  leather will be found the most
convenient instrument for  applying the pressure.
  In most cases, however, in which a temporary compression of the artery is re-
quired, the tourniquet should be employed.   It  is far safer to trust to  this in-
strument than to  the  hands of an assistant,  however steady and strong.  When
the tourniquet is applied with a sufficient degree of tightness, the whole circula-
tion through the limb  may be  completely arrested.   This can never be done solely
by the compression of the  main trunk, the collateral and minor supplying vessels
conveying blood into the limb independently of it.  Then again if the operation
be unexpectedly protracted from  any cause, the fingers of an assistant may  tire,
or stiffen, and, by  relaxing the steadiness of their pressure, allow hemorrhage to
ensue.  For these  reasons, surgeons almost  invariably employ  the  tourniquet in 
152
INJURIES OF  ARTERIES.
amputations; and even the late Mr. Liston, who at one period of his career dis-
carded this instrument, commonly employed it during the latter years of his life.
There are three tourniquets used by surgeons : Petit's  consists of two plates at-
tached to a band  that is buckled round the limb  over a pad  that has previ-
ously been applied  above the artery to be compressed  (Figs. 21 and 33).  By the
action of a quick screw the plates  can be separated,  the band tightened, and the
pad forced against the artery.   In applying the tourniquet, care should be taken
not to screw it up  until the very moment that the compression is required, and
then to do so quickly, and with considerable  force, lest venous congestion of the
limb takes place,  by the veins  being compressed before the  circulation in the
arteries is  arrested.   The horseshoe, and  Signorini's  and Skey's tourniquets
appear to me to  have no advantage over the one described,  and they possess the
disadvantage of not  compressing the  collateral vessels, and consequently of com-
manding the circulation in a less perfect manner than the ordinary instrument.
  The different means that maybe employed for the permanent arrest of hemor-
rhage  are the  application of cold, styptics, cauterization with the hot iron, and
pressure, or the employment of torsion and ligature.
  The application of cold is sufficient  to arrest that general oozing of arterial
blood that is always  observed on a cut surface.  The mere exposure of a wound
that has bled freely,  so lon» as it has been covered up by pledgets and bandages,
to the  cold air, is often sufficient for this purpose.   When this does not succeed,
the application of a piece of lint, soaked in cold water, will usually arrest the flow
of blood.   When it is necessary to do this speedily,  as in some operations about
the  air-passages, a small  stream of cold water may be  allowed to drip into the
wound, and thus cause rapid contraction of the vessels, and consequent cessation
of bleeding.   In cases of bleeding into some of the  hollow cavities of the body,
as the  rectum, vagina, or mouth, the  application of ice is occasionally required.
  Styptics influence powerfully the contraction of the vessels,  and by increasing
the rapidity of formation, and the firmness of the coagulum,  tend to arrest the
hemorrhage; they are principally used in  bleeding from spongy parts, from cavi-
ties or organs, to which other applications cannot readily be made.   The great
objection  to their employment  in some  wounds  consists  in their tendency to
modify the character of the surface, and to prevent  union by the first intention.
The most useful styptics are  the tincture  of  the sesquichloride of iron, spirits of
turpentine, gallic acid, and matico; the application of alum, or touching a bleed-
ing part with a pointed stick of the nitrate of silver,  is also serviceable.
   Cauterization by means of the red-hot iron was almost the only mode of arrest-
ing arterial hemorrhage that was known to the ancients.  It is now comparatively
seldom had  recourse to,  but yet in many cases it is  of  the most  unquestionable
utility, and  superior to any other means that we  possess;  more  particularly in
those cases in which the  hemorrhage proceeds from  a soft and porous part that
will not hold a ligature, or a surface from which many points appear to be bleed-
ing at the same time.  A somewhat conical iron should be used of sufficient size,
and  the hemorrhage will often be stayed more effectually  if it be applied at a black
than at a red or white heat.  As the actual cautery blocks up the artery by a
thick slough or eschar, there is always danger  of a recurrence of the  bleeding
when this separates,  and the surgeon must be on his guard about the sixth or
eighth day lest  it break out again.
  Direct pressure upon  the bleeding part is a  very efficient mode of arresting
hemorrhage from small arteries.  It is not, however,  applicable to all  parts of the
body,  as it is necessary that the vessel should have a bone subjacent to it, so as
to afford a point of counter-pressure; hence it cannot readily be employed in soft
and movable parts, as the  throat or perineum.   Pressure  may be practised in
various ways; sometimes the mere uniform compression of a bandage is sufficient
to arrest the hemorrhage; thus, oozing from a wound may often be  stopped by 
TORSION — LIGATURE.
153
laying down the flaps, and applying a bandage pretty tightly over them.   Some-
times  a weight  applied upon this  will tend still further to arrest  the  bleed-
ing; as for instance, by means of a sand-bag laid upon the part.   In the case of
bleeding from hollow cavities,  as the rectum, vagina, or nares,  the hemorrhage
may be arrested by the pressure of  a plug of sponge or lint, to which sometimes
a styptic may advantageously be added.   When  the hemorrhage proceeds from
the puncture of  a small or moderate sized artery, as of the temporal or brachial,
pressure  should be made against the  adjacent bone  with a graduated compress
and bandage, and be continued for one, two, or three weeks,  until complete con-
solidation of the wound takes place, the vessel becoming obliterated.   The gra-
duated compress should be at least an inch in thickness, and made  of a series of
pledgets of lint of a circular  shape, gradually diminishing in size.   It should be
applied with its pointed end  resting over the wound in the vessel.   In applying
it, a piew of adhesive plaster should be laid over the part on which the pressure
is to be exercised, and a thick slice  of a phial cork, or a fourpenny piece, wrapt in
lint, being placed  on this, the  graduated compress should be bandaged tightly
over the whole.  When  applied in this way, pressure always  acts by inducing
adhesive inflammation and obliteration of the vessel at the point compressed.
   The torsion of arteries for the arrest of hemorrhage, mentioned by Galen, and
revived by Amussat, Yelpeau, and  Thierry, has never found much favor amongst
surgeons in this country.   It may be practised in various ways.  Thus, Amussat
recommends that the artery be drawn out for about half an inch, by one pair of
forceps;  that it then be seized at its attached point with another forceps, and the
end be twisted off by about  half-a-dozen turns.   Fricke advises that the ends be
 not taken off, but merely twisted for six or eight times according to the size of
the vessel.  Thierry simply  seizes  the artery and twists it.   There can be  no
 doubt that hemorrhage from the largest vessel may be efficiently stopped by its
torsion, the artery being placed in  the  condition of one that is lacerated or torn
 through.  The  internal and  middle coats  are  retracted, and the external  one
 twisted into a kind of valve  beyond them.   A coagulum  next  forms within the
 vessel, blocking up its extremity, inflammation then  takes place, gluing together
 the coats of the artery; the twisted end sloughs off,  and  the vessel becomes oc-
 cluded up  to the nearest collateral branch.   The advantage that torsion  is sup-
 posed to possess over the ligature is, that no  foreign body being left in the wound,
 there is less suppuration, and a greater prospect of union by the first intention.
 This  advantage, however, is more  fanciful  than real; the twisted  end acts as a
 foreign body, and  is as likely to interfere with union as the pressure of a ligature.
 Torsion possesses the great disadvantages of being less safe, and less readily prac-
 tised  than the ligature on the larger arteries.  Occasionally, in operations,  how-
 ever,  small arteries, as muscular branches, may advantageously be pinched or
 twisted once or twice in such a way as to arrest the bleeding from them.
   The  ligature is the  means that surgeons commonly have  recourse to for the
arrest of hemorrhage from wounded arteries.
   The ligature had been occasionally and partially employed by the later Roman
 surgeons, but with the decline of surgery fell completely into disuse, giving way
 to such barbarous and inefficient modes of arresting the hemorrhage as the employ-
ment of the actual cautery, the performance of  operations  with red-hot knives,
the application of boiling pitch, or of  molten lead, to the bleeding and freshly
cut surface.  About the middle of the sixteenth century it was revived or re-in-
vented  by that  great luminary of the French school of surgery, Ambrose  Pare.
But so slowly did  the ligature make way amongst surgeons, that Sharpe, surgeon
to Guy's Hospital, writing in 1761, two centuries after its introduction into prac-
tice by  Pare, found it necessary, in his well-known work, entitled, " A Critical
Enquiry into the Present State of Surgery," formally to advocate its employment
for the arrest of hemorrhage from wounded arteries, in preference to styptics or 
154
INJURIES OF  ARTERIES.
the cautery, on the ground that " it was not as yet univereally practised amongst
surgeons residing in more distant counties of  our kingdom."   What, it may  be
asked, was the reason that it took two centuries to promulgate  the use of the
simplest  and most  efficacious means we  possess  in surgery,—a means  that  no
surgeon could now for a day safely dispense with ?  The reason simply was, that
surgeons were totally ignorant of the means employed by nature for the occlusion
of arteries, that they consequently knew not how to  apply a ligature to these
vessels, or what kind of ligature should be used; and that, in their anxiety to
avoid the recurrence of secondary hemorrhage, and to make all safe, they fell into
the very errors they should  have avoided, had they been  acquainted with  the
physiology of the processes that nature employs for the closure of the artery and
the separation of the thread."
  Between twenty and thirty years after the time at which Sharpe wrote, we find
that Hunter introduced that great improvement in the surgical treatment  of'
aneurism,—the  deligation of  the artery at a distance from  the sac, and in a
healthy part of its course: but this  great  accession to the  treatment of a most
formidable disease was but coldly received, and ran some risk of being lost to  the
world  in consequence of the ill-success that attended the earlier operations.  In
Mr. Hunter's first operation,  four ligatures were used, some tight and others
slack; the artery was denuded, so that a spatula could be passed under it; and,
although  in  his subsequent  operations Mr.   Hunter  contented himself with
employing but one ligature, yet the vein  was included in this; and he  did  not
draw  the noose tightly, for fear of injuring the coats of the vessel, in accordance
with  the doctrine of the day;—surgeons  generally  at this  time being haunted
with this dread of injuring, and thereby weakening, the coats of the artery; and
in order to avoid doing so, adopted modes of treatment that almost infallibly led
to ulceration of the  vessel and consecutive  hemorrhage.  The  application  of
several ligatures of reserve, applied slack—the use of broad  tapes—the  inter-
position  of  plugs  of cork, wood, agaric,  or  lead,—of rolls  of lint or  plaster
between  the thread and the vessel, were  some  amongst the plans that were  in
common  use.   And how can we be surprised that the patients  perished of hemor-
rhage, and that the ligature of the vessel was nearly as inefficient and fatal a means
of arresting bleeding as the use of a cautery,  or of  a button of white vitriol.
   It  was not until Mr. Jones, by an  appeal  to experiment, and by means of
a series of admirably conducted investigations, showed that the very point that
surgeons  were anxious to avoid—the division of the coats of the vessel by  the
tightening of the noose—was that on which the patient's safety depended; pointed
out the  form and size of ligature that  was most safe, the  degree of force with
which it  should be applied, and the processes adopted by nature for the occlu-
sion of the vessel—that a more rational practice  was  introduced, and that sur-
geons  at length had full confidence in the use of the ligature.
   The mode of application of the ligature, and the  kind  of ligature to be used
vary according as the cut end of the artery has to be tied in an open wound, or
as the vessel has to  be secured  in its  continuity.  When  a  ligature has to  be
applied to the divided vessel in an open wound,  as after an amputation, the
mouth of the artery must  be seized and  drawn forwards.  For this purpose a
tenaculum, or sharp hook, is not unfrequently used, and in many cases  answers
the purpose  exceedingly well.   There are, however, some  objections to this in-
strument; thus, it  occasionally seizes other  tissues with the artery, and as it
draws the vessel forwards by perforating its coats it has happened that an acci-
dental puncture having been made by it behind the part to  which the ligature is
applied, ulceration of the vessel and subsequent hemorrhage of a fatal character
has ensued; as I have seen happen in  one case.  The most  convenient instru-
ment for the purpose of drawing forward the  artery, and one to which no objec-
tion whatever applies,  is Listen's bull-dog forceps.  These  have  been conve- 
LIGATURE OF ARTERIES.
155
niently modified of late by having the blades expanded just above the points (Fig.
50), so that the ligature can be slipt over the end of an artery that is  deeply

                                   Fig. 50.
seated, as between bones or close to the interosseous membrane of the leg—a situa-
tion in which it is sometimes troublesome to tie a vessel by any other means.   In
some  cases the bleeding point may be so situated  that the ligature is most  con-
veniently passed under and round it by means of an ordinary curved needle.
  The kind of ligature used must vary according to  the size of the vessel.  If this
be small, fine round twine;  if large, dentist's silk, or compressed smooth whip-
cord, should be  employed;  I always  employ  the  latter  in ligaturing the main
artery of the limb.  Before being  used, the ligature  should be well waxed, so
that it may not be too limp; its strength should be tested by knotting it with a
jerk, and if found efficient it may be cut up in pieces eighteen inches in length
for use.  In applying the ligature, care  must be taken that it be put well beyond
the cut end of the artery, that it clear the forceps' points, and that it be  tied
tightly with a reef knot, which does not slip.   One end of the ligature should
then be cut off about  a quarter of an inch from  the knot, and the other left
hanging out of the wound.   The ligature that secures the main artery should
have both its ends knotted together by way of distinctive mark.   It is always
better  to leave one end of the ligature; if both be cut off, the noose and knot
left are apt to become enveloped by granulations or adhesive matter, and after the
healing process is well advanced, or perhaps completed, to give rise to suppura-
tion in and re-opening of the wound.
  When the artery has to be ligatured in its continuity, but at the point wounded,
it must be exposed by as careful a dissection as the state of the parts will admit.
If the surgeon determine to apply a ligature at a  distance from the injury, his
anatomical  knowledge will guide him to  the  vessel.  This is usually done by
cutting through the tissues in  the course  of the vessel; Hargrave,  however,
recommends that in ligaturing arteries the incisions should not be made  parallel
to the course of the vessel, but  in an  oblique or transverse direction over it, and
this suggestion appears to me to be deserving of attention  in  some  situations,
more particularly in the ligature  of the brachial at the  bend of  the arm, or of
the carotid at the root of the neck, &c.  So soon  as the sheath is  reached, the
surgeon must carefully scratch through or divide it, with the point of the scalpel,
being careful  not to open it to a greater  extent than is  absolutely  necessary for
the passage of the ligature,  lest by the destruction of the vascular connexions
between it and the external coat of the  artery,  subsequent sloughing of the
vessel  ensue.   In opening the  sheath, care  should  be  taken  not to wound
any small  branch, lest  the collateral supply be interfered with, and  danger of
secondary hemorrhage induced.   The  ligature should  then be carefully passed
between the vein and artery, taking care to include only the latter, and especially
not to transfix and include a portion of the vein; an accident that usually termi-
nates  fatally by phlebitis  or gangrene.  So also  the surgeon must be on his
guard not to  mistake  any contiguous nerve for the artery, as has  happened to
the most experienced operators;  and also to  avoid transfixing and tying a  por-
tion of the thickened sheath instead of the vessel,  as I have known happen  to a
most excellent surgeon.   The best material for the ligature when applied to the
continuity of an artery, is the dentist's silk or compressed whip-cord, well waxed.
Much ingenuity has been expended in devising instruments for passing it under 
156
INJURIES  OF  ARTERIES.
the artery.  In the majority of cases the common aneurism needle—well ground
down, but rounded at its extremity—is all that is required.   Occasionally it may
be advantageous, as Mr. Fergusson has suggested, to use a needle with a  small
curve.   Many ingenious contrivances have been devised by Trant, Weiss, Coxe-
ter, and others, for seizing and drawing forward the noose from the  bottom of
the wound.   After the ligature has  been passed under the  vessel the ligature
should be tied tightly with  a reef-knot,  and both its  ends left  hanging out of
the wound.   The limb should then  be  elevated and be lightly covered with a
piece of flannel,  or of cotton wadding; care being taken not to apply pressure of
any kind.
  The immediate effects of the application of a  firm round ligature to  an artery
with a proper degree of force, is the division of  the internal and middle coats of
the vessel and the constriction of its outer one.   If we examine the  ligatured
vessel a few days after it has been tied, we find that  the coats  are  contracted,
that there is an internal pyramidal  coagulum, composed of plastic matter at its
base, and fibrinous clot  towards its apex (Fig. 51);   and that the  ligatured
portion of the vessel is surrounded by a  quantity of lymph.  If the  artery be
examined at a still later  period than this—at the end of two or three months,
for instance—it will be found to be converted into a fibro-cellular cord as  high
as the first collateral branch above the ligature (Fig. 53).  Now  these are analo-
gous appearances to what  are met with in an artery that has been cut across and
occluded without the  application of a ligature,  and are  evidently the result of
inflammation of the vessel.  The question  arises how this inflammation is set up
when a ligature is applied.  Is it  by the  pressure of the noose, or by the divi-
sion of the coats of the artery?  That it is not the mere pressure of the ligature
that excites the occluding inflammation is  evident from the experiments of Jones
and of Travers, who found that if the ligature be removed shortly after its appli-
cation, sufficient inflammatory action had been excited in the coats of the artery
to lead to its complete occlusion.  And though any inflammation set up in the
external  coat may cause an effusion of lymph  inside the  vessel, yet that which
is required to repair the breach occasioned  by  the  division of the  internal and
middle coats is the principal source of the plastic deposit.   The changes that take
place in the vessel after the application of a ligature require, however, to be more
carefully studied.
   The division of the internal and middle coats should be done evenly, smoothly,
         Fig. 51.                      Fig. 52.                     Fi- 52.
Femoral artery, fifty-six
hours after amputation.
 Brachial artery, ten
days after amputation.
Femoral artery, six weeks after
        amputation.
and  completely, so as to leave  a wound that will readily take on the adhesive
inflammation.   This is  best done by a small round ligature, applied with such 
LIGATURE OF ARTERIES.
157
degree of force that the surgeon feels the coats give way under his finger.   The
adhesion between the coats is much facilitated by the pressure of the ligature,
which also acts as a support to the vessel.
  The formation of the internal coagulum in the proximal end is the most im-
portant part of the process.   For the first  four-and-twenty hours after the appli-
cation of the ligature there is little, if any, appearance of this.   Usually about
this time, if opportunity offers to examine an artery in the human subject, it will
be found that a small nodule of lymph, of a yellowish or buff color, has been de-
posited in the bottom of the cul-de sac that is formed by the retraction and con-
traction of the  cut ends of the inner and middle coats, so as to close up the ex-
tremity of the  artery.  About the  second or third day this  coagulum will be
found to have assumed  a  conical shape  (Fig. 51), the base being composed of
decolorized fibrine and exudation-matter, firmly adherent to the lower end of the
artery ;  the middle and terminal portions of the coagulum, composed of fibrinous
clot, and of a dark purple or maroon-color, lie loose and floating  in the artery,
extending up as high as the first collateral branch.   About the tenth day, the
inflamed end of the vessel will be found to be tightly and firmly contracted upon
the inclosed plug (Fig. 52),  the dark-colored portions of which now begin to
undergo a process of absorption.   Between this period and the sixth week, the
contraction of the vessel and the absorption of the free  part of the plug  go on
simultaneously (Fig. 53), the interior of the artery becoming darkly stained by
imbibition of the coloring matter of  the coagulum.   Lastly, the  plastic base of
the plug becomes incorporated with the contiguous arterial coats, and undergoes
 eventual transformation into fibro-cellular tissue.
   In some cases (Fig. 55) there  is an imperfect formation of the  internal  plug,
 or even total absence of it, and  not  unfrequently secondary hemorrhage  occurs
 as a consequence.  This condition may arise either from want of plasticity in the
 blood, from an absence  of due adhesive inflammation,  or  from the coats not
 having been properly cut through.   In some
 cases, in consequence of  suppurative action
 being set up in the artery, a kind of disinte-
 gration  or liquefaction  of the  plug  takes
 place after it has been formed.   This I have
 seen occur in a case of ligature  of the caro-
 tid artery, in  which  death occurred from
 visceral disease ten weeks after the operation,
 and in the femoral in cases of pyemia (Fig.
 54).   In the  distal  cul-de-sac of the  liga-
 tured artery I  have never seen any very dis-
 tinct coagulum formed, either in the human
 subject or  in dogs on which I  have experi-
 mented, but merely small detached fragments
 of coagula and some plastic effusion.
   The changes that take place in the exter-
 nal coat are of the most important character.
 After the  internal  and  middle coats have
 been cut through by the ligature, the exter-
 nal would  not be able to resist the  impulse
 of the  blood were it not strengthened and  JftBhigh.er Sh tZ
 consolidated by the  adhesive  inflammation,  pyemia
 The  necessary inflammation  is  occasioned
 partly by the dissection required to  expose
 it, and partly by the pressure and irritation
 of the ligature.  Lymph is  thrown  out between the vessel and its sheath, mat-
 ting together  these parts, and often enveloping the noose and knot in  an ovoid
Fig. 54.
Fig. 55.
Femoral arteries, ten
  Partial absorp-
tion of coagulum
in  femoral, four-
teen  days after
amputation. 
158
INJURIES  OF  ARTERIES.
mass.  Progressively with  the effusion of lymph and consequent  strengthening
of the coats, the pressure of the  noose causes gradual sloughing and ulceration
of the parts included in it.   The mode  in  which  the noose ulcerates its  way
through the external coat is of much importance, as on this depends in a great
measure the success of the  ligature.   There are two sources of danger in  con-
nexion with this process; either  that  the sloughing may be too  extensive, or
that the ulceration through  the artery may take place before the  adhesive plug
is properly and firmly formed.
  The chance of the sloughing being too extensive principally arises  from  the
artery being isolated, and separated from its sheath to too great an  extent during
the  dissection  required  to expose it, in consequence of which, its nutrient  ves-
sels being divided in great numbers, that  portion of the coats of the vessel, de-
prived of  its vascular supply, becomes sloughy; hence the danger  of passing  a
spatula, large  probe, or the  handle of a scalpel  under the  artery, and also of
applying several ligatures.   Premature ulceration of the vessel most commonly
occurs from the patient's constitution being in too debilitated a state to admit of
healthy reparative action.
  So soon as the ligature has ulcerated through that portion of the artery which
is included  in  its noose, it  becomes loosened  and separates; frequently being
thrown off with the discharges, or becoming detached on the slightest traction.
The period of the   separation  of the ligature depends upon  the size of the
artery and the thickness of its coats.  From  the  radial, or  ulnar, it is usually
detached  by the eighth day;  from  the  femoral, iliac,  or  subclavian, about  the
sixteenth  or twentieth days.  In  some cases  the ligature will continue attached
for a much longer period than this, owing to the inclusion of a  bit of a nerve
or of muscular substance within  its noose.   In order to hasten the separation
in these cases, moderate traction  and occasional twisting of the ligature may be
practised.
                        COLLATERAL CIRCULATION.

  When the main artery of a limb has been ligatured, or in any  other way oc-
cluded, it is only  the  direct flow  of blood  that  is interrupted; the  indirect
supply which is conveyed into the limb, or part, by the free inosculations between
the anastomosing vessels of the different portions of the arterial  system, being
sufficient to preserve its vitality, and to prevent the occurrence of gangrene.  So
free  and ready  are the communications kept up between different portions of the
arterial system, that after the largest arteries  in the body, such as the subcla-
vian, iliac, and aorta, have been ligatured, sufficient blood  to  support life is at
once conveyed into  the parts supplied by them.   This collateral circulation is
most active and most readily maintained in early life, when the vessels are pliant
and elastic, readily accommodating themselves to the increased quantity of blood
that they are required to convey.   As age advances, the vascular system becomes
less elastic, and there is a greater difficulty in the establishment and maintenance
of the collateral circulation.  The anastomosing vessels that serve  this  purpose
are  invariably  furnished  by arteries contiguous to that which is ligatured,  and
come off from the same side of the body.  Thus, for instance, afteAhe ligature
of the superficial femoral, it is by the profunda artery  that the  supply of blood
is carried  to the lower extremity.  Thus also, when the common carotid is liga-
tured, the circulation to  the parts it  supplies is not  maintained through the
medium of the opposite carotid, although  the inosculations between the ultimate
branches of the two vessels  is so free upon the throat, upon the face, and within
the cranium;  but it is by means of the  inferior thyroid and vertebral arteries
(branches of the subclavian on  the same side), which become greatly  enlarged,
that the supply of blood is kept up to the parts on the outside, as well  as in the
inside of the cranium. 
                     COLLATERAL  CIRCULATION.                  159

  The supply of blood that is  sent  to  a limb, after the deligation  of the main
trunk, is at first but small in quantity;  being  merely sufficient  for  the  mainte-
nance of its vitality, but not enough for the continuance of the usual actions of
the part.   Hence, although the life of the limb may  be preserved after the
ligature of its artery, it becomes cold, and  the patient is unable to move it for
some time, the  muscles appearing to be completely paralysed; gradually, how-
ever, the supply of blood increases, until, having reached its usual standard, their
normal vigor returns.
   By what mechanism is this accomplished ?   It is due to changes  taking place
in the capillaries;  in the anatomical anastomosing branches  and in  the trunk
itself.
   The capillaries are the first to enlarge ;  and this they appear to do by a vital
process, and not in consequence of the mere increased pressure of the blood, the
temperature of the limb often  rising, in the course of a day or two, to its normal
standard, and sometimes to two or three degrees beyond it, whilst a great sensa-
tion of heat is  experienced in it by the patient.  This period extends over seve-
ral weeks, and  if opportunity be afforded of examining  the limb during its con-
tinuance,  the tissues generally will be found to be preternaturally vascular,
admitting injections freely.
   Coincident with this  increase of activity in the capillary  system, the anasto-
mosing vessels of the part enlarge, becoming very  serpentine,  tortuous,  and
waved, forming circles  or an  interlaced  network.   During this  enlargement
much pain is often experienced owing to their pressure upon neighboring nerves.
This  form  of collateral circulation  commences by a  general  enlargement of all
those  muscular and subcutaneous secondary vessels of the limb, which can nor-
mally be readily distinguished  by the  naked eye.   After this general  enlarge-
ment has continued  for some  weeks  it tends  to localize itself in a few of the
principal anatomical inosculations, until at last it is through  their medium that
the circulation is  chiefly maintained.  Thus, for instance, after the  ligature  of
 the common carotid the supply of blood is ultimately conveyed by the inoscula-
 tions between the superior and inferior thyroid arteries,  and by the vertebral and
 basilar.  When the subclavian  is tied, the circulation of  the upper extremity is
 carried on by the anastomoses between the posterior  and supra-scapular, and the
 branches of  the axillary artery distributed to the vicinity of the shoulder; and
 when the external iliac  is tied, the blood  is conveyed to  the lower limb by the
 inosculation between the mammary and lumbar arteries, with the epigastric and
 circumflex ilii.
   Jones pointed out the curious  circumstance, that  when two anastomosing
 branches approach  one  another they split before  inosculating into
 two or three ramusculi, which by uniting form a circle  of  anasto-
 moses.  Besides this kind of collateral circulation, Maunoir, Porta,
 and  Stilling have noticed vessels running directly between the  ex-
 tremities of the obliterated trunk, forming species of arterial  shoots,
 springing from the stump  of the vessel.
   The change that  takes  place in  the trunk consists in its conver-
 sion  into a fibro-cellular cord, from the point to which the ligature
 has been applied to the first large collateral branch below  it (Fig. 56);
 here  it becomes pervious again, and, receiving the blood poured into
 it through the different anastomosing channels, becoming again sub-
 servient to the purposes  of circulation.   Porta and Stilling have
 shown that, after  a time, down the centre of  this fibro-cellular cord
 a small tortuous central canal  becomes developed, uniting the two
 distant ends of the divided artery.   This is probably the last  change
 that takes place in the establishment of the collateral circulation.
   The collateral circulation is occasionally not sufficiently free to preserve the
 
160
INJURIES  OF  ARTERIES.
integrity or vitality of the parts supplied by it.   As a const'* |uence of this, gan-
grene not uncommonly results, or the limb may become  paralysed or atrophied.
This condition is  most frequently met with in  old  people from ossification  and
rigidity of the arterial system; or it may happen as the result of copious hemor-
rhage, or of an extensive transverse wound of the limb dividing  many of the
anastomosing  vessels.   It more  rarely happens that we  find too great freedom
of the anastomoses, so as to lead to a failure of the purposes for which the liga-
ture has been applied by the rapid admission of blood into the distal  end of the
vessel, and thus perhaps occasioning secondary  hemorrhage.

           PRINCIPLES OF TREATMENT OF WOUNDED ARTERIES.

  The whole  of the doctrine of the  general treatment of wounded arteries by
the ligature may be included in two great principles :  1st,  To cut directly down
on ihe icounded part, and to tie  the vessel there ; and 2dly, To apply a ligature
to both ends, if it be completely divided, or  to the distal as well as  the proximal
side of the ivound if it be merely punctured.
  These principles of treatment were distinctly laid down by John Bell ;*  but
although this great surgeon inculcated forcibly  these rules of practice, surgeons
appear to have been led away by the  erroneous idea of applying the  Hunterian
principles in  the treatment of aneurism to that of wounded arteries, until Mr.
Guthrie, by his practice and  precepts, and by adducing an overwhelming mass
of proof to bear on this important question,  has  recalled the attention of the pro-
fession to the  proper and rational treatment of wounded arteries.
  The principal reason in favor of cutting down directly upon the wounded part
of the injured vessel is, that the ligature of the  main trunk only stops the direct
supply of blood to the limb, but does not interfere with the anastomosing circu-
lation, which finds its way readily into that  portion of the vessel which is below
the ligature, and consequently continues  to escape by the distal aperture in  the
artery.   Thus, though bright arterial blood may no longer jet from  the upper
part of the wound, blood which  has become of a dark color, in consequence of
the changes to which it is subjected in its passage through the vascular network
of the limb, will continue to well out from the lower  aperture in the artery,
entailing  the  necessity of further operative procedure  to restrain  its flow; and
unless this be done, the patient will die of hemorrhage as surely, though perhaps
not quite so speedily, as if no ligature had been applied.   Thus I have seen a
surgeon  endeavor  to arrest the flow of blood from  a wound of the ulnar artery
opposite the wrist-joint by ligaturing the brachial in the middle of the arm, and,
when the blood burst forth as furiously as ever, applying successive ligatures to
the arteries of the forearm with as little success; until at last, by the continued
recurrence of hemorrhage, he was forced to adopt the  simple expedient that
ought to have been had recourse  to in the first instance—of ligaturing the vessel
at the point wounded, which succeeded perfectly in arresting  the bleeding.
  Another reason for the practice now advocated is, that  in some cases the sur-
geon  cannot possibly know what artery is injured unless he seek  for  it in  the
wound itself.   A large artery may apparently be wounded from the direction of
the stab and the impetuous flow of blood that has followed it, when in reality it
is only a minor branch  that has been injured.  Thus, for instance, in hemorrhage
from a stab in the axilla, which proved fatal, notwithstanding the ligature of the
subclavian artery for supposed wound of the axillary, the long thoracic was found
to be the vessel divided; so also the external  iliac has been  ligatured for sup-
posed  wound  of the  common femoral,  when in reality it was the  superficial
external pudic that was injured.
  The rule of cutting  down on the injured  part of the artery applies to all cases
» "Principles of Surgery," vol. i., pp. 350, 390, 8vo. edit. 
TREATMENT OF WOUNDED ARTERIES.
161
in which the wound is still open, whatever be its condition.   However deep, in-
flamed, and sloughy the wound; however ill-conditioned and infiltrated with pus
or blood the neighboring  parts may be,  there is no safety to the patient unless
the vessel be cut down upon and tied at the part injured.   This must always be
done at any period after the receipt of the injury, so long as there is an external
wound communicating with the artery.   An operation of this kind is  often at-
tended with  very great difficulty, not only owing to the hemorrhage that usually
accompanies it and obscures the parts, but also in consequence of the altered con-
dition of the tissues in the wound.  In  order to moderate the hemorrhage, the
pressure  of  an assistant's  fingers on  the artery high  up in  the  limb  must be
trusted to; but a  tourniquet  should  not be applied,  as  it  congests the  parts
below.   A large probe should  then be passed to the bottom of the  wound, and,
taking this as  the  centre,  a free incision should be made in such a direction as
may best lay open the cavity with  the least injury to the muscles and other soft
parts.  After turning out  any coagula contained within it, and clearing it as well
as possible, the wounded vessel must be sought for.  The situation of this may
sometimes be ascertained at once by the gaping of the cut in its coats.   In many
cases, however, it is necessary to relax the pressure upon the  artery, so as to allow
a jet of blood to escape, that may indicate the  position of  the aperture.   The
ligature may then be applied  by passing  an aneurism needle under the vessel, if
it be partially divided; or, if it be completely cut across, by drawing  forwards
the end and ligaturing it, as in an open wound.   In  doing this, care  must be
taken that the ligature be  really applied  to the vessel,  and that a portion of the
sheath infiltrated  with blood, or thickened by adherent coagulum, be not mis-
taken for the artery.   The incisions down to the wounded  artery should  be made
on the side of the wound itself, and through the wound in the soft tissues cover-
ing it.   Guthrie advises,  that in those  cases in  which the wound passes indi-
rectly to the principal artery from the back or outside  of the limb, the surgeon
need not follow the track  of the wound,  but  may cut down on the vessel where
nearest the surface, and then, passing a  probe  through the  wound, the spot at
which the artery has  probably been wounded will be  pointed out, which must
then be ligatured in the usual way.  No operation should be  undertaken unless
the hemorrhage be actually continuing.  If the bleeding have  been  arrested,
however furious it may have been, the surgeon should  never go in search of the
wounded vessel, or undertake any operation unless it burst forth again.   A man
was brought to the University College Hospital with  a deep stab  in the groin
directly in the course of the external  iliac artery; a very  large quantity of
arterial blood had been lost, but the hemorrhage ceased on his admission by the
application of pressure, &c.  From the great and sudden loss of blood it  was sup-
posed that the external iliac had  been punctured, but it was not thought ad-
visable to perform any operation unless hemorrhage recurred.  The bleeding did
not return, the wound healing without any further trouble.
   The second  great principle  in the  treatment  of wounded  arteries  is that the
ligature should be applied to  both ends of the vessel, if it be  cut  completely
across, or on both sides of  the aperture in it if it be only partially divided.   The
reason for this rule of practice is founded on physiological grounds as well as on
practical experience.   If the anastomoses  of the part be  very free, as in the
arteries of the palm or fore-arm, bleeding may continue from the distal end un-
interrupted by the ligature on the  proximal side of the wound.   If less free, it
will probably issue in a stream of dark venous-looking blood in the course of two
or three days.   After the  collateral circulation has been sufficiently established,
bright scarlet blood will burst forth from the distal aperture.  Experience has
shown that it is in this  way that secondary hemorrhage  from wounded arteries
commonly occurs, the bleeding coming from the distal and not from the proximal
end of the vessel.   In some cases the distal end is so retracted  and covered in
                                    11 
162
INJURIES OF  ARTERIES.
by surrounding parts, that it cannot be found to be ligatured.   Under these cir-
cumstances the best practice has resulted by plugging the wound from the bottom
with a graduated sponge compress.
  Although advocating  strongly the importance of the distal  as  well as the
proximal ligature in all cases  of wounded artery, I  am aware that instances are
on record in which the proximal ligature alone, and that even at a distance from
the wound, has proved successful in arresting the hemorrhage; but I cannot do
otherwise than regard these cases as accidentally successful, the distal end having
been better plugged than usual with coagulum; and I am strongly of opinion
that the rule of practice should be that which is laid down by John Bell, and so
forcibly and  copiously illustrated  by Mr.  Guthrie, viz.:  That both ends of a
wounded artery be sought for, and tied in the wound itself.

                         TRAUMATIC ANEURISMS.
  We have hitherto discussed the treatment of an injured  artery having an open
wound communicating with it.  It often happens,  however, that the case is not
so simple as has been described, but that in addition to the wound in the vessel,
we have a subcutaneous extravasation of blood with more or less pulsation, thrill,
and bruit from the projection into it of the blood from the wounded vessel.  This
is the condition called a diffused traumatic aneurism.
   This kind  of tumor consists of an effusion of  blood, poured out by, and com-
municating with  the wounded artery; limited in extent by the pressure of sur-
rounding parts, and partially coagulating in the meshes of the broken-down cel-
lular tissue.   Its boundary, which is ill defined, is composed partly of this coa-
gulum, and partly of plastic matter, effused by the tissues into which it is poured
out, and has a constant  tendency to  extend  by the pressure  of the fluid blood,
which continues to be projected into the centre of the tumor.
   This form of traumatic aneurism is indicated by a subcutaneous, soft, and fluc-
tuating tumor, often of considerable  size, composed of extravasated blood.  At
first the skin covering it is of  its natural color, but it  gradually becomes bluish,
and  is thinned by the pressure to  which it is subjected.   If the wound in the
vessel  be rather large and free, there  will be  distinct pulsation  in  the tumor
synchronous with the beat of  the heart, accompanied by a thrilling, purring, or
jarring sensation, and often a  distinct and loud bruit.  In other cases, again, if
the injured artery be small, or if the wound in it be oblique, and of limited size,
there will be no distinct pulsation or bruit; the tumor being either indolent and
semi-fluctuating, or having an impulse communicated to it by the subjacent
artery.
   These tumors,  if left to themselves, never  undergo spontaneous  cure, but
they either increase in size until the integument covering them sloughs and rup-
tures, or the  external wound which has  been temporarily  plugged by coagulum
gives way; or else they inflame and suppurate,  pointing at last like an abscess,
and when bursting, giving rise to a sudden gush of blood, which may at once, or by
its  rapid recurrence, prove fatal.  In some case, a subcutaneous breach is  made
in the coagulated and plastic  boundary,  and  the blood becoming infiltrated into
the cellular tissue of the limb  or part, gives rise  to syncope, gangrene and death.
   The treatment of these cases  must be  conducted on precisely the same plan as
that of an injured artery communicating with an external wound, the only diffe-
rence being, that in the case of the diffused traumatic aneurism, the aperture in
the artery opens into an extravasation of blood instead of upon the surface.  We
must especially be upon  our guard not to be led away by the term aneurism that
has been applied to these cases,  and not to treat such a condition, resulting from
wound, by the means that we employ with success in the management of that
disease.   In a pathological aneurism the blood is contained within a sac, which,
as will hereafter be shown,  is  essential  for the occurrence of those changes that 
TRAUMATIC  ANEURISMS.                    163
are necessary for the cure of therdisease.  In the diffused traumatic aneurism, there
is no sac, properly speaking, and hence these changes to which a sac is necessary
cannot occur.  I doubt whether there is a case on record, in which the Hunterian
operation for aneurism, applied to the condition now under consideration, has not
terminated in danger or death to the patient, and in disappointment to the sur-
geon.
  The proper treatment of these cases consists in laying open the tumor by a
stroke of the scalpel,  removing the coagula,  dissecting out  the artery, and liga-
turing it above and  below the wound in it.  This  operation, easy in description,
is most difficult and tedious in practice.  The bleeding is often profuse, the cavity
that is laid open is  large, ragged, and partially filled  with  coagula.  It is with
much difficulty often that the artery  is found  under cover  of these, and in the
midst of infiltrated and disorganized tissues,  and when found it is not always easy
to get a ligature  to hold.   In performing this operation, the artery must, if pos-
sible, be compressed between the tumor and the heart; if  it  cannot be so com-
manded, the surgeon must be  ready to  apply his finger to the wound in the
artery at the  moment that the sac is laid open, in order to arrest the gush  of
blood that takes place from the open orifice.   The application of a ligature to the
distal end of the vessel, if completely divided,  is  especially difficult.   Here the
application of the  actual cautery; or pressure, by means of  a sponge-tent,  or
graduated compress, will be found the best means of arresting the hemorrhage.
   Another variety of aneurism, termed the  circumscribed traumatic aneurism,
may follow the wound of an  artery.   This differs entirely from the diffused in its
pathology and treatment, inasmuch as it possesses a  distinct sac.
   There are two varieties of this form of aneurism;  in the first, a puncture is
made in an artery,  or the vessel is ruptured subcutaneously,  as perhaps  in the
reduction of an old dislocation,  an extravasation of blood  takes place into the
tissues in the  neighborhood of the wound, and if there is an  external aperture,
this cicatrizes.   The blood that is extravasated becomes surrounded and limited
by a dense layer of  plastic matter poured  out into the areolae of the neighboring
tissues,  and forming a distinct circumscribed sac, which is soon lined by layers of
fibrine deposited  from the blood that passes through it.  This tumor, usually of
moderate size, and of tolerably firm consistence, pulsates synchronously with the
beat of the heart, and has a distinct bruit, both of which cease when the artery
leading to it is  compressed.  This  form of circumscribed traumatic aneurism
most commonly occurs from punctured wounds of small arteries, as the temporal
plantar, palmar, radial, and  ulnar.
   The treatment to be adopted depends upon the size and situation of the artery
with which the tumor is  connected.   If the artery be
small, and so situated  that  it can be opened without
much after-inconvenience to  the patient,  as  on the
temple, or in the fore-arm,  it should be laid open, the
coagula turned out, and the  vessel ligatured above and
below the wound in  it.  If  the tumor be  so situated
as in the palm, that it would be  difficult and hazardous
to the integrity of the patient's hand to  lay it open, the
Hunterian operation for aneurism should be performed,
as was successfully done in the case (Fig. 57) in which
the brachial was ligatured for  an aneurism  of  this
kind in the ball  of the thumb, following serious injury
to the hand from a powder-flask explosion.
   It is but rarely that this form of traumatic aneurism
is connected with a large artery, but  when it is the
vessel may be ligatured alone, but close to  the sac, in
the  same way as in the  next variety.   If this form of
traumatic aneurism have increased greatly in bulk, so  that the skin becomes
 
164
INJURIES  OF  ARTERIES.
thin and discolored, or inflammation ensues, and symptoms of impending suppu-
ration take place around it, then it would be  useless to ligature the artery above
the tumor, as this would certainly give way,  and secondary hemorrhage ensue.
Here the proper course is to lay open the sac,  turn out the contents, and ligature
the artery above and below the part that is wounded. _
  The next  form of circumscribed traumatic aneurism is  of rare occurrence,
and usually arises from a small puncture in a large artery, as the axillary or the
carotid.  This bleeds freely, but the hemorrhage being arrested by pressure, the
external wound  and that in the artery close.   The cicatrix in  the artery gra-
dually  yields, forming, at  the end  of  weeks  or months,  a  tumor which
enlarges, dilates, and pulsates  excentrically, with distinct bruit, having all the
symptoms that characterize an aneurism from disease, and having a sac formed
by  the outer coat  and sheath of the vessel.  It is at first soft  and compressible
on  being squeezed, but  becomes harder  and  firmer, and  cannot be so lessened
after a time.   It consists of a distinct circumscribed sac, formed by  the dilatation
of  the cicatrix in the  external  coat and sheath of the artery, no blood  being
effused into the  surrounding tissues.   The treatment in these cases consists of
the ligature  or compression of the artery leading to the sac, in accordance with
the principles that guide us in the treatment of aneurism from disease; though
from the healthy state of the coats of  the vessel, the artery may be ligatured as
near as possible to the sac.
                        ARTERIO-VENOUS WOUNDS.
   The wound in the artery may communicate with a corresponding one in a con-
tiguous vein, giving rise to two  distinct forms of disease aneurismal varix and
varicose aneurism.    These  preternatural communications, which  were first
noticed and  accurately described by W.  Hunter, most  commonly occur at the
bend of the  arm, as a  consequence  of the puncture of the brachial artery in
bleeding, but they have been met with  in every part of the body in  which an
artery and vein lie in close juxtaposition, having been found to occur as a conse-
quence of wounds of the subclavian, radial, carotid,  temporal, iliac, femoral,
popliteal, and tibial arteries.  The two forms of disease to which the preternatu-
ral communication between arteries and veins gives rise, differ so  completely in
their nature, symptoms, effects, and treatment, that  a separate consideration of
each is required.
   Aneurismal varix results  when a contiguous artery and a vein having  been
perforated, adhesion takes  place between the two vessels at the seat of injury, the
communication between them continuing pervious,  and a portion of the arterial
blood being projected directly into the veins at each  beat of the pulse.   Opposite
to  the  aperture  of communication between  the two vessels, which is always
rounded and smooth, the vein will be found to be dilated into a fusiform pouch,
with thickened coats.  The veins of the part generally are considerably enlarged,
somewhat  nodulated, tortuous  and  thickened.  The artery above the wound is
dilated; below it is usually somewhat contracted.  These pathological  conditions
are evidently referable to a certain quantity of the arterial blood finding its way
into the vein, and distending and irritating it by its presence  and  pressure, and
less consequently being conveyed by the  lower portion of the artery.
   The symptoms consist of a tumor at the  seat of injury, which can be emptied
by pressure upon the artery leading to it, or by compressing  its walls.  If subcu-
taneous, this tumor is of a blue or purple color,  of an oblong shape, and will be
seen to receive the dilated and tortuous veins.  It will  be found to pulsate dis-
tinctly with  a tremulous jarring motion, rather than a  distinct  impulse.   Aus-
cultation  detects in it a loud  and blowing, whiffing, rasping or hissing sound,
usually of a peculiarly harsh character.   This  sound has very  aptly been com-
pared by Porter to the  noise made by a fly in a paper bag, and by Liston to the 
ARTERIO-VENOUS ANEURISMS.
165
sound of distant and complicated machinery.   The thrill and sound  are  more
distinct in the upper than in the lower part of the limb, and are most perceptible
if it be allowed to hang down so as to become  congested.   Besides these local
symptoms, there is usually some muscular weakness and diminution in  the tem-
perature of the part supplied by the injured artery.
  As this condition, when once formed, is stationary, all operative interference
should be avoided, an elastic bandage merely being  applied.  Should a case occur
in which more  than  this is required,  the  artery must be cut  down upon, and
ligatured on either side of the wound in it.
  Varicose Aneurism.—In this case the opening in the artery and  vein  do not
directly communicate (see Figs. 59 and 61), but an aneurismal sac is formed be-
tween the two vessels, into which  the  blood is  poured before passing into the
vein (Fig. 61).
                                   Fig. 58.
above this tumor, the  vein that has been punctured is dilated into a  fusiform
 Figs. 58 and 59 represent a varicose aneurism at the bend of the arm unopened. Figs. 60 and 61, the
same tumor laid open, showing the circumscribed false aneurism between the two vessels. 
166
INJURIES OF  ARTERIES.
pouch, presenting  the ordinary characters of varix.   The sounds heard in these
tumors arc of two  distinct kinds: there is the peculiar buzzing thrill that always
exists where  there  is a preternatural communication between an artery and vein;
besides  this,  there is a blowing or bellow's  sound dependent  on the  aneurismal
disease.   These signs  are  most perceptible when the  limb  is in  a dependent
position, and  the sounds can often be heard in the veins at a considerable dis-
tance from the seat of injury.   There  is also some impairment in the nutrition
and temperature of the  parts'supplied by the injured vessels.  As the disease
advances, the aneurismal tumor lying between the artery and vein continues to
increase in size, and to become hardened by the deposition of laminated fibrine.
If left to itself, it would probably continue to enlarge until sloughing of the in-
teguments covering it, followed by hemorrhage, took place.   In some cases, the
aperture of communication between the vein  and sac becomes closed, and the
aneurism is converted into one of the false circumscribed variety.
  The treatment of this disease must be conducted on different principles from
                                           those that have  been  laid down as
                 Fis- 61-                    required in the ordinary circumscri-
                                          bed traumatic aneurism; the diffe-
                                          rence depending  upon the fact, that
                                          in  the  varicose  aneurism there is
                                          always a double aperture in the sac,
                                          and that thus the proper deposition
                                          of  laminated fibrine  necessary for
                                          its occlusion cannot take place.  The
                                          sac of such  an  aneurism may be
                                          compared to one  that has been rup-
                                           tured,  or  accidentally opened, in
                                          which we could  consequently not
expect the occurrence of those changes that are necessary for the cure of aneu-
rism by the Hunterian operation.'
  In a varicose aneurism, consequently, the sac must be freely incised, and the
artery tied on either side of the puncture in it.   Now this procedure may, unless
the surgeon be careful,  and properly understand the pathology of this disease,
be attended by some  difficulty.   After the first incision has been made through
the integuments, the  dilated vein will be laid  open, and an aperture will be
seen at the bottom of  the vessel,  from which  arterial blood may be made to
issue.  If  an attempt be made to find the artery immediately below  this aper-
ture, the surgeon will be disappointed, for the sac of the circumscribed aneurism
intervenes  between the  two vessels.   That  this aperture leads into the sac, and
not into the artery, may readily be ascertained  by introducing a  probe into it,
which will be seen to be capable of being carried  sideways, as well as upwards
and  downwards, to a  considerable extent, and in different  directions  altogether
out of the course of the  artery.   In order to expose this vessel properly, a probe-
pointed bistoury must be introduced into this opening,  and the sac of the false
aneurism  slit up to its full extent, the coagula  turned  out, and the puncture in
the artery sought for at the bottom of the  cavity that has been  exposed; this
may now readily be made visible by the  escape of a jet of  arterial blood on
relaxing the  pressure on the upper part of  the artery; a ligature must then be
passed, above and below the wound, and the cavity lightly dressed with lint.

                      ACCIDENTS AFTER LIGATURE.
  The accidents that  may follow the application  of  the  ligature  to wounded
arteries are secondary hemorrhage and gangrene of the limb.
  By Secondary or Recurrent Hemorrhage, is  meant bleeding from  any cause
after the application of a ligature.  This accident may arise  from a  variety  of
 
SECONDARY  HEMORRHAGE.
167
circumstances, which may be divided into two  great  classes: 1st,  those that
are dependent upon the vessel or ligature; and 2dly, those that  are  connected
with some morbid condition of the constitution or of the blood, in consequence
of which  those  changes which are necessary for the occlusion  of the artery
do not take place.
  Amongst the first class of causes may be mentioned any imperfection in the
application of the ligature; as,  for instance, its  being tied too loosely or with
the inclusion  of a portion of nerve, vein,  or muscle; so also the accidental punc-
ture of the artery above the point to which the ligature is applied.
  The  rush of blood through a neighboring trunk, or collateral branch immedi-
ately above the ligature, has been considered as likely to interfere with the forma-
tion of the internal plug; but  I  do not  think that much importance should be
attached to  this, for Porter has tied  the carotid  successfully within one-eighth
of an inch of the brachio-cephalic artery.   Bellingham has ligatured the external
iliac close to its origin; and Key, the subclavian in the vicinity of  a large branch
without secondary hemorrhage  ensuing.   I think, however,  that the presence
of a collateral branch in close proximity  to the distal side of the ligature—more
especially if it be one that  serves to carry on the anastomosing circulation—will
be found to  have a decided tendency in preventing the formation  of an  internal
coagulum.
   The wound of  a  collateral branch  or trunk  immediately above the ligature,
though it do  not  give  rise to  troublesome hemorrhage  at the time, will as I
have seen in  one case, bleed furiously as the  collateral circulation becomes  es-
tablished.
   A diseased state of the coats of the vessel at the point deligated, will occasion
rapid sloughing  and unhealthy  ulceration of the vessel; those plastic  changes
which  are necessary for its occlusion not going on within it.    It has happened
that fatal  secondary hemorrhage has occurred from a large artery, such as the
femoral, in consequence  of a small atheromatous or calcareous patch having given
way immediately above the ligature a day or two after its application.
   The constitutional causes of secondary hemorrhage act by preventing the for-
mation  of a  clot within, and the deposit of plastic  matter without  the  artery;
or if formed, causing their absorption in a few days (Figs. 54 and 55).  Amongst
the most common  of these causes are  those unhealthy states  of  the  system in
which  inflammation of  a  diffused or  erysipelatous character  sets in, which  is
incompatible  with plastic effusion.  In these cases either  no  internal  coagulum
at all  is formed, or if  any is deposited it is  weak, imperfect, and  unable to
resist the impulse  of the blood; or if it have already formed, it speedily becomes
absorbed or disintegrated, offering no resistance to the impulse of  the blood, and
being washed away.
   The occurrence  of erysipelas, phlebitis, or sloughing of the  stump  or wound,
will prevent or arrest the  necessary adhesive inflammation.   Besides  these con-
ditions, there  are  certain states of the blood in  which from  disease, as albumi-
nuria, it has lost its  plasticity,  and cannot yield the products of adhesive  in-
flammation.   Secondary hemorrhage is especially apt to occur in cases of pyemia,
provided that disease assume a somewhat chronic character.   The conditions of
the blood in pyemia being  incompatible with the formation of a firm and plastic
coagulum within the artery, the  vessel  continues or becomes open, and  sudden
hemorrhage will certainly occur.
  The  occurrence  of secondary hemorrhage is usually somewhat gradual, and not
without warning.   The  blood does not burst forth in a gush at once, but appears
at first in  a  small quantity oozing out of the wound and  staining  the  dressings;
it may  then cease to flow for a time, but breaks out again in the course of a few
hours,  welling-up freely  in the wound,  and  either  draining the patient  by
repeated losses, attended by the  phenomena that characterize hemorrhagic fever, 
168
INJURIES OF  ARTERIES.
or else exhausting him so that he falls a victim to some asthenic disease, such as
pneumonia, erysipelas, or  phlebitis.   In other cases again, after a few warnings,
it may burst out in a gushing stream that at once destroys life.
  The opportunities that  I have had of examining the state  of the vessels in
several cases of fatal secondary hemorrhage, lead me fully to concur with Guthrie
and Porter, that the blood  in the great majority of instances comes from the
distal, and not from the proximal, side of the wound.  The  greater tendency in
the distal end of the vessel to bleed, appears to arise partly from  the less per-
fect occlusion of this portion of the artery, and partly from  its  greater  liability
to slough, in consequence of the ligature interrupting its supply of blood through
the vasa-vasorum.   It is no objection to this opinion that the fatal hemorrhage is
often  of an arterial character; for, though it is true that the blood which is car-
ried to the distal end, is, for the first few days after the application of a ligature,
of a  venous hue; yet after the collateral circulation   is once established, it
gradually assumes  a more scarlet tint, and at last becomes completely arterialized.
  Secondary  hemorrhage may come on at any time  between the application of
the ligature and the closure of the  wound.   There are, however, three periods
at which  it is  particularly apt to  occur: 1st, a few days after  the ligature has
been applied; 2dly, about the period of the separation of the ligature; and 3dly,
at an  indefinite time after its separation.
  The hemorrhage which occurs a few days after the application of the ligature,
arises either from some imperfection  in  the tying of the ligature; from disease
in the arterial coats, causing them to give way; or from  want of adhesive inflam-
mation on the face of a stump: when  from  the latter  cause, this is a general
oozing or dribbling of blood from  many points of the surface rather than a gush
from one orifice.   In those cases in  which the artery has been tied  above the
wound only, hemorrhage is very apt to occur at this time.
  When hemorrhage occurs about the time of the separation of the ligature it
may arise from  any of the causes already specified that interfere with the due
formation of an internal coagulum, or that occasion sloughing of the coats of the
vessel.
  Lastly, in some  cases in which the ligature has separated, but the wound has
remained  open, the hemorrhage  may occur either from the cicatrix in the artery
being too weak to  support the impulse of the blood; or from the coagulum being
absorbed  in the way already  mentioned.   The continuance of the open state of
the wound after the separation of the ligature, is, I think, not improbably depen-
dent  upon a morbid condition of the coats of the  vessel which eventually leads
to hemorrhage.   The length of time that will sometimes  elapse between the
separation of the ligature and the  occurrence of hemorrhage is very remarkable;
thus there is a  preparation  in  St.  Thomas's Hospital of a carotid artery  from
which secondary hemorrhage took place in  the tenth week  after ligature; and
South mentions a  case of ligature of the subclavian, in which  the thread  sepa-
rated on  the twenty-seventh day, the fatal hemorrhage occurring in the thir-
teenth week.
  The Treatment  of Secondary Hemorrhage must be considered, as the bleed-
ing occurs from  a stump, from  an artery tied in its continuity,   or from a
wounded  vessel.
  In  all cases of ligature of arteries, care should of course be taken  to  prevent,
if possible, this  occurrence by  keeping the patient  perfectly  quiet, giving no
stimulants, having the bowels kept open, and the  secretions free, and avoiding
any undue traction on the  ligature itself.
   When  the hemorrhage occurs from  a stump a  few days after amputation, if
there be but  slight oozing,  elevating the part, applying cold, and bandaging it
with a roller, so as to compress the flaps, will sometimes arrest the bleeding.   If
it continue, however, or  become more severe, the flaps which will  have^ been 
           SECONDARY HEMORRHAGE  AND GANGRENE.         169

disunited by the effusion of blood, must  be separated and the bleeding  vessels
sought for and tied.  In some cases the ligature will not hold; under these cir-
cumstances the application of the actual cautery will arrest the flow of blood.
If the oozing appear to be pretty general from a number of points, the flaps
being somewhat spongy, I  have succeeded in arresting the hemorrhage by clear-
ing their  surfaces thoroughly of all coagula, and then bringing them tightly
together by means of a roller.
  If the hemorrhage occur at a later period, about  the sixth or eighth day, and
appear to proceed from the principal artery of the part, an effort  may be made
to arrest it by the  application of the horseshoe tourniquet, which occasionally
will stop all further loss of blood.  If the bleeding continue, however, the choice
lies between ligaturing  the artery in the stump itself by making a fresh  incision,
or continuing the  old one up :  or else in  ligaturing the  artery at some distance
above the stump.   I prefer the former method, as in this way the surgeon is led
directly to the wounded and bleeding vessel, and the patient escapes the dangers
of a second formal operation.   But if this cannot be done, it will  be necessary
to tie the main artery of  the  limb just  above the  flaps, or wherever it can be
most readily reached; thus, in amputation of the leg the superficial femoral may
be ligatured;  after removal of a thigh, the same artery, or the  external iliac;
and  in disarticulation  of  the  arm at the  shoulder-joint, the subclavian artery
must be tied,  either above or just below the clavicle.
  When the hemorrhage occurs after a ligature has been  applied to the conti-
nuity of the  vessel, pressure  must first  be tried.   With this view  the wound
should be plugged, and a graduated compress should be very firmly and carefully
applied by means of a ring tourniquet over  the point  from which  the blood
proceeds,  which  in  this way may occasionally be stopped.  Not unfrequently,
however,  this will prove ineffectual, the bleeding recurring from  underneath it.
When this is the case, what course should the  surgeon pursue ?  He may re-
apply the compress once more with great care, after clearing away coagula, and
drying the parts thoroughly;  but should it  again fail in arresting the bleeding,
it is useless to trust to it again, as  the  hemorrhage will certainly  recur, and
valuable time and much blood will be lost in these fruitless attempts at checking
it.   The course that the surgeon should pursue in such a case as  this, is a most
anxious consideration, but one on which his  mind should be clearly and decidedly
determined, as there is but little  time for reflection or consultation, and none for
referring to authorities.
  If the  artery be situated on the trunk,  as  the subclavian, carotid, or one of
the iliacs, there is nothing to be done but to trust to the plugging of the wound,
and in the great majority of cases to see the patient die exhausted by repeated
hemorrhage.
  When the artery is situated in one of the limbs, more efficient procedures may
be had recourse to.   If it be one of the arteries of  the upper  extremity, the
wound should be opened up, and an attempt made to tie  the vessel again in this
with a ligature on either end; should this  fail, or not  be practicable, the artery
must be deligated at a  higher  point than that at which it  had been  previously
tied; should the hemorrhage still continue, or be re-established, amputation is
the only resource left.
  In the lower extremity,  the  treatment  of this form  of secondary hemorrhage
renders the case replete with difficulty.  Here I believe  it to be useless to tie
the artery at a higher point than  that to which the ligature has been already ap-
plied, as gangrene invariably follows this  double ligature of the  arteries  of the
lower extremity:  at least in the two or three cases that I have  seen in  which
this practice has been had recourse to, mortification of the limb has ensued; and
in all the reported cases with  which I am acquainted, a similar  result has oc-
curred.  Under these circumstances, therefore, I should be disposed to cut down 
170
INJURIES  OF  ARTERIES.
on the bleeding part of the vessel, treating it as a wounded artery, and applying
a ligature above and below the part  already deligated;  an operation that would
necessarily be fraught with difficulty.   Should this be impracticable, or not suc-
ceed in checking the hemorrhage, I think that we should best consult the safety
of the patient by amputating at once on a level with the ligature.  Although this
is a severe measure, it is infinitely preferable  to allowing him to run the risk of
the supervention of gangrene, which will require removal of the limb under less
favorable conditions.  If the hemorrhage occur from  a wounded artery, to which
ligatures have already been applied above and below the seat of wound, the same
treatment must be  adopted as in those cases in which the bleeding occurs from
the application of the ligature to the continuity of the vessel.

                     GANGRENE  FOLLOWING LIGATURE.
  After the ligature  of the main artery of a limb, the  collateral circulation is,
under all  ordinary  circumstances, sufficient to maintain the vitality of the part
supplied by the deligated  vessel.   In some  cases, however,  it happens that  the
amount of blood transmitted to the parts below the ligature  is not sufficient to
support their life.  The occurrence of gangrene in this way is influenced by the
age of the patient,  the seat of the operation, and the various conditions in which
the limb may afterwards be placed.
  The  influence of age is not, however, so marked as might be supposed; for
although there can be no doubt that there is a less accommodating power in  the
arterial system to varying quantities of blood at an  advanced  period of life, and
that there would be greater difficulty in maintaining the vitality of the limb after
ligature of the artery in a man  of sixty than in  one of twenty-five; yet I find,
that in thirty cases in which gangrene of the lower extremity followed the ligature
either of the external iliac or femoral arteries, that the average age of the patient
was thirty-five years, as nearly as possible the mean age at which these operations,
according  to  Norris's tables, are generally  performed.   Of these cases  of gan-
grene, two occurred under twenty years of age, eleven between twenty and thirty,
eight between thirty and forty,  and nine above forty.
   The seat of the operation influences greatly the liability to gangrene, which is
much  more frequent  after  the ligature of  the arteries in the lower than  in the
upper extremity.
   Besides these predisposing  causes,  gangrene after  ligature may be directly
occasioned by a deficient supply of arterial blood.
   In some cases this may  arise  from the collateral  vessels being unable, in con-
sequence  of the  rigidity of  their  coats, to accommodate  themselves  to the
increased quantity of blood  they are required to transmit; or they  may be com-
pressed in such away by extravasation as to be materially lessened in their capa-
city.  In  other instances  again, the existence of  cardiac disease may interfere
with the proper supply of  blood to the part.
   Great loss of blood, either in consequence of secondary hemorrhage, or in any
other way, before or after the  application of the ligature, is often followed by
gangrene, and is almost  certain to be  attended by this result if a second ligature
has been applied to a higher point in the lower extremity.   That a diminution
in the quantity of  blood circulating in the system may, under the most favorable
 circumstances, become a  cause of gangrene after the  ligature of the artery, is
illustrated by the statement of  Hodgson, that soon after the introduction of the
Hunterian operation into Paris, it was the custom to  employ repeated venesection
in the cases operated on, the consequence of which was that mortification was of
 frequent occurrence.
   A more common cause of gangrene is the difficulty experienced by the venous
blood  in its return  from the limb.   This difficulty always exists, even  when no
 mechanical obstacle impedes its return, being dependent on the want of a propel 
GANGRENE  FOLLOWING  LIGATURE.
171
vis a tergo influence to drive it on.  The propulsive power of the heart, which
is the main agent in the venous circulation, is greatly diminished by being trans-
mitted through the narrow and tortuous channels of the anastomosing  vessels.
This difficulty to the onward passage of the venous blood may, if there exist any
cause of obstruction in the larger venous trunks, be readily increased to such an
extent as to choke the collateral circulation, and so cause  the limb to mortify.
This mechanical obstacle may be dependent upon the occlusion of the vein by
inflammation excited within it  opposite the ligature, by its transfixion with the
aneurism needle, or by its accidental wound with the  knife in exposing the
artery.  When such an injury, followed  by inflammation, is inflicted on  a vein,
which, like the femoral, returns the great mass of blood from a limb, gangrene is
the inevitable result.
  The occurrence of erysipelas in  the limb after the application of the ligature,
though  fortunately not of very frequent occurrence, is a source of considerable
danger, being  very  apt to  give rise to gangrene by the tension of the parts
obstructing the anastomosing  circulation.   I have in  this way, on two occa-
sions, seen gangrene of the  fingers follow the ligature of the vessels of the
forearm.
  The abstraction of heat from the limb, either directly by the application  of
cold, or indirectly, by the neglect of sufficient precaution to keep up the tempe-
rature of the part, often occasions  gangrene :  thus  Sir A. Cooper has seen mor-
tification follow the application of cold lead lotion to a limb in  which the  femoral
artery has been tied;  and Hodgson has witnessed the same result when the ope-
ration was performed at an inclement season of the year.
  The incautious application of heat may, by over-stimulating the returning cir-
culation of the limb,  especially about that period when the rising temperature is
an  indication of increased action in the capillary vessels, occasion mortification.
In  this way the application of hot bricks and  bottles to the feet have given rise
to sloughing;  and Liston was  compelled to amputate the thigh after ligature of
the femoral  artery, for gangrene, induced by fomenting the limb with hot water.
  The application of  a  bandage,  even  though very cautiously made, is apt  to
 induce  sloughing  and gangrene.   I  have seen this happen when a roller was
applied to the leg after ligature of the  femoral,  with  a view of removing the
oedema.
   The period of supervention of gangrene of the limb extends  over the first three
or four weeks after the ligature of the vessel.  It seldom sets in before the third
day, but most frequently happens before the tenth.
  The gangrene from ligature of an artery is almost invariably  of the moist kind,
on  account of the implication of the veins.   The limb first becomes cedematous,
vesications then form, and it assumes  a purplish or greenish-black tint, rapidly
extending up  to the seat of operation.   In some  cases, though they are rare,
simple mummification of the limb  comes on, the skin assuming a dull yellowish-
white hue, mottled by the  streaks that correspond to the  veins, and becoming
dry, horny, and shrivelled about the extensor tendons of the instep.
   Treatment of Gangrene following Ligature.—Much  may  be done with the
view of preventing this.  Thus : the limb should be elevated, wrapped up loosely
in flannel or cotton wadding, and laid on its outer  side after  the operation.   If
the weather be cold, hot water bottles may be put into the bed, but  not in con-
tact with the limb.  Should  there be any  appearance  of stagnation of venous
blood, the plan recommended by Mr.  Guthrie of employing continuous and
methodical frictions in a direction upwards for twenty-four hours, so as to keep
the superficial veins emptied, may be practised.
  When mortification has fairly set in, amputation of  the limb should be had
recourse to at once as the only chance of saving life, in  all those cases in which
the patient's constitutional powers are  sufficiently strong to enable him to bear 
172
WOUNDS  OF  SPECIAL ARTERIES.
the shock of the operation.  The limb should be removed at the seat of the ori-
ginal wound, or opposite the point at which  the artery has been tied.   In those
cases, however, in which the gangrene follows injury of the femoral artery just
below Poupart's ligament, Guthrie advises the amputation to be  done below the
knee, where it usually stops for a time.  If the gangrene spread, with oedema or
serous infiltration of the limb, the amputation should be done high up;—at the
shoulder-joint, or in the upper third of the thigh.  In these cases a large number
of vessels usually require ligature, having been enlarged by the collateral circu-
lation.
                          CHAPTER  XII.

                  WOUNDS OF  SPECIAL ABTERIES.

  Carotid.—Wounds of the carotid artery,  and of its primary and secondary
divisions, are of more frequent occurrence in civil practice than similar injuries
of any other set of arteries in the body, in consequence of the neck being so fre-
quently the seat of suicidal attempts.  The hemorrhage from wounds of the main
trunks is so copious as often to be immediately fatal.  In the event of a surgeon
being at hand sufficiently soon, the treatment necessarily consists in the ligature
of both ends of the bleeding vessel.   In consequence of the speedy fatality of
wounds of  the  carotid artery and of  its  primary branches, traumatic aneurisms
are  rarely met with in this situation ;  they do, however, occasionally occur, and
the records of surgery contain at least five instances of this kind, in all of which
the common carotid was tied, and the patient ultimately recovered.
  Aneurismal Varix of the internal jugular vein dependent on punctures of it,
or of the carotid artery, usually  the result of sword-thrusts in  the neck, are ap-
parently of more frequent  occurrence than traumatic aneurism in this region;
probably owing to the close proximity of the vein rendering it impossible for the
artery to be wounded on the outer or anterior sides, without first perforating that
vessel.  Cases of this kind are reported by Lane, by Randolph, by Willaume of
Metz,  and others;  in all of which the  wounds resulted from sword-thrusts.  The
symptoms presented by these cases, though offering  the general  characteristics
of aneurismal varix, yet  had several  points that are worthy of special remark.
The wound of the vessels was in  every instance followed by the effusion of a large
quantity of blood into the loose  cellular  tissues of the neck;  the extravasation
acquiring even the size of a child's head, and threatening immediate suffocation,
As  this extravasation subsided, the ordinary characters of aneurismal varix began
to manifest themselves.   The period  at which these symptoms first made their
appearance varied somewhat in the  different cases, but they always  occurred
within four or  five days  of  the  receipt of the injury.   In  none of the cases did
the disease appear to  shorten life, or to have occasioned any dangerous or incon-
venient effects, with the exception of some difficulty in lying on the affected side,
and occasional  giddiness or noise in the head on stooping.
  Varicose aneurism  does not appear  to have been met with in this situation.
 ^ In the treatment of these affections nothing can be done in the way of opera-
tive interference.
  Traumatic aneurisms  of the temporal artery, and of its branches, occasionally
occur as the resuk of partial division  of these vessels in cupping on the temple;
two cases of this kind I have met with, in both of which the disease was readily
cured by laying the tumor open, turning out its contents, and tying the artery on
either side  of it. 
     WOUNDS  OF  SUBCLAVIAN  AND  AXILLARY ARTERIES.    173

  Subclavian.—A wound of the subclavian artery may almost  invariably be
looked  upon as fatal, though in consequence of the manner in which it is pro-
tected by the clavicle these injuries can scarcely occur except from gun-shot vio-
lence.  From the rapidly fatal  nature of wounds of the subclavian artery, trau-
matic aneurisms in this situation are not met with; but when the artery passes
into  the  axilla  below the margin of the first  rib, they are not of unfrequent
occurrence.  Aneurismal varix of the subclavian vein resulting from wound of
the artery in this situation, has, however, been seen, notwithstanding the separa-
tion  that exists  between the two vessels >until they reach the acromial angle of
the subclavian  space.   These  injuries have likewise usually been the  result of
sword-thrusts, and do not require any surgical interference.
   Axillary.—In open wounds of the axillary artery, and of its branches, the
rule  of practice consists in cutting  down upon  the bleeding vessel  wherever it
may  be situated, and ligaturing it on either side of the wound.   It must be
borne in mind that the arterial  branches given off  between the lower edge of the
first  rib and the fold of the axilla being very numerous, a punctured  wound of
the axilla or side of the chest may injure one of these vessels, though from its
course, and the  free flow of arterial blood that has followed the stab,  it may be
supposed that the axillary artery itself has been punctured.   The particular vessel
injured can only be ascertained by following up the wound and ligaturing the artery
that furnishes the blood.
   In some cases, however, the  state of the parts  may be such that it may be
impossible to trace  the artery  at the  depth at which it  is situated, or even to
expose it in a more superficial situation, as in the stump after amputation at  the
shoulder-joint, so as to ligature it effectually.  Under these circumstances, the
main trunk should be tied either  above or below the clavicle: and the success of this
operation has been sufficient to justify our  having recurrence  to it  rather than
exhaust the patient by any prolonged attempts at the ligature of the vessel in the
open wound, though I think that this ought first to be attempted.   Of fifteen
cases in  which  the artery  has been ligatured either  above or below  the clavicle
for hemorrhage  from wounds in the axilla or from stumps, I find that nine were
cured and six died.   Although  the success is about equal  in whichever situation
the vessel be tied, I should certainly give the preference to the supra-clavicular
operation, owing to the greater  facility of its performance, and the  comparative
absence of collateral branches at the seat of ligature.  In some cases, however,
especially after  amputations at  the shoulder, the  clavicle is  pushed  up at its
acromial end, and then the artery might be best reached below the clavicle under
or through the pectoral muscles.
   Traumatic Aneurisms in the  Axilla are not of unfrequent occurrence, arising
directly from gun-shot  wounds, or from the thrust of a knife, sabre, or  other
pointed weapon.  In some cases the injury arises from a subcutaneous rupture of
the vessel, the patient stretching out and straining  his arm in an attempt to save
himself from falling, and  feeling a sudden snap in the axilla, which is  followed
by the formation of a rapidly diffused aneurism.
   There are several cases on record in  which axillary aneurism has resulted from
violent attempts made by  the surgeon in the reduction of old standing disloca-
tions of the head of the humerus.   Thus Pelletan  mentions a case of this kind
occurring  in Paris, in which the tumor being supposed to be emphysematous,
was opened, and the patient perished of hemorrhage.   Warren relates a case of
diffused axillary aneurism resulting from rupture  of the artery, in  consequence
of the surgeon attempting to reduce a dislocation  of the humerus by using his
foot  as a fulcrum in the  axilla, but without taking off his boot.   Gibson has
related three cases of axillary aneurism following  rupture of the artery in the
attempt to reduce old standing dislocations with the pulleys.  These  cases are of
much interest to the surgeon as showing the necessity for great caution in the 
174
WOUNDS  of  special arteries.
use of powerful extending force  in  the reduction of old dislocations, adhesions
having probably formed between the artery and the head of the bone.
  In some of these traumatic aneurismal swellings in the axilla, there is a ten-
dency for them to diffuse themselves with great rapidity,  filling up the whole of
the hollow of the armpit, and extending under the pectorals, even up around the
shoulder.   In other cases again, when more circumscribed, the disease may get
well spontaneously, as happened in cases recorded by Van Swieten, Sabatier, and
Hodgson.   In other instances again, the disease has remained stationary for years,
or has even undergone spontaneous cure.  It cannot however be considered sound
practice to leave a  traumatic  aneurism of this artery without surgical interfer-
ence  after the ordinary  dietetic and hygienic plans of treatment have  failed in
effecting a cure, for it may at any time become rapidly diffused or inflame and
suppurate.
  The treatment of traumatic axillary aneurism must have reference  not only to
whether it is diffused or circumscribed;  but if diffused, whether it be of recent
origin, or have originated from puncture or subcutaneous rupture of the vessel.
  Where a diffused traumatic aneurism of recent origin, rapid formation, and
dependent upon puncture of the artery, is met with in the axilla, the treatment
must be conducted in the same way as that of a wounded artery, without extra-
vasation  in this situation.  The  tumor  should be laid open, the artery  sought
for, and, if possible, ligatured where wounded.   If this be impracticable, it may
be deligated  above the clavicle, and  in this way the patient has been  saved.
There is, however, the danger after this operation, either of secondary hemorrhage
coming on from the  seat of wound, by blood conveyed  through the  collateral
vessels, which open into the subscapular and circumflex arteries; or else, of the
limb  falling into a state of gangrene.  Under either circumstances, amputation
at the shoulder and through the aneurismal extravasation, as practised success-
fully in one case by Mr. Syme, is the only practice that can be had recourse to.
  In those cases of diffused traumatic aneurism of the axilla that arise from sub-
cutaneous rupture of the artery, the  condition of parts is  essentially the same as
where it follows a punctured wound of the vessel, with the exception of the existence
of an external aperture in the integuments, the blood being effused into the loose
cellular tissue of the axilla and under the  pectorals, unconfined by a sac. In
these cases there is a tumor of considerable size, hard or fluctuating, according
to the state  of  coagulation of its contents, with  thrill, pulsation, a gushing hot
sensation, much cedema of the arm, tendency to  inflammation, suppuration, and
gangrene of  the sac.
  In these cases the choice  would lie between treating the injury as a  wounded
artery by direct incision, or ligaturing the vessel above the clavicle.   The first
plan, by direct  incision, has never to my knowledge  been practised, and would
present so many difficulties as scarcely to be a justifiable procedure.   The liga-
ture of the vessel above the clavicle  has been done three times, and of these only
one recovered, two of the patients dying of gangrene and secondary hemorrhage.
In  the successful case, secondary hemorrhage had occurred, and gangrene of the
arm which threatened, was prevented, and the patient saved, by having amputa-
tion at the shoulder-joint performed.
    Circumscribed traumatic aneurisms of the axillary artery, are not uncommonly
of slow formation, existing for several months or  years before they require opera-
tion, although resulting from punctured wound of the armpit.   In chronic cases
such as these, the aneurism is necessarily provided with a firm  and distinct sac,
and approaches closely in its characters to the  pathological form of the disease.
The treatment here cannot be conducted on the principles that guide us in the
management^ of a wound or diffused  aneurism of recent occurrence of this artery;
for _ot only  is the circumscribed aneurism provided with a sac, but the vessel at
the point injured would very probably be found to have undergone changes that 
TRAUMATIC  AXILLARY ANEURISMS.
175
would render it little liable to  admit or to  bear the  application of the ligature.
It would be softened, thickened, and lacerable, with perhaps a wide funnel-shaped
aperture leading into the sac, which would be closely incorporated with the neigh-
boring parts.   But indeed the treatment of this form of circumscribed traumatic
aneurism by the ligature of the artery on the proximal side of the sac, has  been
found to be attended with remarkable success.   In eight recorded cases in which
this operation has been performed, not one fatal  result has  been noted.   In all,
the aneurism arose from stabs or gun-shot wounds, and had existed for various
periods between two weeks and four yearsr  In four of the cases the artery was
ligatured above, and in four below the clavicle; and in one  case of each category
there was suppuration of the sac.
  The particular point at which the artery should be ligatured must depend upon
the condition of the tumor.  If this be of large size, or arise from the upper part
of the axillary artery, above or immediately below the pectoralis minor muscle,
there is no choice but to deligate the vessel above the clavicle.   Should, how-
ever, the principal increase in  the tumor take place in a direction downwards and
forwards under the great pectoral muscle, the portion of the  artery immediately
below the clavicle appearing to be free from disease, the question would arise as
to whether this part might not be selected for the application  of  the ligature;
and  as the results of both  operations have hitherto  been equally favorable, this
must rather be determined by the peculiarities in each case than on more general
grounds.  Most surgeons, I think, would  however  prefer ligaturing  the  artery
above the clavicle, as being a simpler proceeding, than tying it below that bone;
which, moreover, has the  disadvantage of  bringing  the scalpel into very close
proximity with the sac; which, were it to stretch upwards under  the pectoralis
minor to a greater extent  than might be discernible  externally, would  possibly
be opened by the knife, as has even happened in operating above the clavicle.
It has been recommended to apply the ligature between the sac and the origins
 of the sub-scapular, and posterior circumflex arteries, above the former and below
the  latter;  but this is  an anatomical  impossibility if the aneurism be situated
 above the lower border of the  axilla.
   Compression of the artery on the distal  side of the tumor has succeeded in
 curing the disease in a case that was under Dr. Goldsmith  of Vermont.
   The  Brachial Artery and its Branches.—The hemorrhage from wounds
 of the brachial artery may sometimes be arrested by the employment of methodi-
 cal compression, but usually requires  ligature in the ordinary way on each side
 of the aperture.  This vessel may occasionally be the seat of traumatic aneurism
 in consequence of a puncture received in venesection.   This accident, which
 was formerly of frequent occurrence when venesection was practised by professed
 phlebotomists,  now very rarely happens.  Should a surgeon be so  unfortunate as
 to puncture the brachial artery in this way, he may prevent injurious after-conse-
 quences by keeping up a proper  degree of pressure, by means of a graduated
 compress applied immediately on the occurrence of the accident.  With this view,
 the fingers, hand, and forearm, having been very carefully padded and bandaged,
 a well-made graduated compress should be  firmly applied over  the seat of  punc-
 ture, and retained there for at least ten days or a fortnight.   Should the aperture
in the artery not be closed in  this way, either a circumscribed false aneurism,  a
varicose aneurism, or  an aneurismal varix will form according  to its situation in
 relation to the vein.
   In the  Circumscribed  Traumatic Aneurism at the bend of the arm,  follow-
ing  a wound of the  brachial artery in venesection, we have  the usual soft or
semi-solid pulsating tumor, which can readily be emptied  on pressure, and pos-
sesses more  or less bruit.   This  disease may be treated in  one of three ways :
by compression upon or above the tumor; by ligaturing  the artery leading to
it;  or by cutting through the  sac, and deligating the vessel on either side of
the  aperture in it.
N 
176
WOUNDS  OF  SPECIAL ARTERIES.
  The compression of the tumor has often  been successfully practised.   It may
be done by means of a graduated compress, or  the application of a  ring tourni-
quet; the tumor  becoming consolidated, and  gradually undergoing absorption.
Should this plan not succeed, we must be guided in our ulterior measures by the
particular conditions of the case.   If the tumor be  of  recent origin, soft and
compressible ; or,  though of longer duration, large, with a thin sac, it should be
treated by direct incision, and the artery be deligated on either side of the wound
in it.   Should, however, the tumor be small, or but of moderate size, and the
sac be tolerably thick and firm, so as to admit of the deposit of laminated fibrine,
we may treat it by deligation of the brachial artery, either in  the middle of the
arm, or as Anel did with  success, immediately above the tumor.  In the event,
however, of the disease not being cured in  this way, incision of  the sac must be
had recourse  to, as I have known to be necessary in a case in which the brachial
artery was tied above the tumor, which was large with a thin sac, the pulsations
returning in a few days, and the tumor continuing to enlarge.
   Varicose Aneurism, at the bend of the arm, presents the ordinary characters
of this disease.   Occasionally,  though rarely, it would  appear that the  aperture
of communication between  the aneurismal  sac and the vein becomes closed,
and thus the varicose  is  converted into the ordinary circumscribed traumatic
aneurism.
  The treatment of this affection must be conducted on different principles from
that of the ordinary circumscribed  variety, for whatever be  the density of the
sac, it is never, as has  already been explained (p.  165), a perfect one, having
always, an opening in the vein which would prevent its proper closure by the
deposit  of laminated fibrine.   In  four cases related  by Sabatier, which were
treated by Anel's  operation, amputation became necessary in  two,  and in the
other cases, the operation by incision of the sac was required before a cure could
be effected.   The  sac must therefore be laid open, and the vessel tied  on either
side of it in the way that has been recommended in the treatment of that disease,
and with the caution there laid down.   If the varicose aneurism be converted,
after a few days, into the circumscribed form, the aperture in the vein becoming
occluded, the ligature of the artery above the sac may  be successfully employed,
or compression succeed in curing the disease.
  In aneurismal varix of  the  arm, a roller and compress are all that can be re-
quired.
  Arteries of the  Forearm  and Palm.—These vessels  are  very com-
monly wounded by pieces  of glass, earthenware,  or knife cuts.   In every case
the bleeding point must be cut down upon, and both  ends of the  vessel tied.
This rule is peculiarly imperative in this  situation, on account of the freedom of
the anastomosis  through the  palmer arches.   In many  of these cases the
bleeding is  at first  very free, but, being arrested by  pressure,  does not break
out again until eight or  ten days  have elapsed, when, the arm being much in-
filtrated with blood, inflamed, and swollen, double ligature of the vessel, at the
seat of injury, has  to be practised under somewhat difficult and unfavorable cir-
cumstances.
  Traumatic Aneurism of the Radial and Ulnar Arteries usually assumes the
circumscribed form, owing to the  pressure employed at the time of  the injury,
confining the extravasation.   If  it be small and recent, and situated superfi-
cially at the  lower part of the forearm, or if it be in any way diffused, the
better plan is to cut down upon and through the tumor at once, ligaturing the
vessel on either side.  If, however,  the aneurism be deeply seated amongst the
mass of muscles at the upper part of the forearm, near the elbow-joint, the wound
having healed, and the soft parts covering  it being healthy and  firm, the advice
given by Mr. Liston  appears to be most judicious :—rather than  cutting through
the muscles, and detaching their connexions, he recommends that the  aneurism 
wounds  of  the  palmar  arches.
177
should  be left to attain some consistence, and then that the brachial artery be
secured in the mid-arm.
   Wounds of the Palmar  Arches not unfrequently occur from the breaking of
glass or bottles in the hand, or stabs from some pointed instrument, and are always
troublesome to manage.  If the surgeon see the case shortly after the infliction
of the  wound, he should, by enlarging the aperture to a moderate extent, and
with due attention to the tendons and nerves of the  part, endeavor to secure the
bleeding vessel.  Should  he fail in doing this, a  graduated compress must be
well and firmly applied from the bottom of the wound ;  and that artery above
the wrist  which appears  most to correspond  with  the arch wounded,  should
be compressed with a ring  tourniquet, the limb being  placed in  an  elevated
position, and cold assiduously applied.  If the case be not seen until several  days
have elapsed, when the palm has become  infiltrated  and swollen,  pressure can
no longer be borne upon the seat of injury, and it is useless to endeavor to search
for the injured vessel  in the midst of sloughy and infiltrated tissues, through a
narrow wound which cannot be prudently enlarged.  Under these circumstances,
it is necessary to deviate from the ordinary rule of practice in wounded arteries.
The plan that I have more than once  found to succeed is the ligature of that
artery,  above  the wrist, which appears to furnish  the  principal supply of blood
to the wounded arch;  the ulnar, if it be the superficial;  the radial, if it be the
deep; and the application of compression, by the ring tourniquet, to the other.
Should this not succeed, both arteries must be tied.
   Circumscribed Traumatic Aneurism in the Palm is by no means of frequent
occurrence.   It may however follow wounds of the palmar arches.  In such a
case as this it would be clearly out of the question  to lay open the sac, and to
search for the injured vessel in the midst of the aponeurotic and tendinous struc-
tures of the hand.   It would consequently be necessary either to tie the radial
and ulnar arteries immediately above the wrist,  or to ligature the brachial  in
the upper arm.  The latter plan should be preferred; as were the  first mode of
treatment put into practice the sac might continue to be fed by the interosseous
artery,  as happened in a  case of Roux's, in which the patient died of  hemor-
rhage from the palmar aneurism after the ligature  of both arteries of the forearm.
In  the case represented (Fig. 57), Liston successfully ligatured the brachial in
the mid-arm after compression upon it had failed to effect a cure.
   Femoral Artery and its Branches.—The hemorrhage from these arteries
when wounded is from their magnitude  always very profuse.   In all cases,  liga-
ture of the wounded vessel must be practised at the seat of injury.   If a diffused
traumatic aneurism have already formed, the artery should, if possible,  be com-
manded by the pressure of the fingers of an assistant as it  passes over the brim
of the  pelvis, the sac laid open, and the bleeding vessel  sought  for and  tied.
Mr. Guthrie has  collected a great  number of cases, which prove  incontestably
that the general principles of treatment in wounded arteries must not be departed
from when the arteries of the groin or  thigh are wounded.  On the contrary,
the facility with which in most cases the circulation is kept up, and the readiness
with which secondary hemorrhage comes on as a consequence of the free  anasto-
moses in this situation, renders the rule of practice of applying a ligature on  both
sides of the wound in the vessel peculiarly stringent in all recent arterial  wounds
in this part of the body.   Secondary hemorrhage  and gangrene of the limb are
the great sources of danger here.  When gangrene is imminent, or has come on,
amputation is necessarily  the sole resource.   With  regard to secondary  hemor-
rhage, supervening after ligature of the artery at the seat of injury, there is, I
think, no safe course  but removal of the limb.  Where the artery has been tied
higher  up, the hemorrhage appears to have returned, or gangrene to have super-
vened, in all,  or nearly all, the cases in which this was done.  If the traumatic
aneurism have assumed a circumscribed  character, it must be  treated  on  the
                                    12 
178
wounds  of  special arteries.
principles laid  down for  this form  of the disease, the supplying artery being
ligatured  above the tumor; and cases are not wanting in proof of the success of
this practice.
  It occasionally, though rarely, happens  that  a varicose aneurism is formed
in the groin or upper part of the thigh, as the result of wound of artery and
vein in this situation.  It usually presents  the ordinary character of this disease,
but some peculiarities have been met with in some instances.  Thus, in a  case
related by Mr.  Horner, there was a wavy motion in the femoral vein on the
uninjured  side, arising  from the blood in the wounded vessel  communicating a
thrill upwards  to that contained in the vena cava.   In a case related by I)r.
Morrison, it is  stated that a  tumor as large as the  human uterus at the third
month of pregnancy, communicated with the injured vein.
  The treatment of this disease is  exceedingly unsatisfactory;  of four cases in
which the external  iliac artery was tied, a fatal termination occurred  in every
instance, two of the patients dying of gangrene of the limb, and the remaining
two of secondary hemorrhage and consecutive pneumonia.  It has consequently
been proposed  by Mr. Guthrie that the tumor be  laid open, and  the artery
secured above and below the  aperture in it.  As this plan has never  been fairly
put in practice, it would perhaps be useless to speculate on the chances of success
likely to attend it; but yet we must bear in mind, that  laying open an aneurism
of this kind  in the groin is  a very different  matter from adopting the same
procedure at the bend of the arm, or in a situation where the surgeon  can com-
mand the artery on  the proximal side of the sac.   The  gush of blood from so
large an artery  as the common femoral, would be  so great, that with whatever
dexterity the operation were performed, there would be considerable  risk of the
patient suffering a fatal hemorrhage  before the vessel, matted and incorporated
as it would be,  with surrounding parts, could be separated and secured;  and the
ligature of the  vein would probably be followed by gangrene of the limb.
  Recent wounds and traumatic aneurisms of  a diffused kind, connected with
the arteries of the leg and foot, require to be treated by the free exposure of the
bleeding orifice in the vessel, and its inclusion between two ligatures.   In doing
this, if the wound be situated in the posterior tibial or peroneal artery, the sur-
geon will have  to cut freely through  the muscles of the calf.   This he must do
in the direction  of their  fibres, injuring them by transverse incision  as little as
possible, and by taking the track of the wound as his guide, the bleeding vessel
will at last be reached, and must then be tied in the usual way.  In such cases
as these, surgeons have often attempted to arrest the hemorrhage by the ligature
of the superficial femoral or popliteal arteries; and though they have occasionally
been successful, as happened  in a case in which I saw the popliteal ligatured for
a wound of one of  the arteries of the  leg by the late Mr. S. Cooper, yet I fully
concur with  Mr. Guthrie in deprecating this practice, as contrary to good  sur-
gery,  and, with him, regard  the  success  that  has occasionally followed these
operations as purely accidental.
  Small circumscribed aneurisms are occasionally met with in the foot,  in conse-
quence of the wound of one of the plantar arteries, as in operations for club-foot.
If pressure have failed in preventing or curing the disease, the only course left to
the surgeon is to lay the  tumor open, and  to ligature the artery on either side,
in the usual way. 
INJURIES OF MUSCLES  AND TENDONS.
179
                          CHAPTER XIII.

              INJURIES OF MUSCLES AND  TENDONS.

  Sprains, or strains, of muscular  parts without rupture of fibre, are of very
common occurrence, especially about the shoulder, hip, and loins, and are accom-
panied by much pain, stiffness, and inability to move the part.   When occurring
in rheumatic subjects, these injuries not  uncommonly give  rise to severe  and
persistent symptoms.  In some cases painful atrophy, rigidity, or local paralysis
of the injured muscle being induced.
  In the treatment of these accidents, when recent, it will be found that knead-
ing or rubbing the part with a stimulating embrocation, the application of dry
cupping, or, if the pain  be severe, the abstraction of a few ounces of blood by
cupping, together with rest, is most efficient.  If the injury occur in a rheumatic
constitution it will be found useful to give  colchicum and Dover's powder, in the
following form: R.—Extr. Colchici Acetici, gr. i.   Pulv. Ipecac, comp. (Pulv.
Ipecac,  et Opii, U. S.),  gr. x.   Extr.  Coloc. comp. gr. iv., f. pil. iij.  If the
pain continue,  the application of the " thermic hammer"  is exceedingly service-
able, and if local paralysis or  atrophy ensue, the use of the electro-magnetic
apparatus will be beneficial.
  The subcutaneous rupture of muscles and tendons not unfrequently occurs, not
so much from any external violence as by the contraction of the muscle rupturing
its own substance.   In  the majority of cases, when the rupture occurs, it is the
tendon that gives way, most commonly at  its point of  attachment to the  muscle,
which opposes itself, by its vital contractility, to that forcible extension which
must necessarily  precede its rupture.  Sedillot found that in twenty-one  cases
the rapture occurred at the point of origin of the tendon, thirteen times; and in
the remaining eight, the muscle itself was torn.   It  occasionally happens  that
the muscular sheath is ruptured, so that the belly of the muscle forms a kind of
hernial protrusion through the  aperture; or the tendon may be displaced  by rup-
ture of its  sheath.  This usually happens with the  long  head of  the biceps, or
the extensor tendons of the fingers.
  These ruptures most  commonly occur  in elderly people,  who have lost the
elasticity of youth, though  their physical strength be unimpaired.   At the mo-
ment  of the rupture taking place,  the patient usually  experiences a  sudden
shock, as if he had received a blow, and sometimes hears a snap.   He becomes
unable to use  the injured limb, and at the part where the rupture has occurred
finds a hollow or pit, produced  by the retraction of the end of the  torn muscle,
which is contracted into  a hard lump above this.
  These ruptures, though troublesome, are seldom serious.  The tendo-achillis,
the quadriceps-extensor  of the thigh,  the triceps of the arm, the biceps, the
deltoid,  the  recti-abdominis, are the  tendons  and muscles that most commonly
give way, with the relative frequency of the order in which they are placed.
  The mode of union of these injuries has  been well described by Paget.  When
a tendon is cut or torn across, an ill-defined  mass of nucleated blastema of a
grayish pink tint is effused into the cellular tissue  and sheath, between  the cut
ends.  About  the fourth or fifth day, this has become more defined, forming a
distinct  cord-like uniting mass between the ends of the tendon; in the course of
two or three more days, this mass has become tough and filamentous; the tissue
gradually perfecting itself, until it closely resembles tendinous structure,  though
for some time it remains  dull  white, and  more cicatricial in  appearance.   The
strength of this bond of union is marvellously great;  Paget found that the tendo- 
180
FRACTURES.
achillis  of a  rabbit, six days after its division, required a weight of 20 lbs. to
rupture it.   In ten  days the breaking weight was 56  lbs.  Divided nmscles
unite in the same way as tendons do, but less quickly, and by a fibrous bond.
   Treatment.—The  principle of treatment in these cases is extremely simple:
it consists in relaxing the muscles by position, so as to approximate  the divided
ends;  and maintaining  the  limb for a sufficient length  of time in this position
for proper union to take place.   If position be not attended to, the uniting bond
will be  elongated and weak.  Considerable stiffness is often  left for a length of
time—for many months, indeed—after union has taken place.  Warm sea-water
douches, when procurable, followed by methodical friction, will greatly tend to
restore  the suppleness of the parts.
   When  the tendo-achillis is ruptured, the best apparatus consists of a dog-collar
placed round the thigh above the knee, from which a cord is attached to a loop
in the back of a slipper; by shortening this cord, the leg is bent on the thigh,
and the foot  extended, so that the muscles of the calf become completely relaxed.
After this simple apparatus has been used for two or three weeks, the patient
may be allowed to go about wearing a high-heeled shoe for  some weeks longer.
After rupture of this tendon, the patient usually walks lame for two or three
months.
   When  the extensor muscle  or tendon of the thigh is ruptured, the patient's
limb must be kept for some little time in the same position as for fractured knee-
cap, and  then he may be allowed to walk about with a leather splint behind the
knee, so as to prevent flexion of this joint.  In muscular or tendinous ruptures of
the arm, a sling is all the apparatus required, but it is especially in these injuries
of the deltoid that paralysis and atrophy are apt to result.
                           CHAPTER XIV.

                         INJURIES TO BONES.

   A  BONE may be bruised, bent, or fractured.  Bruising of the bone and pe-
riosteum often occurs, and is usually of no great moment, but if severe, or hap-
pening in bad constitutions, or in old  people, it may give rise to serious conse-
quences.
   If  the contusion be severe,  the vitality of a  layer,  or even of the whole sub-
stance of the bone, may be  destroyed,  as  happens  sometimes from  the graze or
contusion of a bullet.  Even a moderate contusion  of some parts where the bone
is but thinly covered, as the shin, or elbow, may give rise to troublesome symp-
toms  from  inflammation of the periosteum.   In old people, the contusion of a
bone  is frequently followed by its atrophy and shortening,  as happens in the
neck  of the femur; and in strumous  constitutions, serious disease  of the bone
may be attributed to this cause.
   In the treatment of bruised bone, leeches  and fomentations are the most im-
portant means that we possess; the  after-consequences will be considered when
we come to speak of necrosis.
   Bending of bone may occur in two conditions :  independent of fracture, it is
most  commonly met with in very young subjects, before the completion of ossifi-
cation, the bone  being healthy, but naturally  soft at this period of life.  It is
occasionally met  with after the adult  age, but  is then the result of some struc-
tural change, by which the natural firmness of the osseous tissue  is diminished.
The bending most commonly  occurs in the long bones, especially the clavicle, 
CAUSES  OF FRACTURE.
181
the radius, and the femur, but sometimes is met with in the flat bones, or those
of the skull, in which depression takes place from a blow without fracture having
occurred.  In many cases of bending both of long and flat bones, there is partial
fracture on the convex side.
  The treatment is simple: the surgeon gradually straightens  the  bone, by ap-
plying a splint on its  concave side, towards which the  bone is pressed by a
bandage and a pad, applied upon its greatest convexity.

                               FRACTURES.
   The management of fractures constitutes one of the commonest duties of the
surgeon, and  hence the consideration of all that relates to their nature and treat-
ment is of the very utmost importance.
   Fractures are invariably the result of external violence.   This may act in two
ways : directly or indirectly.
   The worst  forms of  fracture are occasioned by direct external  violence, the
blow crushing and splintering the bone, as by the passage of a heavy wheel over
a limb, or a gun-shot injury.  When the bone is broken  by direct violence, the
fracture is  always at the  seat  of  injury, and is often complicated with consi-
derable mischief to the soft parts,  the result of the same force that breaks the
bone.   Indirect violence may break a bone in two ways.   One that is more com-
monly talked  of than  seen is by " contre-coup," in which, when  a blow is in-
flicted on one  part, the shock that is  communicated  expends its violence on the
opposite point, where the fracture consequently occurs.  This  form of injury is
only met with in the head; and although its occurrence has been denied, I  can-
not  doubt it, as I have  seen unequivocal instances of this kind of fracture.
   In the next form of indirect violence occasioning fracture, the bone is broken
 by being snapped, as it were, between a resisting medium on one side,  and the
 weight of the body on  the other.   Thus, a person  jumping from a height, and
 alighting on his feet, may break his legs by their being compressed between the
 weight of the body above and the ground below.  The long bones are those that
 are  most frequently fractured in this way, and the fracture occurs at the  greatest
 convexity, or at their weakest point.   When a person jumps from a carriage
 that is in motion, although the height  of the  fall  be not great, yet its force is
 considerable, the body coming to the ground with the same velocity as it was be-
 ing  carried onwards  in  the vehicle.  Hence, fractures received  in  this  way are
 usually severe, and often compound or comminuted.
   Muscular  action is  not an  unfrequent cause of fracture of those bones into
 which powerful muscles happen to be inserted.  This is especially the case  with
 the  patella and some of the bony prominences, such as the  acromion, which are
 broken in the same way that a tendon is  ruptured, by the violent contraction of
 the  muscles attached to them tearing them asunder.  It is not often that the
 long bones are so fractured, but it has happened that the humerus has  been
 broken by a person striking at, but not hitting another; or that the clavicle has
 been fractured by a rider  giving his horse a back-handed blow.  In these cases,
 however, muscular action  may not  have been the sole cause, the weight of the
 limb also tending to  fracture the bone.  Those bones that do not  offer attach-
 ment to any powerful muscles,  as the cranial, for instance, cannot be fractured in
 this way.
   The predisposing  causes of fracture are numerous and varied.
   Some bones are especially liable  to be broken in consequence of  their serving
 as points of support.   Thus, when a person falls upon the hand, the  shock is
 transmitted from the wrist-joint through the radius, humerus, and clavicle, to
 the  trunk; the radius  and clavicle being the weaker bones, are especially liable
 to be fractured under  these  circumstances.  So again, the  situation  of a  bone
 irrespective of use, or  any other circumstances, may predispose  it to fracture; the 
182
FRACTURES.
 prominent position of the nasal bones, and the exposed situation of the acromion,
 render these parts  peculiarly liable to this injury.   The  shape of some bones
 disposes them to fracture;  thus, a  long bone is necessarily more  readily broken
 than a short and thick one; hence, fracture of the tibia and femur from falls on
 the feet are more common  than of the os calcis.  Certain parts of bone are more
 commonly fractured than others.   Those  points  especially into which  powerful
 muscles are inserted, or that are in exposed situations, and  hence liable to injury,
 or to receive the weight of the falling body, are often broken.   Hence, the acro-
 mion, the olecranon, and the neck of the femur, are  commonly fractured.
   Age exercises considerable  influence, not only on the  general occurrence of
 fracture, but  on the peculiar liability of certain bones.  Though fractures may
 occur at all ages, even in  intra-uterine life, Chaussier having dissected a fcetus
 that had  113  fractures, yet, bone being elastic and cartilaginous in early age, is
 less readily broken  than when it has become brittle and earthy, as in advanced
 life.   In children,  fractures most  commonly  occur  in the shafts of the long
 bones; or, at the point of junction between the shaft and epiphysis where ossifi-
 cation has not as yet taken place.   As age advances, the compact tissue of the
 shaft becomes  denser and harder, but the cancellous structure of the extremities
 more dilated  and looser, hence fracture of the neck  of the  femur is especially
 common in old people. In  young persons also, the bone is  usually simply broken
 transversely, but fractures occurring at a more advanced period of life generally
 assume an oblique direction, and become comminuted; so also  they  more com-
 monly extend  into joints than when occurring  in early age.   Occasionally frac-
 ture termed "spontaneous," occurs without any very direct occasioning cause, or
 under the influence  of a degree of violence that would usually be insufficient to
 occasion it.   This may happen in consequence of the texture of the bone being
 weakened  or  rendered more  brittle by disease,  such as mollifies or fragilitas
 ossium, by the cancerous  cachexy,  by syphilis,  by  the presence of cancerous
 growths within the  substance of the bone  itself, or by the  pressure upon, and
 absorption of it, by some  neighboring tumor.   In other cases, again,  it occurs
 without any apparent disease, local or constitutional.   This  usually  happens as
 the result of the brittleness and weakening induced by age.  But  I have known
 a gentleman little above fifty, apparently in perfect health, break his  thigh with
 a loud snap whilst turning  in  bed.   In these cases union rarely takes  place, or
 not without much difficulty.
   Sex necessarily influences the liability to fracture, men being more frequently
 exposed to the causes of this  injury than women.  In women, the bones that
 are  most  frequently fractured are the clavicle, the tibia,  and the neck of the
 femur.   In men, the shafts of the long bones, the cranium, and pelvis, are most
 frequently broken.
   From statistical accounts, it would appear that the  right  limbs are more fre-
 quently broken than the left, being  more exposed to the causes of fracture.  It
 has been supposed that the bones are more brittle  in winter, and hence break
 more readily  than  at other seasons, but  this  is altogether  a mistake, though
 fractures may  be common at this period of the year, from falls being more
 frequent.
   Fractures present  important varieties as  to their nature and  their direction.
 The varieties as to nature depend upon the cause of  the fracture, its seat and
 the age of the  patient.
   Varieties as to Nature.— Fractures are divided into two great classes, accord-
 ing  as they are accompanied, or not, by an open wound.   When the bone is
 merely broken across, the  fracture  is a simple  one.  When one fragment is
 wedged into another, the compact tissue being driven into the cancellous struc-
ture, it is said to be  impacted.  When the bone is broken into several  fragments,
it is comminuted. 
VARIETIES OF FRACTURE.
183
  When the soft parts  covering  the broken ends of bone are torn through, so
that the fracture communicates by a wound with the  surface of the body, it is
said to be compound.   The fracture may be rendered  compound in two ways,
either by the same injury that breaks the bone lacerating the soft parts, as when
a bullet  traverses a limb, and fractures the bone; or else by the protrusion of one
of the extremities of the broken fragment through the integuments covering it;
this necessarily most  frequently  happens  when  the fragments  are  sharp  and
pointed, and the coverings thin, and may be occasioned either by muscular con-
traction  driving the fragment through the skin, or by some incautious movement
on the part of the patient, forcing it through.
  A fracture is said to be complicated when the injury to the bone is conjoined
with other circumstances which are perhaps of more importance  than the  mere
fracture  itself, the complication  constituting perhaps  the most  serious part of
the injury,  and influencing  greatly the general  result of the  case.  Thus, a
fracture may be complicated  with injury of an important internal organ, as of
the brain, lungs, or bladder; the  injury to the  organ being inflicted by  the
projection against  it of  one of the broken fragments.   So also a fracture is  not
unfrequently complicated with the wound of one of the principal arteries of the
part, as  happens especially in the  leg, where the tibial arteries, being in close
contact with  it, are often torn by the broken bone.   In other cases, again,  the
fracture  is  associated  with injury  of  a joint, or  dislocation  of  it.   Besides
these varieties of fracture, it occasionally happens  that a bone is only cracked,
or partially broken.  This especially occurs in the  bending of bone in children,
in which cases the fracture  may be partial  or  incomplete,  merely extending
across the convexity of  the curve made by the bone.   Interperiosteal  fractures
have  been  described, but  this is an anatomical  refinement of little  practical
value.
   The direction assumed by fractures varies greatly, and depends  materially on
the cause of the injury, as well as upon the bone that is fractured.
   The line of fracture may run  through a bone  in  three different directions:
either transversely, obliquely, or longitudinally to its axis.
   The transverse fracture is the  simplest, and is seldom complicated with injury
to neighboring parts.   It chiefly  occurs  in children, and very frequently in  the
articular extremities or  processes  of bones;  it unites readily, and is attended by
but little displacement;  it is  most commonly the result of direct violence, but it
may occur from muscular action, as in the case of the patella, which      Fig  62.
is usually broken  in this way.
   The oblique fracture  commonly occurs from indirect violence;
the breaking force being applied to  the ends, and not across the
shaft.   It often runs  a long  way, more than half the distance of
the shaft of a bone, and is more dangerous than  the transverse,
owing to the obliquity of the fracture causing the ends of the bone
to be sharply pointed (Fig. 62, a), and  thus frequently  to  punc-
ture the skin, or to perforate  an artery.   It is tedious in its  cure,
owing to the fragments being less directly in apposition; hence,
also, there is a greater liability  to  shortening of the  limb;  it  is
principally met with in  the shaft of the long bones of adults and
elderly people.
  The occurrence of  the longitudinal  fracture has been denied,
but I have seen several instances of it.   It consists of a splitting
of a bone in the  direction of  its  axis (Fig. 62, V), and has a great
tendency to  run into a  joint, and to separate the articular ends of
the bone.  It most commonly results from gun-shot injury, but  I
have seen cases of its occurrence from very slight  violence.   The
great danger of  longitudinal fractures  is the implication of the neighboring
 
184
FRACTURES.
 articulation, but in some cases  it extends  a little  distance up the shaft of a
 bone,  stopping short of this.
   The signs of fracture, taken individually and singly, are all more or less equivo-
 cal, and may arise  from  other  conditions of the part, being common to various
 injuries.   It is rather by their simultaneous  occurrence that we consider them
 as pathognomonic of the existence of a broken bone.
   Amongst the more equivocal  signs may be mentioned the occurrence of pain
 in the limb,  which may be owing either to the laceration of the soft parts by the
 broken fragments, or to the general injury inflicted upon it.  So also the existence
 of increased  or diminished swelling is observed in different cases of fracture; the
 augmented swelling being owing either to the extravasation of blood into the
 limb, which  often occurs  to a very considerable extent, even without the wound
 of any principal vessel;  or, to the  approximation  of  the attachments of the
 muscles, by the shortening of the part.  Diminished swelling, or flattening, occurs
 in some cases, in consequence of the weight of the limb drawing the part down,
 and thus lessening natural rotundity.
   The more special and peculiar signs of fracture are three in number : 1st. A
 change in  the shape of the limb ; 2dly. Mobility in its continuity; and 3dly. The
 existence of grating between the broken ends  ofbone<.
   The change in the shape of the limb, due to the  displacement of portions of
 the broken bone, is perhaps the most important sign of fracture;  it  manifests
 itself by a want of correspondence between the osseous points  on opposite sides
 of the body,  by an increase or diminution of the natural curves of the limb, by
 angularity, shortening, or swelling.
   In investigating the existence and extent of displacement in a case of frac-
 ture, the surgeon should always strip his patient, compare the points of bone on
 the opposite  sides of the body, and their relative  situation  to some fixed and
 easily  distinguishable neighboring prominence on the  trunk or injured part of the
 limb.   From this the measurements may be taken,  by grasping the injured part
 and the  corresponding portion of the healthy limb in either  hand, and running
 the fingers lightly over the depressions  and  elevations, marking any difference
 that exists; or,  if greater accuracy be required, measuring by means of a  tape.
 In some cases the  measurement must not be made  between the  trunk and the
 limb injured, or even from one  extremity of the limb  to the other, as shortening
 of the whole member might depend on  other  causes  than fracture, such as
 wasting, disease of joints, or dislocation, but the measurement must be taken
 between different points of the bone actually injured.
  The displacement of a broken bone may be the  direct result of  the violence
 which  occasions  the fracture, the fragments being driven out of their position, as
 when a portion of the skull is beaten in;  or it may result from the weight of the
 limb dragging downwards the lower fragment, as in a case of fractured acromion.
 In some cases, it is either occasioned, or greatly increased, by the  direction of
 the fracture.   Thus, in several  cases of broken tibia which have been under my
 care, the line of fracture being oblique from above downwards, and from before
 backwards, I found the upper end of the lower fragment project  considerably
 forwards, sliding, as it were, along an inclined plane in the upper one, and in
 one of these  cases that I had an opportunity  of dissecting after amputation, the
 direction of the  fracture, rather than muscular action, appeared to be  the cause
of displacement.   In transverse fractures  there is always but slight  displace-

  Muscular contraction is, however, without doubt the most frequent  cause of
 displacement; hence, it has been found that in  paralysed limbs that  are  frac-
tured,  there is but little deformity.   The contraction  of  the muscles of the part
approximating their points of attachment, owing to  the support or resistance
offered by the bone being removed, draws the most  movable fragment out of its 
SIGNS  OF FRACTURE.
185
normal position.   The other causes that have just been mentioned tend greatly
to favor this kind of displacement; but  in some cases, as  in  fractured patella,
the displacement is  entirely muscular, and  in all fractures of the long bones it
is chiefly due to muscular contraction.
  The direction of the displacement is principally owing to the direction of the
fracture, the position of the limb, and the influence of muscular action; it may
be angular, transverse, longitudinal, and rotatory.
  In the angular displacement there is an increase of the natural curvature of
the  limb, the  concavity of the angle being  on the side of the  most powerful
muscles; thus, for example, in fracture of the thigh, the angle projects on the
anterior and outer side of the limb, because the strongest muscles being situated
behind and  to the  inner side, tend,  by their contraction, to approximate the
fragments on that aspect.  This displacement principally occurs in oblique and
comminuted fractures.
  The transverse  or lateral displacement occurs when a bone  is broken directly
across, the fragments  hitching one against another, and so being, as it were,
entangled together.   In this case there is often but very  little deformity.
  In the longitudinal displacement there may be either shortening or elongation
of the limb.   When there is shortening, as most commonly happens in oblique
fractures, it is dependent on muscular contraction, the broken ends of bone being
drawn together so as to overlap one another, or " riding."   In other cases, the
shortening may be owing to the impaction of one fragment in the other.   In
some cases there is preternatural separation of the fragments, the weight of the
limb tending to drag the lower one downwards, or muscular contraction drawing
the upper one  away  from it.
  The rotatory displacement is owing to  the  contraction of  particular sets of
muscles twisting the lower fragment on its  axis, as well as producing shortening
of the limb.   Thus, the  external  rotators in fractures of the neck of the thigh
bone, and the supinators in some fractures of the radius, have a tendency to
twist or rotate the lower  fragment in an outward direction.
  The occurrence of preternatural mobility in the continuity of a bone cannot
occur without fracture, and separation of the fragments from one another; hence
its presence may always be looked upon as an unequivocal sign of the bone being
broken.  It occasionally happens, however, that fracture may  occur, and, owing
to the impaction or wedging together of the fragments, mobility not be perceived;
hence, its absence cannot in  all cases be construed into a proof of the non-ex-
istence of fracture.
  Another sign of much value in practice is the occurrence of crepitus or rather
of the grating together of the rough surfaces of the broken bone, which can be
felt as well as heard on moving the limb. This grating can only occur when the
fragments are movable and in contact, and is  especially perceptible when the
rough ends of the broken bone are directly rubbed against one another, and not
the  smooth periosteal  surfaces merely opposed  or  overlapping.   It is not,  how-
ever, an invariable accompaniment of fracture, being  absent  in  some  cases in
which the fracture is firmly impacted, or when the  fragments are  widely sepa-
rated.  It must not be confounded with crepitation that occurs  in the limbs from
other causes, as from emphysema, or the effusion of serous  fluid into the sheath
of the tendons, which gives rise to a peculiar crackling sensation, very  different,
however, from the rough grating  of a fracture.
  It will thus  be seen that each of these symptoms, taken  individually, is more
or less equivocal, and that it usually requires a combination of at  least two of
them to determine the existence of fracture.   In ascertaining  the existence of a
fracture, the surgeon should  make the necessary manipulations with the utmost
gentleness, but yet effectually, so that no  uncertainty may be allowed to exist^ as
to the seat and nature of the  injury, more  especially when it occurs  in  the vici- 
186
FRACTURES.
nity of a joint.   The increased mobility may be ascertained by fixing the upper
fragment, and rotating  the lower portion of the limb;  the grating, by drawing
down the lower fragment, so as to get the rough surfaces in opposition, and then
grasping the limb at the seat of fracture with one hand, rotating it  gently with
the other.   The  displacement must be ascertained by measuring the limb care-
fully in the way that has been directed, and by comparing the injured with the
sound side.
  A fractured bone is ultimately united by being soldered together by the deposi-
tion of new bone  around, or within, and lastly between the broken fragments.   In
exceptional cases, as in fractures occurring within the capsule of a joint, and in
those of the patella and the olecranon, union is effected by fibrous or filamentous
tissue.  And in some instances that will hereafter be considered, owing to pecu- '
liar local or constitutional circumstances, new bone is not formed, but the uniting
medium is of a fibrous character.
  The new bone that constitutes the bond of union is termed  callus.  In many
cases, a larger quantity of this is temporarily deposited than is permanently left.
This temporary formation of bone goes by the name of the " provisional callus."
It is formed partly external to the fracture, incasing the broken ends, and partly
in the medullary canal, so as  to  include the  fragments between  layers of new
bone, and thus maintain them in contact.  That which is permanently left, and
which intervenes  between the broken ends, is called the "definitive callus."
  The production of callus has been studied with much care by Haller, Duhamel,
Bordenave and Hunter, by Dupuytren, Breschet and Villerme, and more recently
by  Stanley and Paget.   From the observations of these pathologists it  would
appear that the union of a broken bone takes place through the medium of plastic
matter, deposited  by a process of adhesive inflammation set up in the injured
bone itself, its periosteum, and the neighboring soft parts; the lymph thus formed
gradually undergoing development into osseous tissue.  The whole process, indeed,
is strictly analogous to that which takes place in the ordinary healing of a wound
by adhesion and the development of the cicatricial tissue.   The broken fragments
are  at first  movable, and surrounded  by a considerable extravasation of  blood.
In the course of ten or fourteen days this has ordinarily undergone absorption to
a considerable extent;  the periosteum and the medullary membrane in  the
vicinity of the fracture, the tissues around it, and the broken bone itself, become
very vascular, and pour out a quantity of lymph between and around the frag-
ments, as  well as within  the medullary canal,  so  that  the  fractured ends are
ensheathed by a reddish gelatinous mass of a fusiform  shape, thickest opposite
the  seat of injury.   This gradually becomes more and more consolidated, and in
proportion as it becomes firmer, the mobility of the fragments lessens, and the
ends of the bone  becoming smooth by the plastic deposit being adherent to, and
interposed between them,  grating is less distinct.  From the third to the fourth
week  the  lymph  has assumed a sufficient degree of firmness to keep the frag-
ments in apposition, though the bone still yields readily at the seat of fracture.
This lymph, which is poured out not only by the periosteum and bone, but by all
the  soft parts in  the neighborhood of the fracture, gradually undergoes ossifica-
tion, the bony matter being first deposited in a granular manner, Win sufficient
quantity by  the sixth or eighth week to unite the fracture pretty firmly.  The
callus, which is at first soft and spongy, and  differs from  old bone  in  its  micro-
scopic as well as ordinary physical characters, gradually assimilates to  old bone,
both in hardness and in structure; osseous  corpuscles and vascular  laminated
canals forming in it; and it becomes smooth on  the surface, being invested by a
dense cellulo-fibrous periosteum, until by the end of six  or eight months, ossifi-
cation is perfect.   The last process in the consolidation of the fracture is the
formation  of new bone between  the broken  ends.   This does not take  place
definitely until a considerable period after the ensheathing callus has been formed. 
UNION  OF  FRACTURES--CALLUS.
187
This bone is deposited in the plastic matter effused between the fragments, which
undergoes ossification in the same way as the external callus does.   By the time
that this intermediate or definitive callus is fully formed, that portion of the en-
sheathing or provisional callus which is not required for the preservation of the
permanent  integrity of the bone, has been gradually removed, or has moulded
itself closely to the shape and condition in which it will ultimately remain, the
medullary canal having again become free, and the ends of  the fracture rounded
off.  In some  cases the medullary cavity is not restored to its former condition
for a considerable time, continuing to be partially occluded by a thin  septum of
callus.
   According to Paget, the plastic matter that is effused around and between the
bones undergoes ossification in various ways.   Those fractures that ossify quickly
do so most  commonly through nucleated blastema, a fine closely-granular ossific
deposit taking  place in the blastema, and becoming converted into the laminae of
the cancellous tissue, the nuclei becoming probably converted into  hard corpus-
cles.  In other cases again, the  nucleated cells of granulations and plastic  effu-
sions ossify by being transformed into bone.   Then, again, the new bone may be
formed by the  plastic exudation  passing, first of all, through the stages of fibrous
tissue, of cartilage of the purest foetal form, or through fibro-cartilage.
   In those  fractures that are transverse, and that remain in steady  apposition
during ossification, and  more especially if they are but thinly covered by soft
parts, the union appears to  take  place directly  and immediately  between the
opposed osseous surfaces; there  being no appearance of those accessory  deposits
of bone that usually go by the name of " provisional callus."   If, however, the
fracture occurs in a bone  that  is thickly invested by  soft  parts, masses of new
bone will be thrown out around  the fragments, evidently the result of  deposition
from the surrounding inflamed tissues,  rather than from the injured periosteum
or bone.  The influence of neighboring soft parts in determining the  deposits of
new bone is well marked in the tibia.   In a fracture of this bone  we find, that
at the anterior and inner part, which is  thinly covered,  union takes place directly
between  the broken ends;  but at the posterior and outer side, where  there is a
thick envelopment of tissue, a large mass of provisional  callus will often be found
filling up even the interosseous space.   That neighboring parts participate in the
inflammation set up around the fracture, and throw out callus, is  evident by what
takes place occasionally when one of  the  bones of the forearm ■ or leg only is
broken.  Periostitis is then  set up in the unbroken bone, opposite the  seat of
fracture,  and osseous  matter sometimes deposited by  it.   We  have  specimens
illustrating this point in the University College Museum.
   If the fracture be not well reduced,  the ends not being in proper apposition,
or if it is comminuted,  it will commonly be found that masses of new bone are
deposited as buttresses or supports; or, enveloping the splinters, consolidate  them
in this way with the rest of the  shaft.   So, also, if the fractured bones are not
kept sufficiently quiet during treatment, the neighboring parts become irritated,
and provisional callus is formed.   Hence, as Paget has remarked, we commonly
find this deposit in  fractures of  the ribs,  which are kept in constant  motion by
the respiratory actions.  In impacted fractures there is, from the perfect apposi-
tion of the  surfaces, but little callus formed.
   From all this,  I think it is clear that  in simple fractures  the provisional callus
is deposited principally by the  surrounding  soft tissues, and also, to a certain
extent, by the periosteum and medullary canal, its quantity being dependent on
the amount of irritation set up in these textures.   The definitive callus, on the
other hand, is directly and immediately formed by the vessels of the fractured
bone itself,  and the comparative want of vascular supply  to this tissue may account
for the slowness of its formation.
   In compound  fractures, union takes  place by the ends of the bone, which lie
bathed in the pus of the wound, granulating and throwing out plastic matter, 
188
FRACTURES.
which becomes directly converted  into bone.  There is in many cases but little
provisional callus ;  but in most  instances,  a large quantity of accessory osseous
deposit  takes place,  more particularly if the displacement be considerable.   The
uni6n of these fractures precisely resembles that of a wound in the soft structures
—by granulation—the process occupying a much longer time than that which is
necessary  for the union of simple  fractures, consolidation not being effected  for
three or four months.   Rokitansky is of opinion  that superficial exfoliation  of
that layer of bone  which is bathed by the pus, takes place, and that it is after
this has been separated that the  granulations spring up, in which the new bone is
deposited.   I think it admits of very considerable  doubt whether this process
of necrosis goes on in all cases of compound fracture.
  Union of fractures,  like  all other vital actions, takes place more readily and
much more  quickly in the early periods of life than at a more advanced age, and
is always more speedily accomplished in the upper than in the lower extremities.

                   TREATMENT OF SIMPLE  FRACTURES.
  In conducting the treatment of a fracture, the object of the surgeon should be
not only to  obtain a sound and strong limb, but one that presents as little defor-
mity and  trace of former injury as  possible.   In order to  accomplish this, the
broken  ends of the bone must be  brought into as perfect apposition as possible,
the  recurrence of displacement  must be prevented,  and the  local  and constitu-
tional condition of the patient properly attended to.
  When the surgeon is called to a person who has met with a fracture, if it be
a severe one of the upper extremity,  or of any kind of the* lower limbs, he must
see that the bed on which  the  patient may have to remain for some weeks, is
properly prepared by being made  hard,  flat, and  firm, and, if possible, covered
with  a  horsehair mattrass.   The surgeon must then superintend the removal of
the patient's clothes, having them ripped up the seams, so that they may be taken
off  with as  little disturbance to  the injured part as possible.  He next proceeds
to the examination of the broken limb, using every possible gentleness consistent
with acquiring a proper knowledge of the fracture.   After satisfying himself on
this point, the limb should be laid upon a soft pillow, until any necessary appa-
ratus that may be required  has been  prepared.
  When all has been got ready, the reduction of the fracture, or the bringing
the  fracture into proper apposition  must be proceeded with.   This should, if
possible, always be done at  once, not only lest any displacement that exists may
continue permanently,—the muscles, after a few days, becoming shortened, rigid,
and unyielding,  not only allowing reduction to be effected without the employ-
ment of much force,—but also with the view of preventing irritation and mis-
chief to the limb, by the projection of the sharp and jagged ends of bone into
the soft structures.  By early reduction we may sometimes prevent a sharp frag-
ment perforating the skin, thus  rendering a simple fracture compound, or lacera-
ting  muscles  and  nerves,  inducing  perhaps traumatic delirium,  and certainly
undue local inflammatory and spasmodic action.
   The  great cause of displacement  in fractures, has already been  stated to be
muscular contraction; hence in  effecting reduction of a fracture and in removing
the displacement, our principle  obstacle is the action of the muscles of the part.
This must be,  and always may  be, counteracted, by properly relaxing them by
position;  so soon as this is done,  the bony fragments will naturally  fall  into
place; but no amount of extension or counter-extension can get these into position,
and much less retain them  there, unless all muscular influence be removed.
   In ordinary fractures no  force is necessary for this, or should ever be employed
 in  accomplishing it; but attention to the attachment of the muscles of the limb
 and proper relaxation of them,  is all that is required.   In impacted fractures it
 is occasionally necessary to use  force in order  to  disentangle the fragments,  but
this  is the only form of fracture in which its  employment is justifiable.  In 
TREATMENT OF FRACTURES.
189
effecting the reduction, not only must the length of the limb be restored, but its
natural "curves must not be obliterated by making it too straight.
  After the reduction has been accomplished, means must be taken to prevent
the return of the displacement; for if the parts  be left to themselves,  muscular
action, or the involuntary movement of the  patient, would be certain  to_ bring
about a return of the faulty position.  In  many  cases it is exceedingly difficult
to preserve the  fracture undisplaced for the  first few days after its occurrence,
in consequence  of spasmodic  movement of the muscles of the limb, or of rest-
lessness on the part  of the patient.   About this,  however, the surgeon need not
be anxious, as no union takes place for the first week or ten days; at the expira-
tion  of that time, the muscles will have probably lost their irritability, and the
patient have  got accustomed to his position, so that with a little patience, or by
varying the apparatus  and the position of the limb, good apposition may be
maintained.
   The return of displacement is prevented,  and the proper shape and length of
the limb are  maintained by means of bandages,  splints, and special apparatus of
various kinds.  In applying these, care  should be taken not to exert any undue
pressure on the limb.   Pads and  compresses of all kinds  should, if possible, be
avoided; they usually do no good that cannot be effected by proper position, and
often occasion serious mischief by inducing sloughing of the  integuments over
which they are applied.   Screw  apparatus has  been  invented with the view of
forcing fragments into proper  position, but nothing can be more  unsurgical and
unscientific than such barbarous contrivances as  these.
   In cases in which there is much tendency to a return of the displacement, it
 has  been recommended to divide the tendons of some  of the stronger muscles
 inserted into the lower  fragment.   This, however,  can very rarely  be neces-
 sary, and in  those  cases,  in which I have done it, or seen it  done, no material
 benefit has resulted.
   The bandages used for fractures should be the ordinary gray calico rollers,
 about three  fingers' breadth  in  width, and of sufficient length.  In  applying
 them, especial  care must  be taken that the turns press evenly upon every part,
 and  that the bandage be not applied  too tightly in  the first instance.   The
 limb should also be examined from time to time, and if the patient complain of
 any pain or numbness, the bandage  must be immediately removed; for though
 it have not been applied tightly,  swelling of the limb may come on from various
 causes to such  an extent as to produce  strangulation, and consequent  gangrene
 of it, as I have seen happen in at least two instances, the limb requiring amputa-
 tion in both  cases  (Fig. 67).  It is remarkable, that the whole of a  limb will
 fall  into  a state of gangrene under these  circumstances with but little pain,
 and often with very slight  constitutional disturbance, the  parts having  their
 sensibility deadened by the  gradual congestion  and infiltration of the tissues.
 When such an unfortunate  accident happens,  immediate amputation must be
 had recourse to.  Before applying  the  bandages- in a  case of fracture, and as
 often as they are taken off, it is a good  plan to sponge the limb with warm soap
 and water, which prevents the itching  that otherwise occurs  and is  sometimes
 very troublesome.                                                .
   The splints  that are  used in cases  of fracture, are of various kinds.   Tin,
 wood, leather,  and gutta-percha, are the materials usually employed.   For  some
 kinds of fracture special,  and often very complicated, apparatus is very generally
 used; but the surgeon should never confine himself  to one material, or one ex-
 clusive mode of treating these injuries, as in different  cases  special  advantages
 may be obtained from different kinds of splints.  Wood and tin are principally
 employed in the lower extremity, where great strength is required to counteract
 the weight of  the  limb and the action of its muscles, and care must be taken  to
 pad very thoroughly splints made of these materials.   Leather, gutta-percha, and
 pasteboard, are more commonly useful in fractures of the upper extremity, though 
190
FRACTURES.
they may not unfrequently be employed with advantage in the lower limbs.  In
applying them, a pattern should first be cut out in brown paper of the proper size
and shape; the material must then be softened by being well soaked in hot water,
and moulded on to the part whilst soft; so soon as it has taken the proper shape/
it should, if leather or gutta-percha is used, be hardened by being plunged into
cold vinegar  and water; the  pasteboard must be allowed to  dry of itself.   Its
edges may  then be pared and rounded, and its interior  lined with wash-leather
or lint.   These  splints have the advantage of great  durability, cleanliness, and
lightness.
   Special  apparatus should be employed as little as possible in the treatment of
fractures.  It is scarcely ever necessary in simple fracture, and is far more cum-
bersome and  costly than the means  above  indicated, which are all that can be
required.  I have no hesitation  in saying, that a surgeon of ordinary ingenuity
and mechanical skill may be fully prepared  to treat successfully every fracture
to which he can be called, by  having at hand a smooth deal plank half  an inch
in thickness, and a sheet of gutta-percha, undressed  sole-leather, or pasteboard,
to cut into splints as required.
   To these simple means the starch bandage is an invaluable addition.   Although
various  plans for  stiffening and fixing the bandages in  cases of fracture, by
smearing them with white of eggs, with gum, &c, have been employed at vari-
ous times,  it  is only of late years that the full value  of the starch bandage has
been  recognised by surgeons,  chiefly through the practice and writings of M.
Seutin of Brussels.
   The advantages of the starch bandage in the treatment of fractures, as well as
in many other injuries and diseases, consist in its taking the  shape of the limb
accurately  and readily, and maintaining it by its  solidity;  in  being light, inex-
pensive, and  easily applied, with materials that are always at  hand.  From its
lightness, it possesses the very great and peculiar advantage in fractures of the
lower extremity, of allowing the patient to  remain up and to move about upon
crutches, during nearly the whole of the treatment, and thus, by rendering con-
finement to bed unnecessary,  preventing the tendency to those injurious conse-
quences that  often result from these injuries; and, by enabling the  patient to
keep up his health and strength by open air exercise, facilitating the consolidation
of the fracture.  In addition to  this, the  patient will often be able to  carry on
his business  during  treatment.   By employing the starch bandage in  the way
that will be immediately pointed out, I scarcely ever find it  necessary  to keep
patients with  simple  fractures of the leg in bed for  more than  three  or  four
days, thus  saying much of the tediousness and danger of the treatment.
   The following is the mode of applying  this apparatus that is adopted at the
University  College Hospital, and that will always be found to  answer.   A dry
roller is first applied to the limb, the osseous prominences of which are carefully
and thickly padded with cotton wadding.   If it be the lower extremity that is
injured,  and the fracture is very movable, a many-tailed bandage will be found
to be most  convenient.  This  must be smeared with stiff starch; over this should
be laid splints of thick and coarse pasteboard, properly cut to  fit  the limb, ex-
tending beyond the joints nearest to the fracture, and well soaked in thin starch.
If much strength is not required, as in children, or in some fractures of the upper
extremity,  a few slips of brown paper, well starched, may be substituted for the
pasteboard.  A  bandage  saturated with  thick  starch must  now be  firmly ap-
plied; and, lastly, this is to be covered by another dry roller, the inner sides of
the turns of which may be starched as it is laid on.   During the application of
this apparatus extension must  be  kept up by an assistant, so as to keep  the frac-
ture in position; and, until the starch has thoroughly dried, which usually takes
from thirty to fifty hours, a temporary wooden splint may be applied to the limb,
so as to keep it to its proper length and  shape.  The drying of the starch may, if
necessary, be  hastened  by the application  of hot sand-bags to the  apparatus. 
STARCH BANDAGE  IN  FRACTURES.
191
After the bandages have  become quite dry, the temporary splints must be  re-
moved, and the patient may then be allowed to move  about on crutches, taking
care, of course, to keep the injured  limb well slung up, and not to bear upon it
or to jar it against the ground (Fig. 64).   In the course of about  three  or four
days after  its application, the  apparatus will usually be found to have loosened
somewhat, the  limb  appearing to shrink  within it.   Under  these  circum-
stances it  becomes  necessary to cut it up with  a  pair of  Seutin's pliers, such
as are represented in the annexed
wood-cut (Fig. 63).  This section                    Fis-63-
must  be made along  the more
muscular part of the limb, so that
the skin covering the bones be not
injured, as represented in Fig. 65,
and after paring the edges of the
splint,  it must be reapplied by
means of tapes or  a  roller.   In  some cases it will be found advantageous to adopt
the practice of M. Burggraeve, of Ghent, and to envelope the whole limb in a
thick layer of cotton wadding before applying the starched bandage ;  this being
elastic, accommodates  itself to the diminution in the  size of the limb, and thus
keeps up more equable pressure.  Indeed, of late, I have invariably adopted this
practice, and found much  advantage  from it.  In trimming the edges of the
splint, it should not be removed from the limb, and after this has been done the
apparatus must be tied together again with tapes or a roller.   If the fracture be
compound, a trap  may be cut in the apparatus opposite the seat  of injury, through
which the wound  may be dressed (Fig. 66).
  Although fully recognising the great advantages to be obtained  by treating
fractures on this plan, and employing  the starch bandage  in  almost  every case
that came under my care, I did  not think that
it was  a safe practice to  have  recourse  to  it
during the early  stages of fracture, until,  in-
deed, the swelling of  the limb  had begun to
subside.   I therefore never applied  it until
the sixth, or eighth, or tenth clay, keeping the
limb  properly  reduced  upon  a splint, very
lightly bandaged, wet with cold  evaporating
lotions until this time, fearing that  if the ban-
dage was applied at too early a period, the  in-
flammatory turgescence of the limb  might give
rise  to a slow  strangulation of it under  the
bandages.
  During the  last year,  however, I have  fol-
lowed Seutin's plan in a great number of cases,
at least fifty or sixty, of fracture of all kinds,
putting the limb up in the starch apparatus im-
mediately on the occurrence of the  injury, and
have found  the practice an extremely success-
ful one, even  in  fractures of  the thigh;  so
much so, that at the hospital I now rarely use
any other plan of treatment.  I find  that  the
moderate pressure of  the bandages, aided pro-
bably by the great evaporation that  goes  on
during the drying of  so extensive and thick a
mass of wet starch, and which produces distinct
sensations of cold in the limb,  takes down the
extravasation most effectualUy, and enables the patient usually to  leave  his bed
Fig. 64.
 
192
FRACTURES.
about the third  day after the injury, when the fracture is in the  leg  or ankle,
and about the sixth when it is the thigh that is broken; so that very commonly
Fig. 65.
Fig. 66.
we now treat all patients with simple  fractures of the leg, and many of those of
                       the thigh, especially in children, as out-patients.
                          Various  accidents are liable to occur during the
                       treatment of a fracture ; some of these are of a general,
                       others of a special, character.   Amongst the more ge-
                       neral accidents,  tetanus, traumatic delirium, and erysi-
                       pelas, may be mentioned as the most common. Amongst
                       the more special the occurrence  of spasm of the muscles
                       of the limb,  abscess, oedema, gangrene, and a tendency
                       to pulmonary and cerebral congestion, are those that
                       have most to be guarded against.
                          In order to prevent the occurrence of these conditions
                       the  general health must be carefully attended to, the
                       bowels being kept open, the room well ventilated, nourish-
                       ing diet allowed, and long confinement to  bed avoided
                       by the use of the starch bandage.
                          The  treatment of the more  general accidents pre-
                       sents nothing that need detain  us here ;  but those that
                       are more special and  peculiar to fractures,  require con-
                       sideration.
                          Spasm of the muscles of the limb, owing to  the irn-
                       tation produced by the fragments, is best remedied by
                       reduction, and the maintenance  of the fracture in proper
                       position,  by moderate pressure with  the bandage.  If
the spasm be dependent upon nervous causes, full doses of opium will not unfre-
quently afford relief.   In some  cases, it is of a permanent character, producing
considerable  displacement of the fragments.  Under these  circumstances, the
division  of the  tendons  has  been  recommended, but  this  practice  appears
to be  an  unnecessarily  severe  one, and  may certainly most  commonly  be
avoided by attention to the other plans  of  treatment which have been sug-
gested.
   Considerable extravasation of blood is frequently met with in cases of simple
fracture, causing great swelling and tension of the limb.    By the continuous ap-
plication of cold evaporating lotions,  these collections  are usually readily  ab-
sorbed, and the surgeon should  never be tempted by any feeling of fluid or of
fluctuation to open them,  as he would thereby infallibly convert the simple into
a compound fracture, and give rise to extensive ill-conditioned suppuration.  In
some of these cases of extensive extravasation, the limb appears to relieve itself
of the serous portion of the blood effused, by the formation of large bullae or
 
         ACCIDENTS  AND  COMPLICATIONS  OF  FRACTURE.     193

blebs, which burst  or  subside, without any material inconvenience.   The ex-
travasation very rarely, indeed, runs into abscess;  if it do, it must of course be
opened, and treated upon ordinary principles.
   (Edema and gangrene of the limb, may occur  as the result of tight bandag-
ing, or else  by the swelling of the limb consequent upon extravasation or inflam-
matory infiltration causing  strangulation of it within  a bandage that has been
but lightly applied.   The occurrence of such accidents should make the surgeon
cautious in  applying a  bandage with any degree of tightness in the early stages
of fracture, or, in those cases in which there is already much swelling; and the
 apparatus should at once  be removed whenever the  patient complains, even of
 slight uneasiness.   An excellent plan of judging of the activity of the circula-
 tion in a fractured  limb after it has been put  up, is to  leave  the ends of the
 fingers or toes uncovered by the bandage, when by pressing upon  one of the nails,
 the freedom of the circulation may be ascertained, by noticing the rapidity with
 which the blood returns under it.
   In fractures occurring in old people, there is a great tendency to pulmonary
 and cerebral congestion, partly from  determination of the blood, and partly as a
 consequence of the long confinement required; these fractures commonly proving
 fatal in this way.   The use of the starch bandage, by enabling the patient to get
 about, is  the most effectual prevention to these accidents.
   Fractures may be complicated with various important local conditions.  Thus
 the extravasation of blood into the limb may arise from a wound of some large
 vessel, and this may go on to  so great an extent as to occasion  strangulation of
 the tissues; if not checked by position and cold applications, it may give rise to
 gangrene, and lead to amputation.   In other cases, again, the soft  parts in the
 vicinity of the fracture may be contused to such a degree that they rapidly run
 into slough, thus rendering  it compound; or a wound may exist,  not communi-
 cating with the broken bone, but requiring much modification of treatment, and
 special adaptation of apparatus.
   The most serious complication of simple fractures, consists in their implicating
 a joint.   The fracture may extend  into a neighboring  articulation,  and thus give
 rise to considerable inflammatory action, though in some cases no inconvenience
 results even though the capsule be  perforated by a sharp fragment; but in  stru-
 mous subjects it may lead to ultimate disorganization of the articulation, requir-
 ing excision, which I have several  times had  occasion to do  in these cases.
  The complication of dislocation  with fracture often occasions great difficulty
 to the surgeon, as it becomes necessary to reduce the  dislocated joint before the
 fracture is consolidated.  In several cases of  this description which have fallen
 under my care, I have succeeded in reducing the dislocation at once, by putting
 up the limb very tightly in wooden splints, so as to give  a  degree of solidity to
it, and  to permit the lever-like movement of the shaft of  the bone being em-
ployed ;  and then, putting the patient under chloroform, have replaced the bone
without much difficulty.  Should the surgeon have neglected to reduce the dis-
                                    13 
194
FRACTURES.
location in the first instance, it will be necessary for  him to wait until the frac-
ture has become firmly united, and then, putting up the limb in splints, or in
starch, to try to effect the reduction, which  however will then be attended by
very great difficulty.
  In cases of simple  fracture occurring in the  neighborhood  of,  or implicating
laro-e joints, passive motion is  very commonly recommended  atthe end of from
four or six weeks; I think, however,  with Mr. Vincent, that this is often apt to
do more  harm  than good,  and is seldom required,  the natural  action of the
muscles of the part being fully sufficient to restore the movements of the articu-
lation, which may be assisted by friction and douches.

                          COMPOUND FRACTURES.
  A compound  fracture  is that form of injury in which there is an open wound
leading down to the broken bone, at the seat of fracture.  These injuries are not
only far more tedious in  their cure than simple fractures, but infinitely more dan-
o-erous.   The tediousness depends upon the communication of the fracture with
the external air, causing it to unite by a slow process of granulation, instead of
by the more speedy adhesive action that occurs in the simple form  of injury.
The danger  is likewise partly due to the same cause, the process  of granulation
and suppuration being often attended by such  profuse  discharge of  pus,  from
abscesses  or long-continued exfoliation of bone;  or by the supervention of secon-
dary disease, such as hectic, phlebitis, pneumonia, or  erysipelas; as to lead to the
eventual loss of limb or life.  Besides these dangers,  which may be looked upon
as  of a  remote kind, the  violence that  occasions a compound  fracture  often
shatters the limb to such an extent, as to lead to the  immediate supervention of
traumatic gangrene, to the loss of life by hemorrhage, or to the certain and speedy
disorganization of the limb, as the consequence of the reactionary inflammation,
  As there are, therefore,  not only prospective dangers of great magnitude to be
encountered in these injuries, but also immediate risk of a very serious character
to be met, the first question that always presents itself in a case of  compound
fracture is, whether the limb should be removed, or an attempt be made to save
it.   It is  of great importance to  settle this point at once, for, if  amputation be
determined upon,  it should be had recourse to  with as  little delay as possible,
there being  no period in  the progress of the case so favorable for the performance
of this operation as the first four-and-twenty hours.   Should  an  injudicious at-
tempt have  been made at saving  the limb, the surgeon must wait until suppura-
tive action has been set up before he can remove it; and then, he  will very com-
monly find that  the occurrence of some of the diffuse inflammatory affections of
an erysipeloid character will render any operation impracticable; or the superven-
tion of traumatic gangrene may compel him to have recourse to amputation under
the most  unfavorable  circumstances.  At a late period in the progress of the
case, amputation may be required in order to rid the patient of  a necrosed and
suppurating limb that is exhausting him by the induction of hectic.
  Though advocating the  early performance of  amputation in those cases which
imperatively require it,  I  am  aware  that these operations are very  commonly
fatal, especially when practised near the trunk; but yet, this  cannot with justice
be  urged as an argument against their  performance, as immediate amputation
should never be had recourse to except in the  most  severe cases, in which it is
evident that the patient's life must in all probability be sacrificed, by the unsuc-
cessful  attempt to save  the limb.  In determining the cases in which imme-
diate amputation should be performed, no very  definite rules can  be  laid  down,
and much must at last be left to the individual  judgment and experience of the
surgeon.  One  will attempt to save  a limb which another condemns.  But, in
coming to a conclusion upon  this important question, he must  bear in  mind,
that though it is imperative to do everything in his power to save a limb,  yet 
AMPUTATION  IN  COMPOUND  FRACTURES.          195
that the preservation of the patient's life is the main point, and that that course
is the proper one which offers the greatest prospect of effecting this. In coming
to a conclusion on a question of such vital moment as this, he must be guided,
not only by the nature and extent of the fracture, but by the age,  constitution,
and habits of the patient (pp. 119, 125).
  Those fractures must be looked upon as most unfavorable in which the wound
is the consequence of the violence that breaks the bone, and  in which there is
much laceration of, and extravasation into, the soft parts; more particularly if
the integuments are stripped off, portions of the muscular bellies protruding, and
the planes of cellular tissue between the  great muscles of the limb torn up and
infiltrated  with blood.   Injuries of this description occurring in  the lower ex-
tremity always require amputation.  In  the  arm, they are  not  so  serious, and
admit of the member being saved, unless the bones be greatly comminuted.
  The complication of a compound fracture  with the wound of a large  joint,
more especially if there be crushing or splintering of the bones  that enter into
its formation, when occurring in the lower extremity, is always a case for ampu-
tation. When  the elbow and shoulder joints are extensively crushed and injured,
amputation of the arm  must be  practised; but if the injury be localized, and
the soft parts be in a favorable state, resection of the articulation may be success-
fully practised.  These operations are  usually somewhat irregular  proceedings,
being conducted according to the extent of the wound, and consisting rather
in picking out  the shattered fragments of bone than in methodical excision.
  When one of the larger arteries of the limb has been wounded by the violence
that occasions the fracture, or has been lacerated by the broken bone, there may
be copious arterial hemorrhage  externally,  as  well  as  extravasation into the
general cellular tissue of the limb.  These cases most commonly require imme-
diate amputation.   But whilst the patient is  being examined, and  preparations
made for the operation, care must be taken that a dangerous quantity of blood
be not lost.  This must be prevented by the elevated position and  the  applica-
tion  of  a  tourniquet.   For  want of this simple precaution  I have seen  very
large and even fatal quantities of blood  gradually lost, by being allowed slowly
to trickle from the wound.
  In these cases it has been proposed, by some surgeons of great eminence, to
enlarge the wound in the limb, or to make an incision down to the fracture, and
to attempt to tie the artery where it has been injured.   In most cases, however,
this is scarcely practicable, as the surgeon would have to grope in the midst of
bleeding and infiltrated tissues, and would experience the greatest  possible diffi-
culty  in finding  the wounded  vessel  after  a search which would materially
tend to  increase the  disorganization of  a limb.   Even  after the  removal of a
limb in this condition it is by no means easy to find the artery that has poured
out blood;  how much more difficult must it not be then to search for it success-
fully during life.
  The ligature of the artery at a higher point of the limb does not  hold out
much prospect of success, for the same  reasons that render its  employment
inadmissible in ordinary wounds of  arteries.   If, then, proper means directed
to the wound, such as position, pressure, or perhaps the  attempt at ligature if
the artery be easily reached,  are not successful, no course is  left to the surgeon
but to amputate the limb without delay.  This  is more especially the case if
it be the lower extremity that is injured.  In the arm there is a better prospect
of our being able  to arrest the bleeding without having recourse to this extreme
measure.
  If, however, the compound fracture be unattended  by any of the complica-
tions that have just been mentioned, occurring in a young and otherwise healthy
subject,  we must,  of course, attempt to save  the limb, and shall generally
succeed in doing so. 
196
FRACTURES.
   In the  management of a  compound fracture,  special  apparatus,  such  as
 M'Intyre's, Listen's, or the bracket-splints, double inclined planes, swing boxes
 and fracture beds, are often necessary, in order to obtain access to the wound, so
 as to dress it properly, and to  place the limb in the best position for union.
   The reduction of compound fractures must be accomplished with the same
 attention to gentleness as  in  that of  simple ones.  In  the majority of cases no
 great difficulty is experienced  in effecting this, and after  it has  been done, the
 limb should  be placed on a well-padded splint, properly protected in the neigh-
 borhood of the  wound with oiled silk, so as  to  prevent  soiling of the pads by
 blood  and discharge.  In some cases, however, considerable difficulty arises in
 the reduction, from the protrusion of one of  the broken fragments which has
 been driven  through the skin, either by careless  handling of the limb in carry-
 ing  the  patient, or else by the muscular contractions dragging the  lower frag.
 ment forcibly upwards, and thus  causing perforation of the integument.   The
 protruded bone must, if possible,  be gently replaced, by relaxing the muscles of
 the limb, and thus bringing the soft parts  over it.  In some cases, however, it is
 so tightly embraced by the skin, which appears to be doubled in underneath it,
 that enlargement of the wound becomes necessary before  it can be replaced. In
 other cases again it will be found that reduction cannot  be effected or maintained
 unless the  sharp and projecting point  of bone be sawn off.  This must be done
 carefully by  protecting the neighboring soft parts with a  split card.  The limb,
 as I have found in several cases in which it has been necessary to have recourse
 to this procedure,  is not ultimately weakened by it.
  After  the reduction,  the great object is, if possible, to convert the compound
 into a simple fracture by the closure of  the  external  wound.  If this  can be
 accomplished, the  tediousness  and danger of the case are greatly lessened, the
 whole process of  suppuration, with all its attendant evils, being saved to the
 patient.  If  the wound be small, clean cut, and occasioned  by the protrusion of
 the fragment rather than by the direct violence which occasions the fracture, we
 may hope to  succeed in our object by  following Sir A. Cooper's recommendation
 of applying to it a piece of lint soaked in its blood;  or, what is better, saturated
 with collodion, and thus obtaining union  by adhesion.   If the wound be large,
 if a joint have been opened, if it  have been inflicted by  the same violence that
 breaks the bone, or if there  be much bruising of the edges and surrounding
 tissues, with  extravasation into the limb, this direct union cannot be expected to
 take place.   Under these  circumstances it is, I  think,  best to  apply from the
 very first water-dressing, so as to allow a vent for the discharges that take place
 after the first four-and-twenty hours.
  After  the  position of the  limb has been thus attended to, an endeavor must
 be made to moderate the local inflammatory action, and to lessen constitutional
 irritation.  The local action may be moderated by the use of irrigation (Fig. 3),
 and  by the application of  cold evaporating lotions to the  part, which should be
 elevated  and but  lightly covered, the  bed-clothes being well raised by means of
 a cradle, so as not  to press on  the  limb and to allow space for the evaporation of
 the cold lotion; care being taken,  at the same time, that the bandages be applied
 very loosely,  merely with a sufficient degree of force  to  retain the limb upon the
 splint, as inflammatory infiltration  that might rapidly induce strangulation of the
 part is apt  to ensue.  The constitutional irritation must  be subdued by the admi-
 nistration of opiates, together  with an aperient, on  the morning following the
 accident, which  must  be  repeated from time  to time during the first few days.
 Moderate antiphlogistic regimen must be had recourse to, and  the patient be
 disturbed as little as possible.   In many cases suppuration rapidly sets in, and if
the patient be addicted  to  drinking, the constitutional disturbance  soon  assumes
the irritative form; under these circumstances, it is of great moment that sup-
port, and even stimulants,  be freely given ; they must be  allowed from the very 
TREATMENT OF  COMPOUND  FRACTURES.           197
first, and increased in proportion to the depression of the patient's strength, or as
symptoms of nervous irritation come on.
  If there  be much extravasation of blood into and bruising of the soft parts,
great tension of the limb, followed.by unhealthy suppuration and sloughing, will
take  place in the neighborhood of the wound;  free incisions are then required
to remove the tension  and strangulation of the tissues, and by letting  out  the
broken-down blood and pus to lessen the risk of the occurrence of gangrene.   So
soon as suppuration is fairly established, a light poultice, or thick water-dressing,
should be  applied, and the burrowing of matter prevented by making counter-
openings where necessary, by the application of a compress,  and by attention to
the position of the  limb.   The fracture apparatus  must be kept scrupulously
clean, especially in  summer; the bandages changed as often as soiled, and  the
pads well protected with  oiled silk.   During  this period various  complications,
such as erysipelas,  inflammation  of the absorbents and veins, and low forms of
pneumonia, are apt to  occur, requiring special consideration  and  treatment; so
also, if the discharge be abundant, hectic,  with its sweats and  gastro-intestinal
irritation, may come on, requiring full support of the powers of the system, and
the administration of the mineral acids and other remedies, according to circum-
stances.  As the confinement to bed is necessarily very prolonged  in these cases,
often extending through many weeks and months, the  state of the patient's back
should be attended  to,  and he  should early be placed upon  a water-cushion, or
hydrostatic bed, lest sores supervene.  As the wound gradually heals, water-
dressing must be substituted for poultices, so as not  to sodden the parts, and
encourage suppuration, and in time the red or blue wash for the water-dressing.
The bone will often be observed  lying white  and bare, bathed in  pus, at  the
bottom of the wound.  But, though in this apparently unfavorable condition, it
may recover itself; lymph gradually being deposited in points on its surface by
the action of its own vessels, and this becoming vascularized, covering  it with a
layer of florid granulations.   In other cases, necrosis to a greater or less extent
will take place, and perfect consolidation does not occur until the bone has sepa-
rated.   In some instances, a large quantity of provisional callus is thrown out,
in which the necrosed bone is  implicated, and then  the process of separation
becomes extremely tedious and protracted, and amputation may not uncommonly
become necessary,  from the powers of the  patient being unable to bear up in so
prolonged a struggle.   So soon as some consolidation has taken place,  the  limb
should be firmly put up in gutta-percha or  leather splints, with a starch bandage,
so as to enable the  patient to be got out of bed,  to change  the air of his room',
and  thus  to  keep up  his  general  health.  In fitting these splints, care must
be taken to  make  an  aperture opposite the  wound,  through which it may be
 dressed (Fig. 66).
   The time required for the proper consolidation of a compound fracture varies
greatly according to the amount of injury done to the bones and soft parts, the
age  and constitution of the patient.  Under  the  most favorable  circumstances,
it requires double or treble the time that is necessary for the union of a simple
fracture.  Much stiffness of the  limb from rigidity of the  muscles and tendons
will continue for a  considerable  length of  time;  this  may gradually be  removed
by frictions and douches.
   Secondary amputation may become  necessary from  the  occurrence of  trau-
matic gangrene, when  it must be done in accordance with the principles already
laid  down when speaking of that  operation;  but more frequently it is  required
from failure of the powers of the patient in consequence of irritative and asthenic
fever, induced by the general disorganization of the limb, or by hectic resulting
from profuse suppuration and slow necrosis of the bones.  Under  these circum-
stances, the constitution suffers from the  local irritation which  is the source of
the wasting discharge, but by removing this  in  time, and seizing an interval in 
198
FRACTURES.
which constitutional action may have been somewhat lessened, the patient's life
will in^all probability be preserved; the results of secondary amputation for com-
pound fracture under these conditions being by no means unfavorable.  Indeed,
it is remarkable to see how speedily the constitutional irritative hectic symptoms
subside after the removal of the source of irritation, the patient often sleeping
well, and taking his food with appetite the day after the operation.
  The proper period to seize for the performance of secondary amputation in the
earlier stages of the injury  is often a most critical point.   As a general rule,
it may be stated, that  if the limb be not removed  during the first twenty-four
hours,  eight or ten  days must be allowed  to elapse before the operation is done;
as during that time constitutional irritation  and suppurative fever are  of too
general and  active  a character  to render fresh shock to the  system admissible.
But when once the actions appear to tend to localize themselves, the suppuration
becoming more abundant, the  redness  extending but slowly, and the constitu-
tional symptoms merging into an asthenic form, then the  limb may be removed
with the best prospect of success; the more the action is localized  the better
being the chance of the operation succeeding.
  In  many cases the symptomatic and suppurative fever so rapidly merge into
the asthenic form,  that the surgeon must seize the  best moment he can for the
performance  of the amputation.  Under these circumstances  the  operation is
seldom very successful, the stump becomes sloughy, erysipelas or diffuse inflamma-
tion of the cellular tissues comes on, or symptoms of pyemia set in, and the patient
speedily dies.   In other cases again, there is a  marked interval between the stages
of the inflammatory and suppurative  fever, and the  supervention of the typhoid
symptoms, lasting for twelve or twenty-four hours, or even longer.  During this
the mischief may be looked upon as in a great measure of a local character; the
constitution has been disturbed by the setting up of the inflammatory action, but
this  having terminated in suppuration, it has not  as yet become  seriously de-
pressed by the continued irritation of the discharge from the injured limb, or
poisoned by the absorption of morbid matters  from it.
  The  patient's  powers  must not, however, be allowed to sink to the last ebb
before amputation  is performed, as then, if the shock do not destroy life, inter-
current and visceral congestion, or some low form  of inflammatory mischief, will
not improbably prove fatal.   Much as "conservative" surgery is to be admired
and cultivated, and hasty or unnecessary operations to be deprecated, I cannot
but think that the  life of the patient is occasionally jeopardized, and even lost,
by disinclination on the part of the surgeon to operate sufficiently early in cases
of compound  fracture, and by too  prolonged  attempts at  saving the injured
limb.
  The success of the  operation will in a great measure depend upon the after-
treatment  of the case.  Large quantities of stimulants and support are often
required in London practice  to prevent the patient  from sinking.   I have often
given with  the best success  eight or ten  ounces of  brandy, twelve or sixteen of
port wine,  with two or three  pints of  porter in  the  twenty-four hours after
these  operations, with beef-tea, arrow-root (or meat, if the patient will take it)
and have found it absolutely necessary to do so lest  the  patient  die exhausted.
   At a later period than this, when some weeks or months have  elapsed, and the
fracture has not united, the  bones necrosing, and the patient being worn out by
hectic, amputation  must be  performed* at any convenient moment, and is often
then done with great success if it be not  deferred too late; for here the mischief
is entirely local, and the constitution suffering only by the debility resulting from
it, quickly rallies when the cause of this  is removed.
   A  fracture is  occasionally so badly set that it  becomes necessary to break or
bend the callus, in order to improve  the condition of the limb.  When the dis-
placement is angular, and the consolidation not very  firm, this may be done 
UNUNITED  FRACTURES.
199
pretty readily, but if the  displacement be longitudinal, and much  time has
elapsed  since the occurrence  of the injury, it will  be impossible to remedy
the deformity.   During the first four  weeks the bond of union between the
fragments is  so yielding that the angular  displacement may be remedied  by
putting up the fracture  afresh day by day, by the employment of pressure, and
by the application of the roller in the opposite direction  to that in which it had
been previously applied.  After  this period, the deformity can only be  remedied
by forcibly bending or breaking the callus, and then putting up the fracture
again, when speedy and perfect consolidation will ensue.   In this way I  have
several times  remedied  fractures that  had got  into a faulty position,  although
five or six weeks had elapsed from the occurrence of the  injury.
   [In many cases of angular displacement where perfect consolidation has  occurred,
the resection originally proposed  for anchylosis by Dr. J. Rhea Barton of this city
can be performed.   This process consists in the removal  of a  triangular osseous
wedge  from the deformed  bone;  the base of the wedge corresponding to the
convex portion of the displacement; its apex should not, however, extend  com-
pletely through the shaft, but should terminate in it one-fourth or one-sixth of
an inch from the  corresponding side.   The bridge uniting the upper and lower
portions of the shaft should now be fractured by the application of force in such
direction as will avoid injury to  any adjacent vessel or nerve.   The limb should
then be carried into its natural position: the external wound closed, and the case
treated as one of compound fracture.   This operation has been several times re-
peated by Professors  Mutter and Pancoast, and always with the most gratifying
result.—Ed.]
               UNUNITED FRACTURES AND FALSE JOINTS.
   Some bones when  broken never unite by callus or plastic matter, their  frag-
ments merely being kept firm by the intervention of the aponeurotic structure,
of the part, as is the  case with  the patella.  This, which is owing to a want of
apposition of the  fragments, and is dependent on the  condition of the  part, can-
not be considered a diseased action.
   It happens, however,  occasionally in fractures of the  shafts, or the  articular
ends of long bones, that proper union has not taken place at the usual time, or
does not take place at all.   This  may be owing to one of three circumstances :
1st.   That no uniting material of a stronger kind than fibro-cellular tissue has
been formed.  2dly.   That  the plastic matter that has been  thrown out has only
developed into fibrous  tissue,  not  having undergone osseous transformation;
or 3dly. That true bony union has taken  place,  but, owing to some peculiar
state of the patient's health, the callus has  become  absorbed, and the fracture
loosened.
   In the  first and third conditions we  have an ununited fracture;  the ends of
the bone which are rounded being merely connected by, and enveloped  in a loose
fibro-cellular tissue.
   In the  second  condition we have a  false joint, the ends of the  bone  being
tied together by strong  fibrous bands.   The structure of these  false joints, which
has been carefully studied by Rokitansky, presents two distinct varieties. In the
first, which partakes of  the character of a hinge joint, and which occurs princi-
pally in the shafts of the long bones, we find that the ends of the fracture  are
smoothed and rounded, invested with a dense fibrous periosteum, and  united to
one another by thick bands of  ligamentous tissue, in such a way as  usually to
admit  of  considerable lateral  movement, though  sometimes they are  tolerably
firm.
   In the other variety the joint  partakes of the ball-and-socket character, usually
to a very imperfect degree,  but sometimes in a sufficiently well-developed manner,
one end of the bone  being  rounded  and invested by periosteum,  the other, cup- 
200
FRACTURES.
shaped, and covered by firm, smooth, fibroid tissue.  The bones are united by a
kind of capsule, in which a synovia-like fluid has occasionally been found.   This
kind of false joint is chiefly met with in  fractures occurring about the articular
ends of bones.
  The causes of ununited fracture and false joints are constitutional and local.
  The principal constitutional cause appears to be a cachectic state of the system,
occurring from some debilitating disease, such as phthisis, scurvy, or cancer, or
from any depressing cause, in consequence of which there is not sufficient repa-
rative power for the production or proper development of the plastic matter, by
which the  fracture  should be united.   If it have been  deposited, it may, under
the influence of these constitutional causes, again become absorbed, and the frac-
ture thus loosened.  In spontaneous fractures union seldom takes place very readily
or perfectly.
  Pregnancy is said to have a tendency to interfere with the proper union of a
fracture; this,  however, I consider doubtful, as I have had under my care, and
have seen a considerable number of cases of fracture in  pregnant women, which
united in the ordinary manner.
  Age  does not appear to  exercise any influence on the occurrence of disunion
in fractures, which is indeed most common in the early and middle  periods of
life, when fractures are most frequently met with.  I have on two occasions, in
my own practice known very firm and  perfect consolidation of fracture of the
shaft of the femur take place in women of ninety years of age and upwards.
  The  local  causes  are various and  important.    The  anatomical condition of
the fragments as regards their vascular supply, is perhaps that on which want of
union  is most  immediately dependent.   For proper union to take place  it is
necessary that the callus be deposited from both sides of the fracture.   If one
fragment is so  situated that sufficient blood is not sent to it for this purpose, dis-
union may occur.   The influence of  the rupture of the nutritious artery of the
bone by the line  of fracture running  across it, and thus interfering with the
vascular supply of one of the fragments, has been investigated by Gueretin, and
the occasional  occurrence of  atrophy  of the bone after fracture has been shown
by Curling to be dependent upon the supply of arterial blood through this vessel
being interrupted.  Gueretin has collected cases that tend to prove the  direct con-
nexion between the occurrence of ununited fracture and the want of proper arterial
supply to one of the fragments.  Thus in the humerus, the course of the nutritious
artery is from above downwards, and  of thirteen cases of ununited fracture, nine
were found to be situated above the canal in which this  vessel is lodged.  In the
forearm where  the nutritious artery passes from below upwards, of eight cases of
ununited fracture seven occurred below this vessel,  and only one above.  Mr.
Adams has, however, shown that the  number and size as  well as the  position of
the nutritious  arteries varies considerably, and  hence  the objection that non-
union  may occur in a, fracture of any part of the shaft of a long bone,  whereas
the nutritious artery is only found at  one spot, can scarcely be considered a very
valid one.  It is certainly owing in a great measure to this want  of vascular
supply that  intracapsular  fractures  almost invariably  unite by fibrous tissue
rather than by bone, and that when bony union takes place the callus is chiefly
formed  by the surface  connected with  the  shaft.   In  some  cases of intra-
scapular fracture of the humerus no union whatever takes place, the detached
fragment necrosing in consequence of its being entirely deprived of all supply
of blood.
   Some bones are much more  liable  than others to disunion of their fractures.
According to the statistics collected by Norris, it would appear that the femur,
the humerus, the bones of the  leg, and of the forearm, and lastly the lower jaw,
are those  in which ununited fractures  most frequently occur, and that in the
order which has been given. 
UNUNITED  FRACTURES.
201
  The occurrence of ununited fracture is occasionally attributed to the mobility
or want of proper apposition  of the fragments, and  doubtless in some cases it
may be so occasioned: but I believe that these causes are not nearly so frequent
in their operation as the  constitutional and local conditions that  have already
been pointed out.  The interposition of a piece of muscle between the fragments
may occasion  disunion.  Of this I saw an interesting instance some  years  ago
at the Westminster Hospital,  in which want of union in a fractured femur  was
owing to the entanglement of a portion of the rectus muscle between the frag-
ments.
  The treatment of ununited  fracture must chiefly be conducted with reference
to the  constitutional cause of  disunion,  though local  measures  must not be
neglected.  If callus have not been formed, or after formation, have been  ab-
sorbed under the influence of a cachectic  state of the system, the improvement
of the patient's health, at the same time that the fracture is put up again firmly,
so that the ends of the bone  are  brought in close apposition, may bring  about
perfect union.  I have  lately had under  my care  at the  hospital, a  man with
ununited fracture of the femur from absorption of the callus four months after
the occurrence of the injury,  under the influence of incipient phthisis  and  de-
bility induced by want of food, in whom  perfect consolidation  of the  fracture
has taken place  by giving him cod-liver oil and good  diet, with rest in bed,  and
a starch bandage to the limb.  If there is no very evident  cause for  the  dis-
union, putting up the fracture firmly in leather  or gutta-percha splints, with a
starch bandage, and then allowing the patient to move about upon crutches, so
that his general health may not  suffer, at the same  time that a tonic plan of
treatment is had recourse to, will occasionally suffice.  In  some cases  the  em-
pirical administration of mercury is attended  with  success.  In a case of un-
united fracture  of the humerus  that was  admitted into the  hospital  under  Mr.
Liston, fifteen weeks after the occurrence  of the injury, union took place within
a month by putting tip the limb in splints, and  salivating the  patient.  When
the disunion arises from malignant disease nothing can be done.
  When the disunion has become very chronic, and a, false joint has once formed,
it will be necessary to have recourse to operative procedure before union can be
attained.   All operations that are undertaken in these cases are conducted on
one of two  principles:  either with the view of exciting  such inflammation in
the false joint and the neighboring tissues as will lead to the formation of lymph
capable of  undergoing osseous transformation;  or  else, by removing the false
joint altogether, to convert the case into a  recent compound fracture, and to treat
it in the  same way that  such  an accident  would be managed.  It can easily be
understood  that  operative procedures  conducted on  these principles  are of too
serious a character to be lightly undertaken, or to be had recourse to until other
measures have failed.   The mortality following  them being, even according to
published statistics, considerable, and probably very much greater than has been
laid before  the profession.
  Amongst the first set of operations—those that have in  view the excitation of
sufficient inflammation to cause deposit of proper plastic matter—the  simplest
procedure consists in the introduction of acupuncture needles, or in the subcu-
taneous section of the ligamentous band with a  tenotome.   In this way I have
known union  effected in a patient  of Mr.  Liston's, who had a false joint in the
shaft of the femur, though not until after the fracture had been converted into a
compound one, and much danger and suffering incurred.  Four years after the
consolidation of the ununited fracture, the patient was readmitted into  the  hos-
pital, under my care, with fracture  of the same bone two  inches lower down
than the  former injury, and on this occasion union took place in the usual manner
and time without any difficulty.
  The introduction of a seton across the false joint, though occasionally success- 
202
SPECIAL  FRACTURES.
ful, is apt to  give  rise to dangerous and even fatal consequences, from arterial
hemorrhage, erysipelas, diffuse  inflammation and suppuration of the limb.  The
threads must not be left beyond a few days, when sufficient action will have been
induced.   A modification of the seton consists in passing a silver wire around
the fracture,  and by gradually  tightening this, to cut through the false joint at
the same  time that inflammatory action is  excited in it.   In performing this
operation, it must  be  borne in mind that large arterial  branches, and  even  the
main trunk, especially in the thigh, may become firmly attached to the  callus,
so that unless care be taken, they may readily be wounded.
   Dieffenbach has excited the requisite degree of inflammation by driving three
or four ivory pegs into holes bored by means of a  gimlet in  the ends  of  the
fractured  bone, which are exposed for this purpose.   The soft parts  are then
laid down over  them, and after a few weeks the pegs, which have loosened in
consequence  of  the removal or absorption of their ends, should be taken out.
This plan of treatment is favorably  spoken of by those who have employed it on
the Continent, and has succeeded in the hands of Mr. Stanley and Mr. Teale,
in this country; the irritation of the pegs appearing to occasion the effusion of
a large quantity of callus, sufficient for the consolidation of the fracture.
   The operation of removing the false joint may be performed by cutting down
upon it, and  resecting the ends of the bones, or else by destroyiug the articula-
tion with  caustic potass.  The  excision of a false joint is necessarily a dangerous
operation, and by  no  means a successful one, erysipelas, phelebitis, and  diffuse
suppuration of the bone occasionally supervening.   Of 38 cases  collected by
Norris, in which the ends of the bones were either resected or scraped, 24 were
cured ; 7  derived no benefit, and six died.   In those cases that are successful by
this method,  some shortening of the limb must be expected to result, and if the
fracture  be very oblique, it would  of course be impossible to remove more than
a very limited portion of it, and, consequently, very perfect union could scarcely
be anticipated.   The  application  of caustics to the exposed bones is so coarse
and uncertain a  method, as to find but little favor amongst surgeons of the present
day.
   On reviewing the various methods that have been recommended for the re-
establishment of union between the separated fragments, it would appear that
the excitation of proper inflammatory action, by the  introduction of the seton,
or  by driving in ivory pegs, promises the most satisfactory result.  It is by no
means necessary to remove the fibrous band  that intervenes between the frag-
ments in  cases of false joint, for if the proper amount of inflammatory action be
set up, this either  undergoes osseous transformation, or a sufficient quantity of
callus is thrown out around it to consolidate the fracture.
  i

                           CHAPTER  XV.

                         SPECIAL FRACTURES.

  In considering the nature and treatment of fractures of particular bones, we
shall at present confine  our remarks to fractures  of the  face  and  extremities.
Injuries of the bones of the head, spine, and chest, derive their  principal interest
and importance from  their  complication with lesion of some internal and con-
tained  organ; hence the consideration of these can with more propriety be refer-
red to  that of these parts.
  Fractures of  the  Bones of the Face.—The nasal bones, being thin as 
            fractures of the bones  of the  face.         203

well as exposed, are not unfrequently broken.  When fractured they may remain
undisplaced, but are  more commonly depressed;  the  ridge of the  nose being
beaten  in.   The swelling and ecchymosis that usually  attend  this  fracture
render its detection difficult, and must  be reduced before any treatment is adopted.
The bone that is depressed should be  raised with the broad end of a director, or
by the introduction of a pair of polypus forceps into the nostril, which expand
in opening, and push it into proper position.
   If the  septum alone be broken,  the same treatment  must be adopted towards
it.  Usually, after being replaced, the position is maintained; but in some cases,
where there  is a  tendency to sinking of the nostrils, the introduction of a plug
into the nares will be required to replace and retain the bones.   The hemorrhage,
which is usually pretty abundant, may be stopped by the application of cold, but
occasionally the nostrils require plugging.  If the lachrymal  bone be broken,
together with the  nasal, the ductus ad nasum may be obstructed, and the course
of the tears diverted.   In an injury of this kind I have seen pretty extensive
emphysema of the eyelids and forehead occur on the patient attempting to blow
his nose.   In some  cases the  injury inflicted to the nasal bones extends through
the ethmoid  to the base of the brain,  and may thus occasion death.  This I have
seen occur from a severe blow on the  face with a piece of wood.
   [Fractures of  the hyoid bone  are of exceedingly rare occurrence, and when
met  with are  generally  the  result either of  a forcible grasp, or other direct
violence.   One case, however, the result of muscular action, has been reported by
Ollivier d'Angers.  The symptoms of this fracture are easy of recognition.  The
bone is generally heard to snap at  the time of the reception of the injury, rapid
swelling ensues, threatening suffocation, great pain is present,  which is increased
by all attempts at deglutition  or speaking, and crepitation may in some cases be
detected.  The treatment consists in coaptation of the fragments, when displace-
ment exists, and  this  may be best effected by the introduction  of the index
finger of  one hand, behind the root  of the tongue, and pressing the posterior
fragment outwards and forwards, while at the same time the  anterior fragment
may be acted upon by the other hand.   Should these  attempts fail, and suffoca-
tion be apprehended, it may become  necessary to introduce the point of a tena-
culum subcutaneously, and replace  the fragment.  The head should  then be
kept in a flexed position, so as to favor union, which generally takes place by bony
deposit.  The same  symptoms also characterize fracture of the larynx, of which,
however, only one or two cases have been reported.—Ed.]
   The malar  and  superior  maxillary bones  are seldom broken unless  great
and direct violence has been had  recourse to, and  their fracture  is  usually ac-
companied by external wound, as in gun-shot injuries of these parts.   More
commonly the alveolar processes are detached, and the teeth loosened.  The treat-
ment then consists of binding the teeth together with gold wire.  In some rare
cases all the bones of the face appear to have been  smashed and separated from
the skull  by the infliction of great violence.  Thus, South relates the case of a man
who was  struck on the face with the handle of a crane, and in whom all the bones
were separated and  loosened, " feeling like beans in a  bag."   Vidal de Cassis
also  records the  case of a man who, by a fall  from a great height, separated all
his facial bones.
   [In fractures of the body of the malar bone,  the replacement of the fragments
and the application of a compress, held in situ by Barton's bandage for the lower
jaw, will  generally answer every indication ; but it sometimes  happens  in frac-
tures of the zygomatic arch, that  spicula of bone are  driven  into, and between
the fibres of the temporal muscle,  and produce great pain in mastication.   Hence
it becomes necessary in these cases to  cut down  and remove the  fragments.—Ed.]
   The lower jaw  is  frequently broken, owing to its prominent situation; though
its arched shape enables  it to resist all but extreme degrees of violence.   Frac- 
204
SPECIAL  fractures.
tures of this bone  are usually compound, the laceration of the gum causing them
to communicate with the external air.  And not unfrequently they are comminuted
as well, but yet from the freedom of  the  vascular supply to  the bone rapid and
very perfect union takes place in  it.
  Fracture of the lower jaw may occur in various situations.   I have  seen it
most frequently in the body of the bone, near the symphysis, extending between
the lateral  incisors; or these teeth and the  canine.  The symphysis itself is not
so commonly fractured, the  bone being thick in this  situation.   The angle is
frequently broken, but the  neck and coracoid  process rarely  give way.  The
signs of fracture of the lower jaw are very obvious.   The great mobility of the
fragments,  the crepitus, the irregularity of the line of teeth, and of the  arch of
the jaw, laceration of and bleeding from the gums, and dribbling of saliva, indi-
cate unequivocally the nature of the injury.  The displacement and mobility of
the fracture  are greater the nearer it is to the symphysis.  If the bone  happen
to be broken on both sides of this line, the  middle fragment is much dragged
out of  place by the depresser muscles of the lower jaw.  In fracture about the
angle and ramus, the  deformity is not so great, owing  to  the muscles that coat
and protect either side of the bone in this situation  preventing the fragments
being displaced.
  The treatment is simple  enough in  principle, though often not very easy of
accomplishment.   It consists in  maintaining the parts in apposition by suitable
apparatus for four or  five weeks,  during which time mastication must be inter-
dicted, the patient living on sop, soups, and fluid nourishment of all kinds, and
talking prohibited.  The apparatus that commonly suffices consists  of a gutta-
percha splint, moulded to the part, properly padded, and  fixed on with  a  four-
tailed bandage;  the two fore-ends of which are tied behind the neck, whilst the
two others are knotted over the top of the head.  Any teeth that are loosened
must be left in, as they will probably  contract  adhesions,  and fix  themselves
firmly; and, if necessary, the sound teeth may be fixed together with gold wire,
or dentist's silk.   When depression, especially near the symphysis, is considerable,
an apparatus which fixes the chin and the line of teeth  has been invented by Mr.
Lonsdale for  the purpose of steadying the  fragments, and answers the purpose
extremely well.
  [The treatment adopted in this country,  in those cases of fracture  of the lower
maxillary bone, which are attended  with  but little displacement, consists in the
application only of retaining compresses and of Barton's  bandage for the lower
jaw.   In  oblique fractures accompanied with separation of  the  fragments, the
use of  the  pasteboard  cup  and the same bandage will generally suffice; the re-
tention of  the fragments in coaptation may also be materially assisted by the
adjustment over the teeth and gums of the silver clamp proposed by  Dr.  Mutter.
In  fractures of the perpendicular  ramus, the sides of the cup  splint should be
lengthened, so as to extend  up to the zygoma.—Ed.]
  In fractures of the body  of the lower jaw by. gun-shot injury,  there is great
comminution and splintering of the bone, followed by copious and fetid discharge,
which  being  in part swallowed, may  reduce the patient  to  a state  of extreme
debility.   In these cases, Dupuytren recommends the lower lip to be cut through,
the splinters  taken away, and, if necessary, a  portion of the bone  resected, so
as to convert the wound into one  similar to what results after the partial  removal
of the  lower jaw for disease  of the bone.
  The Clavicle is often broken, partly owing to its exposure to direct violence,
and partly to its action in preserving the shoulder at a proper distance from the
trunk, and being  the only direct osseous support of the upper extremity, receiving,
by  transmission through the scapula, every shock that is communicated to the
hand when the arm is in an extended position,  hence blows on the shoulder and
falls on the hand are common causes of fractured clavicle.   This bone would be 
FRACTURES  OF  THE  CLAVICLE.
205
 more frequently broken than it is were it not that it resembles two segments of a
 circle looking in opposite directions, so as to form an S shape, which  admirably
 enables it to withstand indirect violence.   Most frequently the great  convexity
 is broken, the  bone bending  here  when  pressed upon from its extremity, the
 curve becoming increased, and at last giving way; in other cases it is fractured
 nearer the acromion, under the acromio-clavicular and coraco-clavicular ligaments;
 and, lastly, its tip may be broken off external to the outermost point of insertion
 of the trapezoid ligaments, between it and the acromion.  The signs will depend
 upon the seat of fracture.   When the  bone is broken between the conoid and
 trapezoid ligaments, there is  little, if any,  displacement, but pain on pressure,
 some  crepitus on moving the shoulders, and slight irregularity in running the
 finger along the bone.   When the fracture is  external to the trapezoid ligament,
 there is a remarkably oblique displacement  of  the
 scapular fragment, the  articular  surface of which is
 turned forwards and inwards, with a slight inclination
 downwards,  nearly at right angles  to the rest of the
 bone, apparently by the dragging of  the  weight of
 the shoulder, the point of which with the scapula is
 rounded  forwards  (Fig. 68).   When  the  fracture
 occurs about the middle of the bone, or at  any part
 on the sternal side of the scapular ligaments, there
 is a remarkable degree of  deformity, owing to  the
 displacement of the  outer  fragment in a  direction   a. Fractured.
 inwards and downwards.  This displacement is owing   h- Heaitby clavicle.
 to two causes,  the  weight of the arm dragging the  fragment down, and  the
 action of the  muscles that  pass from  the  trunk to the  shoulder  drawing  the
 scapula and  the whole of the upper extremity, forwards and inwards towards the
 mesial line,  when the support of  the clavicle is removed.   The outer  extremity
 of the inner fragment appears to be elevated,  the skin being drawn tensely over
 it; but this is  rather owing to the depression of the outer portion of  the bone;
 it is in reality kept fixed by the antagonism between the sterno-cleido-mastoid and
 great  pectoral muscles.   On looking at a patient with fracture of the clavicle in
 this situation, the nature of the injury is at once evident.  The flattening of the
 shoulder with its point approximated towards  the sternum, the great prominence
 formed by the end of the inner fragment over which the skin is tightly  stretched,
 the sudden depression under this, and the crepitus, which can be easily induced
 by raising and  rotating the shoulder at the same time that the elbow is  pressed
 to the side, indicate in the most unequivocal manner the nature of the injury.   The
 attitude of the patient is remarkable;  he  sits, leaning his  head down to  the
 affected side, so as to relax the muscles, and supports his elbow and forearm in
 the sound hand, in order to  take off the weight of the limb.
   Fracture of the clavicle in  infants not unfrequently occurs, and is  apt to  be
 overlooked.   The child cries and suffers pain whenever the arm is moved.   On
 examination, an irregularity with some protuberance will be felt about the centre
 of the bone.
  Comminuted fracture of the cavicle from  direct violence is often a serious acci-
 dent, as the  subclavian vein  and subjacent plexus of nerves, or the upper part of
 the chest, maybe seriously injured as well.   In a case of this kind that was under
 my care some  time  since the subclavian vein was apparently wounded,  great
 extravasation of blood taking place about the shoulder and neck, and the  circula-
 tion through the veins of the arm so much interfered with as to threaten gan-
 grene.  The case did perfectly well, however, by the  continuous application of
 arnica lotions to the shoulder,  and attention  to the position of the arm.
  Treatment.—When the fracture occurs  at  the tip of the acromial end of  the
clavicle, a figure of  8 bandage around the shoulders, and keeping the  arm in a
sling, will prevent the tendency to displacement forwards. 
206
SPECIAL  FRACTURES.
   When the bone is broken underneath the scapuloclavicular ligaments, there
 is but little displacement, and the same treatment will suffice.  But when the
 fracture is situated towards the middle of the bone, or indeed at any point to the
 inside of these ligaments, then the management is more difficult, and there are
 three  principal indications to be attended to, in order to correct the triple dis-
 placement of the scapular fragment.
   By placing a thick, wedge-shaped cushion with  its broad end upwards in the
 axilla,  and then bringing the elbow closely to the  side, the  outer fragment is
 drawn outwards, and by pressing the elbow well backwards the tendency to rota-
 tion forwards of the shoulder is removed,  and the broken  bone  brought into
 proper position.  By elevating the shoulder, and  taking off the weight of the
 arm by means of a short sling that passes  well under the elbow,  the displace-
 ment downwards is remedied.   In applying the  necessary apparatus care must
 be taken to bandage the fingers separately, to pad  the palm of the  hand with
 cotton wadding, and to apply a roller up  the arm  as high as  the axillary pad.
 Before applying  the roller, the elbow must always be  flexed, otherwise undue
 and dangerous constriction of the  arm  may occur.   The pad should be firm,
 made  of bed-tick stuffed with  bran,  six inches  long,  five  broad, and three
 thick at its upper part;  the sling must support the elbow, and  the  hand should
 be well raised across the chest, so that the fingers  rest upon the upper part of
 the sternum.
   The elbow must be kept to the side by a few turns of a roller, or by means of
 a padded belt.   In  children, in whom these fractures often occur, there is fre-
 quently a difficulty in keeping the bandages properly applied; under these cir-
 cumstances the starch apparatus  will be found very useful, care being taken to
 re-apply the  apparatus so often as it becomes loose,  lest deformity result.  It has
 been recommended to treat fractured clavicles occurring in females, to whom any
 irregularity of union in  this situation would be very annoying, by keeping the
 patient in bed for the first two or three weeks.  [In fractures of the clavicle, the
                                       indication is, to carry the shoulder, and
                Fl£- 69-                  with it the humeral fragment of the clavi-
                                       cle, upwards, outwards, and backwards;
                                       and this is best done by the application
                                       of  the apparatus of Dr.  Fox, of the
                                       Pennsylvania Hospital (Fig. 69). This
                                       consists of a stuffed collar of muslin, to
                                       be applied to the sound shoulder; of a
                                       firm wedge-shaped pad, acting as a ful-
                                       crum, which is retained in the axilla of
                                       the injured side by tapes attached to
                                       its  thick  extremity, crossing upon the
                                       uninjured shoulder; and of a sling for
                                       the elbow and forearm.
                                         The cord from the humeral portion of
                                       the sling  is carried  behind the  back,
                                       and attached to the posterior portion of
                                       the collar; the attachments of the two
                                       carpal cords are made in front in a simi-
 ......                       lar  manner;  and by traction on the
three, the indications will be fulfilled; the collar acting as the point of resistance.
—Ed.]                                           a       ^
  Fractures of the  Scapula.—Fracture of the body of the scapula is not
very commonly met with, and when it occurs, being always the result of consi-
derable direct violence, it is usually associated with serious injury to  the subja-
cent ribs and trunk.   The thick  layer of muscles  overlying this bone not only
 
FRACTURES  OF  THE  SCAPULA.
207
protects it, but prevents displacement, and  renders the detection of its fracture
difficult.  The fracture usually takes place across the bone, immediately below
the spine, but occasionally it may be split  longitudinally or starred.  If ascer-
tained, it should be treated by the application of a body-bandage.
  Fractures in the vicinity of the shoulder-joint are of common occur-
rence, and may happen  either in the bony points of the scapula that overhang
this articulation, or else in  the upper end  of the humerus.   Not  unfrequently
there is double fracture in the neighborhood of this articulation; thus the acro-
mion may be broken as well  as the head of the humerus.   These complications
necessarily throw  some difficulty in the  way of the diagnosis of  these fractures.
In many cases also the amount of contusion, and the rapid  swelling that takes
place, obscure the nature of the injury.
  The acromion,  forming as it does  the very tip of the shoulder, is more fre-
quently broken than any other of the bony  structures in this neighborhood.  The
signs of this fracture are very obvious; when the acromion is broken off  near its
root, the arm hangs as a dead weight by the side, and the  patient, feeling as if
his arm were dropping off, supports it with the other hand.  There is flattening
of the shoulder, which is most marked  by  looking at the patient from behind;
and the head of the humerus can be felt  somewhat lower  in the axilla than
natural.  On running the finger along  the spine of the  scapula, a sudden ine-
quality in the line of the bone can be  detected, and on raising the elbow and
rotating the  arm,  crepitus can be felt, the rounded outline of the shoulder being
restored.
   In many cases the tip of the acromion only is broken off (Fig.  70).   When
this happens, the nature of the injury may be suspected
by the patient being unable  to raise his  arm to a level
with  his head, so as to touch  the  crown, owing to
some of the fibres of the deltoid having lost their points
of attachment; and it may be determined by the exist-
ence in a minor degree of some of the preceding signs,
which prevent  the accident being  confounded with
paralysis of the deltoid from contusion.
   The treatment consists principally in raising the
elbow, so as to take off the weight of the limb, and to
push  up  the acromion by the head  of  the humerus.
At the same time a pad may be placed between the
elbow and the side, in order to direct the  arm some-
what upwards and inwards, and the limb must be fixed
in this position by a bandage and sling.   The union
may take place either by bone or ligament.  [In the
treatment of this fracture the apparatus of Dr. Fox
may be advantageously employed; the conical pad must however be placed with
its thick end downwards, in order to carry the elbow away from  the side.   A
strip of adhesive  plaster applied over the acromion will also assist in retaining
the fragment in apposition.—Ed.]
   The coracoid process  is  but seldom broken; never, indeed, except by very
direct violence.   There is in the museum of the University College a preparation
showing a fracture of the base of this process, implicating and extending across
the glenoid  cavity.  The attachment of such powerful muscles as  the pectoralis
minor, biceps, and coraco-brachialis  would displace  the fragment considerably,
were it not that  it is  kept in position by the ligaments to which it gives inser-
tion, and whose fibres are expanded over it.
   The only treatment that can be adopted  is to put the arm in a sling and fix it
to the  side.
   Fracture of the neck of the scapula probably never occurs,  and  there can be
 
208
SPECIAL  FRACTURES.
 little doubt that Sir A. Cooper and Mr. South are correct in stating that cases
 so described are in reality instances of fracture of the upper end of the humerus,
 There is,  according  to Mr. South, no preparation in any museum in London
 illustrating fracture of the neck of the  scapula.  Indeed, on looking at the great
 strength of this portion of the  bone, and the way in which it is protected by the
 other parts about the shoulder, it is difficult to understand how it can be broken.
   [A number of cases of fracture of the neck of the scapula have been reported •
 in all instances, however, the line of fracture passing behind the base of the cora-
 coid process.  The symptoms of this injury are first, the existence of a depres-
 sion immediately under the  acromion process, owing  to the fall of the arm and
 outer fragment of the scapula; secondly, the presence of a  tumor in the axilla
 formed by the  head  of the bone; thirdly, the lengthening of the arm; and
fourthly, crepitation, which can be  produced when the parts are  brought into
 position.
   The facility with which replacement can be effected, and all deformity removed,
 distinguishes this injury from a luxation, in which we have rigidity, and immova-
 bility of the limb.  The  treatment consists in the retention of the fragment in
 apposition,  which  can be conveniently effected  by the apparatus of Dr. Fox,
 aided by the application of a pad to support the fragment.—Ed.]
   Fractures of the Humerus.— Fracture of the upper articular end of the
 humerus not unfrequently occurs, constituting an important class of injuries, which
 have been carefully studied by Sir A. Cooper,  and more recently by Mr.  R. "W.
 Smith, whose work on fractures  deserves  the  attentive  perusal of every practi-
 tioner.
   Five kinds of fracture of the humerus are met with in  the immediate vicinity
 of the shoulder joint.  Two of these are intracapsular, viz., simple fracture of
 the anatomical neck  and impacted fracture of this  portion of the bone.  The
 remaining  three are extracapsular,  viz., fractures of the surgical neck, simple,
 and impacted ; and separation of the great tubercle from the head of the bone.
   Intracapsular fracture of the neck of the humerus.—When the fracture occurs
 at the anatomical neck the head  of the bone is detached  from the tubercles and
 the neck, a little above, or, at the line of insertion of the capsule.   These frac-
 tures are occasioned by severe falls on the  shoulder, and are most frequently met
 with in adults.
  The signs of this injury are by no means very distinct, though much light has
 been thrown upon  them by the recent labors  of Mr. Smith.  There is loss of
 motion in the shoulder with some swelling and considerable pain;  on examining
 the part its proper roundness is found to be preserved, and the head of the bone
 can be felt in the axilla; on grasping the shoulder firmly, and rotating the elbow,
 crepitus can be detected.  By  further  examination it may be ascertained that
the bony points in the neighborhood of the articulation are perfect; and, by the
absence of special  signs, that will  hereafter be  mentioned, indicative of other
fractures of the humerus high up, the nature of this injury may be determined.
  When this fracture is impacted,  the upper fragment penetrates the lower one.
In consequence of this, the  axis of the humerus is directed somewhat inwards
towards the coracoid process, the  elbow projecting  slightly from the side, there
being at the _ same  time a hollow  under the acromion.   There  is  consequently
more deformity about the joint  in  the impacted than in the simple intracapsular
fracture,  with the same impairment of motion, but only slight crepitus.
  In fracture of the anatomical neck of the humerus the portion of bone broken
off is truly  a foreign body in the joint, and  being unconnected with  any ligamen-
tous structure, may perish, and thus give rise to  destruction of the articulation.
When this  does not take place it is probable that impaction of the fragment has
occurred, and that thus its life  is maintained;  or it may happen, as Mr. Smith
supposes, that its vitality is  occasionally preserved in  consequence of some par- 
FRACTURES  OF  THE  HUMERUS.
209
tial union being kept up between it and the rest of the bone by untorn shreds of
capsule.  In either case the principal reparative efforts are made by the lower
fragment, which deposits callus abundantly.
   Treatment.—As there is often much  swelling from  contusion in these cases,
local antiphlogistic treatment by means of leeches and evaporating lotions should
be had recourse to, for a few days.   A  pad may then  be  placed in the axilla,
and a leather or gutta-percha cap fitted to the shoulder and upper arm, the limb
having previously been bandaged.   The hand must be supported in a sling, and
the elbow fixed to the side.  In examining and reducing these intracapsular
fractures, no violence should be employed,  lest the impaction of the fragment be
 disturbed, or portions of untorn capsule, on which the ultimate osseous repair of
the injury is dependent, be broken through.
   Extracapsular fracture of the neck of the humerus.   In these
injuries,  the bone is broken through the  surgical neck, or  that
 portion which is below the tubercles, but  above the  insertions of
 the pectoralis major, latissimus dorsi,  teres major,  and  deltoid
 muscles  (Fig.  71).  This accident may occur in children  as well
 as in adults; in the  former the separation taking  place through
 the line of junction between the epiphysis and the shaft of  the
 bone.   In this fracture there is double displacement; the head of
 the bone and upper fragment are rotated outwards, being under
 the influence of the muscles  inserted into the great tubercle, whilst
the shaft is drawn upwards and  inwards under the coracoid
process, by the muscles going from the trunk to the arm,  and by
the flexors  of the limb.
   The signs of this fracture are sufficiently obvious.   The glenoid
cavity is filled by the head  of the bone, which  can be felt in it.
Below this  there is a depression, crepitus is easily produced,  and
there is  great mobility of the lower fragment; but the most re-
markable sign is the  prominence  formed by the upper end of  the
shaft of the humerus, which project's under the integuments,  and
can readily  be felt under the  coracoid  process, especially when
the elbow  is pushed  upwards  and  rotated.   The  axis  of  the
bone is also directed obliquely upwards  and inwards towards  this
point.  In consequence of this fragment, which is often very sharp
and angular, irritating the  nerves of the axillary plexus, a good deal  of pain
is complained of in the arm and fingers.   This sign, however,  is not met with in
children, owing to the greater smoothness of the fractured surfaces.
  The impacted extracapsular  fracture of the neck  of the humerus has been
especially treated of by Smith in his very excellent work on fractures.  In this
injury the superior fragment being penetrated by the inferior one, the continuity
of the bone and its firmness are in a  great measure preserved; hence, the usual
signs of fracture, such as  mobility,  displacement, and crepitus, are  not readily
obtainable, and indeed the signs of this injury are chiefly negative.  Thus, there
is impairment of motion, slight  deformity about the joint and  upper part of the
arm, and some crepitus; but only obtainable with difficulty, and by firmly grasp-
ing the head of the bone whilst the  elbow is being rotated.
  The treatment usually recommended consists in bandaging the limb, putting a
pad in the  axilla, a leather or gutta-percha cap over the shoulder, bringing the
elbow well to the side  by means of a oandage, and supporting  the hand only in
a sling, so that the weight of the arm may be allowed to drag on the lower frag-
ment, and thus lessen the displacement.
  In the  management of these fractures, I have found  a very convenient appa-
ratus to consist of a leather splint about two feet long by six inches broad, bent
upon itself in the middle, so  that one half of it may be applied lengthways to the
                                    14
 
210
SPECIAL  FRACTURES.
chest, and the other half  to the inside of the injured arm, the angle formed by
      the bend, which should be somewhat obtuse, being well pressed up into the
f\   axilla.  In this way the  limb is well steadied, and  the  tendency to  dis-
      placement inwards of the lower fragment corrected.
        [The most convenient mode of treating fractures of the surgical neck of
      the  humerus, is by  the application of the same apparatus  that is used in
      this country in the  treatment of fractures of the shaft.  This consists of
      a rectangular  and of three humeral splints.  The surgeon must, however,
      take the  precaution of padding conically the  upper  end of the humeral
portion of the  rectangle,  in  order to prevent the inward  displacement of the
lower fragment.—Ed.]
  In some cases fracture  of the neck of the humerus is followed by atrophy of
the bone, though good union has taken place.
  Separation of the great tubercle of the humerus occasionally occurs from falls
and blows upon  the shoulder;  but more commonly as the  result  of the violent
action of the three external rotator muscles, which are inserted into it.  In this
injury there is a double displacement; the tubercle is carried upwards and out-
wards away from the head of the bone, and under and external to the acromion
process; the shaft is drawn upwards and  inwards by the muscles passing from
the trunk  to the arm,  as  well as by the flexors of the arm, in such a way that
the head of  the bone lies upon the inner edge of the glenoid cavity under the
coracoid process, and is indeed  almost luxated.   The consequence of this double
displacement is a great increase in the breadth of the shoulder, which is nearly
double its natural size;  on examination, a rounded tumor, the head of the bone,
movable on rotating the arm, can be felt under the coracoid process, whilst another
osseous mass, the great  tubercle, may be felt at the outer and back  part of the
joint; between these a sulcus is perceptible, and crepitus may be felt by bringing
the two portions of  bone  in  apposition, and  rotating the arm.   This accident,
which is of  rare occurrence,  has been most carefully described by Guthrie and
Smith, to whom a knowledge of its pathology is due.
  The principle of treatment consists in an attempt to bring and retain the de-
tached tubercle in contact with the head of the bone; this may  be done either
by mechanical means, or by relaxation of the muscles.
  The treatment by mechanical means consists in placing  a pad in the axilla,
and bringing the elbow to the  side, so as to throw out the head of the bone, at
the same time  that, by means  of  a  compress, the tubercle is pressed into the
proper position, the  arm being supported in a sling.   The treatment by relaxation
of the muscles  consists in elevating and extending the arm from the trunk; in
carrying this out, it is necessary that the patient be confined to bed, the arm being
supported on a  pillow.
   Fractures of the  shaft of the  humerus are usually somewhat oblique from
above, downwards and outwards.  The nature of the accident is at once detectible
by the great mobility of the fragment, the ready production of crepitus, and the
other ordinary signs of fracture.  The displacement usually consists in the lower
fragment being drawn  upwards and to the inner side of the upper one, which is
often somewhat everted.   The  treatment is of the  simplest character, flexing the
elbow, bandaging the arm, and the application of two or three well-padded splints
being all that is necessary.   In applying a splint to the inner side of the arm,
care must be taken that it do not press upon the axillary vein, lest oedema of the
limb occur.
   [The displacement in fractures  of the shaft of the humerus may be twofold,
according as the line of fracture be above or below the insertion of the deltoid
muscle.  If it  be above,  the upper fragment will be drawn inward  towards the
ehest by .the action of the armpit muscles, whilst the lower fragment will be dis-
placed upwards and  outwards by the combined action of the deltoid, biceps, and 
FRACTURES  OF  THE  HUMERUS.
211
triceps muscles.  If, however, the bone be fractured below the point of the in-
sertion of the deltoid, the  reverse displacement will occur, the upper fragment
being thrown upwards and outwards, whilst the lower portion of the shaft, acted
upon by the muscles attached to the forearm, will be  carried inwards and up-
wards.   In either case the same treatment must be pursued, viz., the coaptation
of the displaced fragments, the  envelopment of the limb from the  fingers to the
shoulder in 'a  roller-bandage, and the employment of one rectangular and three
short humeral splints.   The rectangular splint should be applied to the inner
and anterior side of the arm and forearm, and the humeral splints to the anterior,
posterior, and external surfaces  of the arm.   The  limb must be supported  by a
sling.—Ed.]
   Fractures  in the neighborhood of the elbow-joint, may occur through
any  of the osseous prominences in this situation.   They are very commonly
complicated  with dislocation, with considerable contusion of and  injury to the
joint, or perhaps with comminution  of the bones and considerable laceration of
the soft parts covering them.  In most cases swelling speedily comes on, tending
to obscure materially the nature of the injury.
   The separation of the lower  epiphysis of the humerus  in children before its
ossification  is complete, is  by no means  an unfrequent
accident, the fragment being carried backwards, with           pis-72-
the bones of the forearm  connected  with it, so as to
cause considerable displacement posteriorly.   It  may
readily be replaced, but  slips out of its position again,
with crepitus, as soon  as it is left to itself.
   A transverse fracture of the lower end of the humerus,
just above the  elbow, occasionally occurs in adults.  In
these cases the displacement backwards of the forearm
and lower fragment, the pain and crepitus, indicate the
nature of the accident.
   Fracture of either condyle of the humerus may arise
from blows and falls on the elbow.  There is  conside-
rable pain  about the  seat of injury but usually not
much displacement.   Crepitus, however, may  readily
be felt by rotating the radius, if it  be the external  condyle that is injured ; or
by flexing and pronating the forearm, if it be  the internal condyle that has been
detached.
   The treatment of all these injuries must be conducted on  very similar  prin-
ciples.  The swelling and inflammatory action, which rapidly supervene, usually
require local antiphlogistic  treatment, the application of cold  lotions, or of irri-
gation, the arm  being flexed, and supported  in  an easy position on  a proper
splint.   After  the subsidence  of the  swelling, the fracture, whatever be  its
precise nature, is best maintained in position by being put up in angular splints,
the forearm being kept in  the mid-state between pronation and supination, and
well supported in a sling.   It is in these particular fractures that passive motion,
if it ever be employed, may be  had  recourse to, a tendency to rigidity about the
joint being otherwise often left.  The motion should be begun in adults at the
expiration of a month  or five weeks;  in children at the end of three weeks after
the occurrence of the accident.
   [In fractures of  the condyles of the humerus, the treatment pursued in the
Pennsylvania Hospital, is the one introduced  by the late  Dr. Thomas Hewson,
of this  city; which  consists in the employment  of  an  angular  splint, made
slightly concave upon  its under surface so  as to fit along the anterior surface of
the arm and forearm.   By this means  a sufficient  degree of extension of the
forearm is obtained, and, at the same time, all the tendency to excoriation over the
condyles, so often observed in the application of the lateral splints, prevented.—
Ed.]
 
212
SPECIAL  FRACTURES.
    The only fracture of the bones of the forearm that commonly occurs in the
 vicinity  of the elbow-joint, is that of the olecranon;  this may occur from fills
 upon the elbow, or from muscular action.  The displacement is usually consider-
 able,  the fragment  which is  detached  being drawn upwards by  the  triceps
 muscle.  Occasionally, however, when the ligamentary expansion of the tendon
 of this muscle is not torn through, there is but little separation of the fragments.
 In the  majority of cases, as it occurs from direct violence, there is much swell-
 ing about  the  joint, and not unfrequently the fracture  is compound.   The
 treatment consists  in keeping the arm extended for about three weeks, by means
 of a light wooden splint applied along  its  anterior aspect; at the end  of this
 time it may be gradually flexed.   When the separation of the fragments is con-
 siderable, bony union does  not  take place; but when the tendinous expansion
 of the triceps has  not been torn, the fracture unites by osseous  deposit.
   Fracture of the coronoid process is an accident of very rare occurrence, but
 would occasionally appear  to happen  by falls upon the palm of the  hand, the
 forearm being forcibly driven backwards.   It may occur from  the contraction
 of the brachialis anticus muscle, as in the case of a boy, reported by Mr. Liston,
 who by hanging from a high wall for too long a  time, met with this fracture.
 When it occurs, the forearm is dislocated backwards, crepitus being detected as
 it is replaced in position.   The treatment consists in flexing the elbow, placing
 the arm in a sling, and keeping the joint quiet.   Union takes place by ligament
 and not by bone.
   Fractures of the middle of the forearm are of very common occurrence, both
 bones being  usually  broken, with much  shortening, angular displacement, and
 crepitus.   Occasionally one bone only is fractured, from the  application of direct
 violence.  When this is the case, more attention will be required in establishing
 the precise nature  of the injury.
   The treatment is simple; a splint, somewhat broader  than  the  arm,  should
 be placed on either side of it,  and  a narrow pad laid along  the  interosseous
 space, in order that the patency of this may be preserved; no bandage  should
 be place under the splint.  If masses of callus happen to be thrown out across
 this interval, the prone and supine movements of the hand will be lost, and the
 utility of the limb  greatly interfered  with.
  _ [The displacements resulting from fractures of the forearm, are of several
 kinds; we  may  have angular deformity taking place either in the  antero-pos-
 terior, or in the lateral diameters of the limb, or we may have the two fragments of
 the radius inclined towards the ulna,  by the action of the pronator quadrates on
 the lower, and of the  pronator teres  on the upper fragment.   In those cases in
 which the  fracture of the  radius  has taken  place above the  insertion  of the
 pronator teres, an excessive supination of the upper fragment is apt to follow, in
•^consequence of the unchecked action of the supinator brevis, and of the  biceps
 muscles.   The pronator teres will at the same time tilt  the upper  end of the
 lower fragment over towards the ulna; hence arises the indication in the treat-
 ment of this peculiar fracture, of dressing the forearm in the supinated position,
 and retaining it thus by means of an anterior and of a dorsal splint.  The object
 of  this position, is to obtain a  regular union between the extremities  of the
 radial fragments, and  thus  to preserve  to the  patient  complete supination  and
 pronation of  the hand.
   The rule  in the treatment of all  other fractures of  the forearm, is that the
 limb be dressed in a position midway between pronation and supination.—Ed.]
    Compound fractures of the elbow-joint are necessarily serious accidents.  If
 the articulation be simply opened with little laceration of the surrounding soft
 parts, and no comminution  of the bones, the  limb may very  commonly be  pre-
 served by the employment of active  antiphlogistic treatment.   If the bones be
 much shattered, the soft parts not  being seriously implicated, removal  of the 
FRACTURES  OF  THE  RADIUS.
213
splinters, and perhaps more or less complete resection of the injured joint, will
enable the surgeon to save the rest of the limb.   But if the soft parts be exten-
sively contused and torn as well as the bones comminuted, amputation of the arm
will be required.
  Compound fractures of the forearm seldom give  much  trouble or require am-
putation, but very commonly  lead to obliteration of the interosseous space, and
thus impair the after-utility of the limb.
  Fractures  of the lower extremity of the  radius, near the  wrist, are
of common  occurrence  from falls upon  the palm  of the hand, giving rise  to
very considerable and remarkable displacement, which has often been mistaken
for dislocation of this joint.  The  importance of these fractures, not only  in a
diagnostic point of view but  also in reference  to  their  treatment, has caused
them to be carefully  studied  by  surgeons,  and  their nature and pathology
have been especially investigated  by Collis, Goyrand,  Voillermier,  Nekton, and
Smith.
   The signs of a fracture of the radius in the neighborhood  of this joint are
so  peculiar, that, when once  seen,  they may always be          Fig-. 73.
recognised without difficulty as diagnostic of the injury.
 The deformity occasioned  by this  accident gives rise to a
remarkable undular distortion of the wrist.  On looking
at the injured limb sideways, it will be seen that there is
a considerable  dorsal prominence  apparently situated on
the back of the carpus.   Immediately  underneath this,
on  the palmar aspect of the wrist, just opposite the annu-
lar ligament, there  is a remarkable hollow or arch most
distinctly marked  at, and indeed  confined  to the  radial
side of  the arm;  a little above this, that is to say,  on the
lower part of the palmar  aspect of the forearm, there is
another rounded prominence,  not  nearly so  large  or dis-
tinct however as the one on the dorsal aspect.   On look-
ing at the back of the  hand it will be seen to be  placed
somewhat obliquely to  the axis of the forearm,  the ulnar
border being somewhat convex, and the styloid process of
this bone  projecting  sharply under  the skin  (Fig. 73).
The radial side of the wrist is,  on the contrary, somewhat
concave, appearing to be shortened.
   The  pain about the seat of injury  is very severe, and
by moving the hand,  especially by making any  attempt
hand is perfectly useless,  the  patient being unable to support it.  All power
of  rotating  the  radius  is  lost, the patient  moving the whole of the arm  from
the shoulder at once, and  thus apparently, but not really, pronating  and supi-
nating it.  Crepitus can often be felt, but in some  cases the most careful exami-
 nation fails to  elicit it, unless  the  hand  be very forcibly drawn downwards and
 then rotated.
   This fracture usually occurs from half an inch to an inch above the articular
surface of the radius.  The cause of the particular deformity that is observed,
and indeed the general  pathology  of the injury, has  been the subject of much
discussion, in a great measure owing, I believe, to  the opportunity  of dissecting
recent fractures of this kind  being not very frequent.  Three years ago I had
an  opportunity of dissecting and carefully examining  the state of  the limb in a
woman  who died in University College Hospital, twelve days after  meeting with
this accident.   On examining the left arm, which  presented all the signs of this
injury in a marked degree, a  transverse fracture of the radius was found about
an  inch above its articular surface.  The lower  fragment was split into three
portions, between which the upper fragment was so firmly impacted to the depth
is  greatly increased
at  supination.  The 
214
SPECIAL  FRACTURES.
Fi*. 74.
Fi"
!_
of more than half an inch as  to require some force in its removal.   The three
portions into which the lower  fragment was split were of very unequal size; the
two posterior  ones being small, consisting merely of scales of bone, the third
fragment, the largest, comprising the whole of the articular surface of the radius,
wh?ch was somewhat tilted upwards and  backwards.  To this  fragment were
attached the supinator longus, and  the greater part of the pronator quadratus;
the ligaments  and the capsule of the joint were  uninjured. _
   This case presents the appearances usually met within this kind of injury, the
lower fragment being displaced  in such  a way that its articular surface looks
                              slightly upwards, backwards, and somewhat out-
                              wards, so  as to be  twisted as it were upon  its
                              axis  (Figs.  74, 75).  The upper fragment is
                              always found  in  a  state  of pronation, and, in
                              many cases, is driven into and firmly impacted
                              in  the lower one.
                                 To  what is  this  displacement of the lower
                              fragment due ?   Is it to muscular  action, or to
                              the peculiar manner in which the two fragments
                               are locked into one  another ?   Muscular action
                               cannot I think  be considered the sole, or indeed
                              the chief cause of this deformity, for although
                               the supinator longus is attached to  the  lower
                               fragment, and with  the radial extensors would
                               influence the position of this portion of the bone,
                               yet it must be borne in  mind that their anta-
                               gonists, the pronator quadratus  and  the flexor
                               muscles of the wrist, are  likewise attached  to,
            and exercise their action directly  upon  this  fragment, and would
            have a tendency to counterbalance the action of the supinators and
            extensors.   These muscles also are by no means powerful, and would
            certainly not be  able  to withstand  ordinary efforts  at remedying
 the displacement, which in many cases  are  unsuccessful.   That the deformity
 is the result of impaction I feel  convinced, notwithstanding  the elaborate argu-
 ment by Mr. Smith in opposition to this view, and my conviction  is founded on
 an examination  of several specimens  of consolidated fracture  of the radius
 preserved in the different collections in London, upon the dissection of the case
 already  alluded to, and upon the  difficulty in any other way of accounting for
 the occasional  impossibility of properly reducing these  fractures.   The great
 traction that  is usually required to remove the  deformity, and  the absence of
 distinct crepitus in some cases, until  after forcible traction has been employed,
 also indicate the existence of impaction.   At the  same time I do not doubt that
 it occasionally happens that these fractures are not impacted; this would appear
 to be the case in  those instances  in which crepitus is easily detected, and  the
 fracture readily reduced.
   The  mode in which the impaction and  deformity occur appears  to me to be
 as follows.  When a person falls on the palm  of the hand, the  shock, which is
 principally received on the ball of the thumb, and the radial side of the wrist,
 is not directed immediately upwards in the axis of the  radius; but the force,
 impinging in a direction obliquely from before  backwards, and from without in-
 wards,  as well as from below  upwards, has a tendency to rotate  the lower frag-
 ment on its own axis, and  to tilt  the articular surface somewhat  upwards  and
 outwards.  As the upper fragment descends,  its posterior  surface  of compact
 tissue is forced  into  the cancellous structure  of the lower fragment, to such
 a depth as will admit  of the two anterior portions of compact tissue coming
 in contact, and thus the upper line of compact tissue is driven into the lower 
FRACTURES  OF  THE  RADIUS.
215
fragment to an extent corresponding to the degree with which  this  fragment
is rotated upwards and backwards.   If the  bone be brittle, or  the force be con-
tinued after this  amount of impaction has taken place, the lower fragment will
be splintered.
  The prominence of the styloid process of the ulna  is the result of the short-
ening of the radial side of the wrist and hand consequent upon the impaction.
  Besides this injury, Mr.  Smith has described a  fracture of  the lower end of
the radius in consequence  of  falls upon  the back of the hand, in which the in-
ferior fragment is displaced forwards.   In these cases the character of the de-
formity indicates the nature  of the  injury.  It can readily be reduced, with a
feeling of crepitation, by traction.
   In another variety of fracture in this situation,  the lower end  of the radius
and that of the ulna are broken  off, resembling very closely dislocation of the
wrist backwards.  But the fact of  the existence of grating, of the ready reduc-
tion of the swelling, and of the styloid  processes of the radius and of  the  ulna
continuing to be  attached to, and following the  movements of the carpus, will
be sufficient to establish the diagnosis.
   The treatment of  the ordinary fracture  of the  radius near the wrist is best
 conducted by the apparatus introduced by Nekton (Fig. 76).  This consists of
 a pistol-shaped wooden splint, which is placed along the outside of the arm, reach-
 ing from the elbow to the extremity of the fingers.   Forcible extension and
 counter-extension should be practised, with the view  of disentangling the frag-
 ments and removing the dorsal prominence.   The splint thickly padded  opposite
 the lower fragment should then be applied to the outer side of the  arm,  and the
 hand being brought well down to its ulnar side, should be bandaged to the bent
 part of the splint.   Another short  splint, reaching from the bend of the elbow
 to the lower extremity of the upper fragment should now be placed along  the
 inside of the arm,  after having been well padded along  its radial  border, so as
 to counteract the tendency to pronation of this part of the bone.  The arm must
 then be placed in a sling.  The fracture unites in  the course of a month or five
 weeks, and passive motion of the  joint may then be commenced, but it will  be
 at least three months before the stiffness of the hand and wrist are so  far dimi-
 nished, even by the use of frictions and douches, so as to enable the patient to
 use  the fingers.  It sometimes happens that the radius on both sides is broken
 at the same  time in  this situation, constituting  a somewhat serious condition,
 inasmuch as the patient is not able to feed  or assist himself in any way during
 the  treatment.
  [In the treatment of fractures of the lower end of the radius, Dr.  J. R. Barton
of this city some years since recommended the application of two straight splints,
and  of two compresses, one to be applied over the lower fragment, and the other 
216
SPECIAL  FRACTURES.
beneath the inferior extremity of the upper.   But of late, Dr. Bond has advocated
the use of the box splint (Fig. 77), in which the palm of the hand rests upon a block,
                                                       the  extremities of the
                                                       fingers remaining free.
                                                       By  dressing the  limb
                                                       in this  position,  the
                                                       muscles  will  be  re-
                                                       laxed,  and no  undue
                                                       pressure exerted upon
                                                       their tendons.   A bet-
                                                       ter chance of escaping
permanent stiffness will be  afforded; should this, however, result, despite the
efforts of the surgeon " the hand  will not entirely have lost its uses.   For the
hand, thumb, and fingers being placed very  nearly in the position  of their  most
frequent uses, the  interossei, the lumbricales, and the several short muscles  of
the thumb, will, by causing only a  very limited motion, enable the hand to per-
form very many of its useful functions."—Ed.]
   Fractures of the metacarpus and fingers are of so simple a character in every
way as scarcely to call for detailed  remarks.  In the treatment, rest of the part
upon a leather or pasteboard splint  is all that is requisite.   In compound fracture
of these bones, every effort should be made to save the part; if removal becomes
necessary,  it should be to as limited an extent as possible.
   In fractures of the pelvis, the clanger depends not so much on the extent
of the fracture as on its complication with internal injury and the violence with
which it has been inflicted.   Fracture may extend in any direction across the
pelvic bones,  though most  commonly it passes  through  the  rami of the pubes
and  ischium, and  across  the body of the  ilium, near the sacro-iliac articulation.
In some  cases the symphysis  is broken through, and in others the fracture ex-
tends across the body of the pubes.
   It occasionally happens that a portion of the crest of the ilium is broken off,
but  this is of little  consequence,  even though  the  bone  continues depressed.
When the rami of the pubes and  ischium,  or the whole body of  the ilium, are
broken through, there is, of course, considerable danger from internal injury.  If
the  patient escapes this, the fracture,  however  extensive  it may be may unite
favorably.   I had  lately a patient under my care at the hospital with a  fracture
extending through the rami of the pubes and ischium, and across the ilium, in
a line parallel with,  and close to the sacro-iliac  symphysis,  so as completely to
detach one-half of the pelvis,  but  who recovered without any bad consequences
occurring.
   The nature of the injury is usually  apparent  from the great degree of direct
violence that has been inflicted upon the part,  from the  pain that the person
experiences in moving or in coughing, with an  impossibility to stand, in conse-
quence of a feeling as if the body was falling to pieces when he attempts to do
so, with mobility of the  part and  crepitus  on seizing the  brim of the pelvis on
either side and moving it  to and  fro.  In examining a patient with suspected
fracture of the pelvis, care  should,  however, be  taken not to  push the investiga-
tion too closely, lest  injury be inflicted by the movement of the fragments.  In
those cases, indeed, in which the fracture does not extend  completely across the
pelvis,  or  in which it is seated in the deeper parts  of the ischium, an  exact
diagnosis may be impossible.
   In a fractured pelvis, the principal sources of danger arise from injury to the
bladder and urethra, with consequent  extravasation of urine; from laceration of
the  rectum, or fracture of the acetabulum; and in examining the pelvis, no rough
handling should be allowed, lest injury  to these parts  be inflicted  by the frag-
ments.
 
            FRACTURES  OF  THE  NECK OF  THE  FEMUR.         217

  In the treatment,  the first thing to be  done is to pass a catheter into the
bladder, in  order to ascertain the condition of  the urinary apparatus; if it be
injured, measures  that will be hereafter described must be had recourse to.
The next thing is to keep the part perfectly quiet, so as to bring about union.
With this view, a padded belt, or a broad flannel roller, should be tightly applied
round the pelvis, the patient lying on a hard mattrass.  The knees may then be
tied together, and a leather or gutta-percha splint put upon the hip of the side affect-
ed, so as to keep the joint quiet, and to prevent all displacement of the fragment.
   Fracture  of the acetabulum is of  rare occurrence, and  can only happen when
the pelvic bones have been extensively broken.   There  is a preparation  in the
University College Museum, exhibiting a comminuted fracture of this articular
surface  as well  as  of the ilium.   Sanson  and  Sir A.  Cooper  have seen the
acetabulum  separated into  its  three primitive fragments, and the head of the
femur driven into the pelvic cavity.
   As some  displacement of the head of the femur would occur  in these cases,
they might be mistaken for dislocation, more especially as inversion of the foot
has  been noticed.  The crepitus and free mobility would however serve as dis-
tinguishing  signs.
   With regard to treatment, the application of a leather splint and broad padded
belt, and local antiphlogistic means is all that can be done.
   Fracture of the sacrum is an extremely rare occurrence.   The only instance
with which  I am acquainted is in  the Museum of the College of Surgeons.   The
coccyx, though more exposed, is also but seldom broken.   When fractured, the
pain is  usually severe, there being much contusion and inflammation of the  liga-
mentous expansion that covers  this bone,  so that the patient is scarcely able to
walk or sit.   This pain may continue for months and even years.   South relates
the case of  a gentleman who broke his coccyx by sitting on the edge of a snuff-
box, and who suffered such severe pain  that he was obliged to wear a pad on
cither tuberosity of the ischium, in order that the  coccyx might  be in a kind of
pit, and free from all pressure when he sat.
   Fractures of the femur are of great practical interest,  from  their fre-
 quency and  severity.   They may occur in the upper articular end of the bone,
 in its shaft, or in its lower end.   In these different situations every possible
 variety of fracture is often met  with.
   Fractures of the pelvic end of the bone may  be divided into those that occur
through the neck within the capsule of the joint,—those that occur  outside the
capsule, and into those that implicate the trochanter alone.
   Intracapsular fractures of the neck  of the femur are of two kinds, the simple,
in which the bone is merely broken across, and the impacted, in which the lower
portion of bone is driven into the upper fragment.
   This intracapsular fracture may almost be looked upon as a special injury of
advanced life, being but seldom met with in persons under fifty.   Thus  Sir A.
Cooper states that of 251 cases that he met with in the  course of his practice,
only two were in persons below this age.  It may, however, happen at an  early
period of life.   Thus,  Mr.  Stanley has recorded the case of a lad of eighteen,
who met with this injury.   Another remarkable circumstance in  connexion  with
it is, that  it commonly  occurs from  very  slight degrees  of violence, indeed
almost  spontaneously.  Thus, the jarring of the foot in  missing a step in going
down stairs,  catching  the  toes under  the carpet, tripping upon  a stone,  or
entangling the foot in turning in bed, are sufficient  to occasion it.   It is especially
in women that this injury is met with.
   The  occurrence of this fracture in old age is  owing indirectly to the changes
in structure, shape, and position of the head and neck of the femur with advan-
cing years.   The cancellous structure of these parts becomes expanded, the cells
large, loose, and loaded with fluid fat.   The compact structure, especially of the 
218
SPECIAL  FRACTURES.
under part of the neck becomes thinned  and proportionally weakened, especially
about the middle of the neck, which, appearing to yield to the weight of the body,
is shortened ; and  instead  of being oblique in its direction, becomes horizontal,
inserted nearly at right angles into the shaft.   In consequence of these changes
in structure and  position, it becomes less able to bear any sudden shock by which
the weight of the body is thrown upon it, and  snaps under the influence of very
slight degrees of violence.  When it breaks, the capsule may remain uninjured, but
the prolongation of it which invests the neck of the bone is usually torn through.
In some cases, however, this cervical reflexion is not ruptured, the lower portion
of it especially often remaining for some length of time untorn,  at last, however,
giving way under the influence of the movements of the limb, or by being softened
by local inflammatory action.  As the violence occasioning the fracture is generally
but slight, and as the vascularity of this  portion of the  bone is trifling in old
people, there is but little extravasation of blood.
  The fragments are almost always so separated that the fractured surfaces are
not in apposition (Fig. 78), the upper end of the lower fragment is drawn above and
to the outer side of the head of the bone, and at the same time is twisted so that its
broken surface looks  forwards.   The head remains in the acetabulum, attached
by the ligamentum teres, and sometimes preserving a connexion with  the  lower
fragment, through the medium of some untorn portions of the fibrous membrane
investing the neck.  The capsule is uninjured.
  Mr. Smith has observed, that in some instances  the  two fragments become
interlocked or dovetailed as it were into one another, in consequence of the line
of fracture being irregular and dentated.
  The signs of an intracapsidar fracture  of the neck of the  femur are altera-
tion in the shape of the hip, crepitus and pain at the seat of injury, inability to
move the limb, with  shortening and eversion of it.  These we  must consider
separately, as important modifications of each are sometimes noticed.
  The alteration in the shape of the hip  is evidenced by some flattening of the
part, the trochanter not being  so prominent as usual.   This process is also ap-
Fig. 78.                                  Fig. 79.
proximated to the anterior superior spine of the ilium, and on rotating the limb
is felt to move to and fro under the hand,  not describing the segment of a circle
so distinctly as  on the sound side.   This  sign, however, is not very marked  in
many cases.   During this examination crepitus will usually be felt, though this 
            FRACTURES  OF  THE  NECK  OF  THE  FEMUR.         219

occasionally is very indistinct  and even  absent, more especially if the  limb be
not well drawn down at the time it is rotated, so as to bring the fractured surface
in apposition; and much pain is experienced by the patient  on any movement
of, or pressure upon, the joint.
   The attitude of the limb is so peculiar, as in  general to indicate at once to the
surgeon what has happened.   There is  an appearance of helplessness about it
that  is striking.   As the patient is  lying on his back in bed it is everted, short-
ened somewhat, with the knee semi-flexecl (Fig. 79);  on requesting him to lift
it up, he  makes  ineffectual  attempts to do  so,  and at last ends by raising
it with the toe of the opposite foot, or with his hands.   On being taken out of
bed  and placed upright, the injured limb hangs uselessly, with the toes pointing
downwards, and the  heel raised and pointing to the inner ankle of the sound
side, the  patient  being  unable to rest upon  it.   In some  cases,  however, it
happens that after the fracture has  occurred the patient can lift the limb some-
what, and with much exertion, from the couch  on which he was lying;  or can
even manage to walk a few paces, or to stand  for  a few minutes upon  it,  with
much pain and difficulty.  This is owing either to the cervical reflexion of the
capsule being untorn, or else to the fragments not being separated, having become
locked into one another; and  it usually occurs  in those cases in which the other
and  more characteristic signs of this fracture are not well marked.
   Eversion of the limb  is almost an invariable accompaniment of this fracture.
It is most marked in  those cases in which the  shortening  is  most considerable.
This eversion has  usually been attributed to the action of the external rotator
muscles that are inserted into the upper end of the lower fragment.  But I cannot
consider this  as the only, or, indeed, the principal cause, of this position; for,
not only is it very difficult to understand how these muscles can rotate outwards
the  limb after their  centre of motion has  been destroyed by the fracture of the
neck of the femur, their action being  rather in a direction backwards than  rota-
tory under these circumstances, but we find  that  the  limb falls  into an everted
position in those cases in which the fracture  being in the shaft, and altogether
below the insertions of these muscles,  no influence can be exercised  by them on
the lower fragment.   I look upon eversion in  cases of fractured thigh as not a
muscular action at all, but as  being simply the natural  attitude into which the
limb falls when left to  itself.  Even  in  the sound state, eversion  takes  place
spontaneously whenever muscular action is relaxed, as  during  sleep, in paralysis,
or in the dead body; and in the injured limb  in  which there is, as  it were, a
suspension of muscular  action, it  will occur equally.   Indeed,  the shortening
that takes  place will  specially tend to  relax the external rotators, and thus still
more prevent their influencing the position of the limb.
   Inversion of the foot in cases of intracapsular fracture  has  been noticed in a
few  cases.  I have seen one instance of this ; Smith, Stanley, and other surgeons,
also  record cases.   The   cause of this deviation from the usual symptoms of this
injury has  been a good  deal discussed.   It has been attributed by some to the
cervical ligament  not having been torn through  at its inner side,  but that,  as
Stanley observes, may prevent eversion, but cannot occasion inversion ; by others
to the fact  of the lower fragment in these cases being always found in  front of
the upper  one.  This circumstance, which  is  much insisted on by Mr. Smith,
appears to  me to be  rather the result  than the cause of the  inversion, for any
rotation inwards  of the lower fragment by the adductor muscles of  the thigh
would have a tendency to draw the  upper end of this fragment  to the anterior,
or, in other words, the inner side of the upper one.   I  am  rather disposed to
think that  this inversion is owing, in some cases at least, to the external rotators
being paralysed by the violence they receive from the injury  that occasions the
fracture, and that thus the adductors, acting without antagonists,  draw the thigh and
leg inwards.   In  the instance that fell  under my observation, and in some of those
that  have been published, the fracture resulted from  direct injury to the hip, 
220
SPECIAL  FRACTURES.
and was not occasioned by the patient jarring his foot, or by any indirect violence
operating at the end of the limb.
  The shortening in cases of fracture within the capsule seldom exceeds, in the
first instance, half an inch to an inch, depending on the extent of the separation
between the fragments ; and cannot, indeed, in the early periods of the fracture,
very well exceed the width of the neck of the bone, as the capsule is usually not
torn  through.   After the fracture has existed some time, the capsule of the joint
may yield,  allowing  greater separation between the fragments, and then it may
amount to  two, or even two and a  half  inches.   It not uncommonly happens
that  the  shortening, which  is at first but very slight, about half an inch, sud-
denly increases to an  inch or more;  this is accounted for on  the supposition of
the cervical ligament, which had  at first not been completely ruptured, at last
giving way entirely; or, it may be owing to the fragments which were  originally
interlocked becoming separated.   It is in those cases in which  there is but slight
separation  of the fragments, and consequently  little  shortening, that  the other
signs of  fracture are not very strongly marked, and that the patient  preserves
some power over the movements of the limb.
  The constitutional disturbance in intracapsular fracture of the neck of the
femur in old  people is often considerable, and  the injury frequently terminates
fatally, from  the supervention  of congestive pneumonia,  an asthenic state of
system, or  sloughing of the nates from confinement  to  bed during treatment.
Hence, this injury must always be considered as one of a very dangerous, and
not unfrequently fatal character.
  The treatment of these fractures turns in a great measure upon the  view that
is taken  of their mode of union, and on  the  constitutional  condition of the
patient.  In some cases no union occurs, but the  head of  the bone remains in
the  acetabulum,  being hollowed into a  smooth,  hard, cup-shaped  cavity, in
which the  neck, which has become  rounded off and polished, is received, and
plays as in  a socket.
  The union of the intracapsular fracture of the neck of the femur takes  place,
however, in the great majority of cases by fibrous  tissue.   This is owing to two
causes.   In the first place, to the  circumstance  that  the fractured surfaces are
not in apposition with one another, which I  look upon as  the most important;
and  secondly, that the vascular supply sent to the head of the bone,  consisting
only of the blood that finds its way through  the vessels of the  ligamentum teres,
is insufficient for the proper production of callus.
  In some cases, however, bony union  takes place.  This occurrence can only
happen when, in consequence of the cervical ligament being untorn, or the frac-
ture  being  impacted, the surfaces are kept in some degree of apposition, and the
vascular  supply to  the  head of the bone is speedily augmented by  the blood
carried into it through the medium of the plastic matter that is deposited between
the fragments; under no other circumstances is it probable  that osseous  union
takes' place in  these fractures;  hence the  infrequency of its  occurrence, there
being  in all probability not more than eighteen  or  twenty cases on  record as
having occurred in this country.  When bony union has taken place, the head
will  usually be found to be somewhat twisted round in such a way that it looks
towards tiie lesser trochanter, owing to the eversion that has  taken place  in the
lower fragment.
  As these fractures do not unite  by bone, unless the  fragments are in good
contact, it  is useless to confine  the  patient  to bed for any long period,  if the
signs indicate considerable  separation between the fragments, or if the patient
be very aged and feeble.   Under these circumstances, lengthened confinement
to bed most  commonly proves fatal by the  depressing influence it exercises on
the general health, by the intercurrence of visceral disease, or  by the  superven-
tion  of bed-sores.   It is, therefore, a good plan to keep the patient in bed merely 
FRACTURES  OF  THE  NECK OF  THE FEMUR.         221
Fig. 80.
for two or three weeks, until the limb has become somewhat less  painful, the
knee being well  supported upon pillows.   After this time, a leather splint should
be fitted  to the  hip, and the  patient be got up upon crutches.   There will be
lameness during the remainder of life, but with the aid of  a stick and properly
adjusted splint, but little inconvenience will be suffered.
   When the fragments do not appear  to be much separated, there being but
little shortening and indistinct crepitus, and more particularly if the patient be
not very aged, but in other respects sound and well, an attempt may be made to
procure osseous  union.   This may be done by the application of the long thigh
splint,  or if this  cannot very readily be borne, by the double inclined plane, with
a padded belt strapped round  the hips.   This apparatus  should be kept applied
for at  least two  or three months, when a leather splint may be put on and the
patient be got upon crutches.  During the whole of the  treatment,  a generous,
and, even stimulating diet should  be ordered, and  the patient  kept  on a water-
bed or cushion.   In these fractures  of the neck of the  femur, the starched
bandage  will  often  be found to be most useful.   It may be applied as  in frac-
tured thigh,  but should have additional  strength in the  spica  part,  and indeed
may be provided with a small pasteboard cap so as to give  more efficient support.
In old people, this plan of treatment is especially advantageous, as it  enables
them to sit up or even to walk about, and thus prevents all the  ill effects of long
confinement to bed.
   The extracapsular fracture of the neck of the femur  is commonly met with
at  an  earlier period of life  than the  injury
which  has just been described, being most fre-
quent between the ages of thirty and forty.   It
is the  result of the application  of great and
direct violence upon the hip, and occurs equally
in both sexes.
   This fracture may be of two kinds, the simple
and the  impacted.   In both cases the neck  of
the bone is commonly broken at, or  immedi-
ately outside, the  insertion of the  capsule  of
the joint.  The fracture is  almost  invariably
comminuted,  indeed I  have never seen  a case
in which the great trochanter was  not splin-
tered into several  fragments.  In  many in-
stances the lesser  trochanter  is detached, and
the upper end of the shaft  injured  (Fig. 80).
This splintering of the  trochanter is owing to
the same violence that breaks the bone, forcing
the lower end of the neck into  the  cancellous
structure of this  process, and thus, by a wedge-
like action, breaking it into fragments.   When the  neck  continues locked in
between these, we have  the impacted form of fracture.
   The  signs of extracapsular fracture vary according as it is simple or impacted,
but in both cases they partake  of the  general character of those that are met with
in fractures within  the  capsule.  The individual  signs,  however, differ consi-
derably from  these.
   The  hip will usually be found much bruised and swollen from extravasation of
blood, which  is  usually considerable.   The  crepitus is very distinct and loud,
being readily  felt on laying the hand upon the trochanter, and moving the limb.
The separate  fragments into  which the trochanter is splintered may occasionally
be felt  to be loose.   The pain is very  severe  and  greatly increased  by any at-
tempt at moving the joint, which to the patient is impossible.
  The  eversion is usually strongly marked, and the position of the limb is cha-
 
222
SPECIAL  FRACTURES.
racteristic of complete want of power in it.  Inversion occurs more frequently in
this fracture than in that within the capsule.   Smith finds that of seven cases of
inversion of the limb in fractures of the neck of the femur, five occurred in the
extracapsular fracture; and of  fifteen cases of extracapsular fracture, this condi-
tion was met with in three.  When there  is  much  comminution  of the tro-
chanter the foot will commonly  remain in any position in which it is placed, but
generally has a tendency to rotate outwards.
   The shortening of the limb is very considerable, being never less than from an
inch and a quarter to two inches and a half, and often  extending to three or four
inches.
   The impacted extracapsular fracture of the neck  of the thigh bone  occurs
when the upper fragment  is driven into the cancellous structure of the lower
                        one, remaining fixed there (Fig. 81).   The signs  of
                        this form of fracture are often of a somewhat negative
                        character, rendering its  diagnosis and detection ex-
                        tremely difficult.   In many cases there  is pain  about
                        the hip, with  slight eversion of the foot, and  some
                        shortening, usually  amounting to about half an  inch,
                        but never  exceeding  one inch.   There  is  but little
                        crepitus, in some cases none can be  detected, and the
                        patient can frequently raise the foot for a few inches off
                        the couch on which it is laid, and even  walk upon it
                        with a hobbling motion,  though  with much pain.  In
                        consequence of the impaction the limb  cannot  be re-
                        stored by traction to its proper length, and consequently
                        incurable lameness always results from this injury.
   The diagnosis of the different forms of fracture of the neck of the thigh bone
from one  another, and from other injuries occurring  in the vicinity of the hip
joint, is a matter  of considerable importance, and  often of no slight  difficulty.
Between the intracapsular  and  the ordinary extracapsular fractures there can be
no difficulty; all the signs of the latter being so much more strongly marked
than those of the former injury, the difference of age and the degree of violence
required to break the bone being also important elements in the diagnosis.  It
is more difficult to  distinguish  between the intracapsular fracture  and the im-
pacted extracapsular fracture.   In the  former case, however,  the  crepitus and
eversion are more marked,  and  the injury usually occurs from less direct violence
than when the  fracture is outside the capsule.   In the latter case, also, traction
cannot restore the limb to its proper length as in the former instance.
  In severe contusions of the hip there is sometimes eversion of, and  inability
to  move the limb, so that at first sight  it might be supposed  that the  bone was
broken.  In  these  cases, however, the  absence of shortening  and crepitus will
always establish the  diagnosis.  The difficulty is greater, however,  in  those in-
stances in which the hip-joint having been the seat of  chronic rheumatic inflam-
mation, the limb is already somewhat shortened; here, however, the  history of
the case, and the fact of the shortening  not being of recent occurrence, will be
sufficient to establish the nature of the injury.  The  diagnosis of these injuries
from dislocations will be considered in a subsequent chapter.
  In the extracapsular fracture  of the neck of the femur, death not uncommonly
results from the severity of the  injury, the pain and irritation of the fracture, and
the consequent shock to the system.   The great extravasation of blood into the
tissues of the Jimb has been known to be sufficient to account for the fatal result.
When the patient lives, bony union takes place, large irregular stalactitic masses
being commonly thrown out by the inferior fragment, so as to overlap the several
splinters of bone.   This callus is most abundant posteriorly in the inter-trochanteric
space (Fig. 82).
 
FRACTURES  OF  THE  SHAFT OF THE FEMUR.         223
  The treatment of the extracapsular  fracture may very conveniently and effi-
ciently be  conducted by means of the long  splint, a padded belt, if  necessary,
being strapped firmly round the hips underneath it; or the
plan recommended by Sir  A. Cooper, of placing the pa-          Fig. 82.
tient on a double inclined plane, with both feet and ankles
tied together, and  a  broad belt, well padded,  firmly
strapped round the body, so as to press the fragments of
the trochanter firmly against one another, will be found
an excellent mode of keeping the limb of a proper length
and the fragments in contact.
  Occasionally the  fracture extends through the  tro-
chanter major without implicating the neck of the bone.
Here there is shortening to about three-fourths of an
inch, with  much eversion and crepitus readily felt. This
fracture, which unites firmly and well by bone, must be
treated in the same way as the last.
   Compound fracture of the neck of the femur can only
occur from  bullet wounds.    These cases require amputa-
tion at the  hip-joint, unless the excision of the injured
head of the bone, as recommended by Mr. Guthrie, be
thought worthy of a  trial.
  Fractures of the shaft of the femur are of very common occurrence;  every
possible variety of this injury being met with here.   They are usually oblique,
except in  children, when  they are commonly transverse,  and  are often com-
minuted, double, or compound.
  The signs are well marked.   There is shortening usually to a considerable ex-
tent, with eversion of the  limb, crepitus readily produced, and much  swelling,
from the approximation of the attachments of the muscles.  The lower fragment
is always drawn to the inner side of the upper one  and rotated outwards; and
when the fracture is  high up there is  a great tendency to angular deformity,  in
consequence of the projection outwards of the lower end of the upper fragment.
  I have lately had an opportunity of ascertaining by dissection the  condition of
parts that leads to the eversion and projection forwards of the lower end of the
upper fragment in fractures of the femur, in the case of an old man who died
about three hours after meeting with a  compound comminuted  fracture of the
middle and lower thirds of the right thigh-bone, and in whom this  condition of
the upper fragment was very distinctly marked.   It  was found that the gluteus
maximus and medius could be divided without affecting the position of the  bone;
but when the gluteus  minimus was cut across, it yielded somewhat.   The pyri-
formis and  external rotators were now felt to be excessively tense, and on cutting
these across, the end of the fragment could at once be drawn inwards, all oppo-
sition ceasing.  The projection forwards still remained, however, and this, which
was evidently due to  the tension of the psoas and iliacus muscles, yielded at once
on dividing them.  It would thus appear that there is a double displacement of
the  lower end of the upper fragment,—outwards, depending on the action of the
external rotators, and forwards,  owing to  the contraction of the psoas and iliac
muscles.
  The treatment of fractures of the shaft of the  thigh-bone may be conducted
in four different ways; each of which presents advantages in particular forms of
these injuries; hence an exclusive plan of treatment should not be adopted.
  1st. The fracture may be treated by simply relaxing the.muscles of the limb.
This is effected by laying it upon its outer side, flexing the thigh well  upon the
abdomen and the leg upon the thigh, and  supporting it in  this position  by an
angular wooden or leather  splint, extending from  the hip to the knee, or outer
ankle, and  by a short inside thigh splint.   This position I  usually adopt in
 
224
SPECIAL  FRACTURES.
fractures about a couple of inches below  the  trochanters, in  which  there is a
great tendency to the projection outwards of the lower end of the upper frag-
ment, and find these cases turn out better in this way than by any other plan of
treatment.
   2d.  Extension, without regard  to muscular relaxation, by  means of Liston's
long splint and perineal band, will be found  a most successful  plan of treating
fractures in the middle and lower part of the thigh.
  .In employing the  long splint for  the treatment of these fractures, care must
be taken that it be of sufficient length to extend about six inches below the sole
and  nearly as high  as the axilla.   The perineal band  should consist of a soft
handkerchief covered with oiled silk, and must be gradually tightened.
   In cases of  compound fracture where the aperture exists in the posterior
and outer part of the limb, I have found  a long thigh splint made of oak and
bracketted opposite the seat of injury, the most convenient apparatus, enabling
the limb to be kept of a  proper length,  and the wound to be dressed at the same
time (Fig. 83).
                                   Fig. 83.
  3d. The double inclined plane is especially useful in many compound frac-
tures of the thigh, often admitting of greater facilities for dressing the wound,
and the general management of the case, than any other apparatus that can be
applied.
  4th. The starched bandage may  be employed in most  cases.  In treating
fractures of the  shaft of the femur  with the starched bandage, the following
plan will be found convenient.  A dry roller should  be applied to  the whole of
the limb evenly and  neatly, which must then be covered with a thick layer of
wadding; a long piece of  strong  pasteboard, about four inches wide, soaked in
starch, must next be applied to the posterior part of the limb, from the nates to
the heel.   If the  patient  is very muscular, and the thigh  large, this must be
strengthened, especially at its upper part, by  having  slips  of bandage  pasted
upon  it.   Two narrower strips of pasteboard are now  placed along either side
of the limb, from the hip  to the ankle, and another  shorter  piece on the fore-
part of the thigh.   A double  layer of starched bandage should now be applied
over the whole, with a strong and well-starched spica.   It should be cut up and
trimmed on the second or  third day, and then reapplied in the usual way.  With
such an apparatus as this I have treated many fractured thighs, both in adults
and  children,  without confinement to bed  for more than  three or four days
(Fig. 64).   The points to be specially attended to are that the  back pasteboard
splint be very strong, at the upper part especially, and that the spica be well and
firmly applied.
  [The treatment of fractures  of the  thigh generally adopted by American
surgeons, consists  in the  application of the  apparatus  of Desault, as modified
by Dr. Physick.   This is composed of two splints;  of which the external (Fig.
84) should  be  sufficiently long to extend from the axilla to about four inches
beyond the sole, whilst the internal or short one should reach from the perineum
to nearly the same point.   About two inches  from  the inferior extremity of the
long splint a grooved block projects, over which the extending band is carried.
Both splints should  be enveloped in a splint cloth.   The  perineal, or counter- 
FRACTURE OF THE PATELLA.
225
extending band is made of muslin stuffed with cotton, and should be provided at its
extremities with strong tapes, or better still with-a strap and buckle, these should
          be passed through mortises  in the  upper extre-
  Fig. 84.    jnity 0f ^e iong Splin^ and \,y this means, coun-         Fig. 85.
 f^"""]    ter-extension can be  obtained  in a  line nearly
 |a a    parallel with the  axis of the body.   To  prevent
 I        excoriation of the perineum, it is well to encase
          the counter-extending band  in chamois  leather.
          Extension should be   effected by the buckskin
          gaiter, by a handkerchief,  or else  according to
          the plan  proposed  by Dr. Ellerslie  Wallace of
          this city, by means of two long stout strips of
          adhesive  plaster.   These should be  applied on
          either side of the limb in a longitudinal direc-
          tion, and  should  reach from above the  knee to
          beyond the sole of the foot:  two or three  circular
          adhesive bands will effectually prevent them from
          slipping.   The projecting ends of the longitu-
          ninal strips, being either knotted together, or else
          attached to a small block below the sole, will allow
          of amply sufficient extending  force.   The re-
          maining portions  of the apparatus consist of com-
          presses ;  of a short anterior splint,  should there
          be any tilting upwards of the superior fragment,
          and of  two junk bags.   These latter should be
          placed  between  the  limb and the splints, and
          lateral pressure exerted by means of several trans-
          verse tapes carried  around the whole apparatus.
            Quite recently, Dr. T. Hewson Bache, whilst resident physician in
          the Pennsylvania Hospital, affixed to the inferior extremity of the long
          splint, an adjusting screw, by means of which a regular and equable
          extension can be produced; the apparatus is  so arranged  that  the
          extending power can  always be made to act in the line of the longi-
          tudinal axis of the limb.   In a case of fracture of  the femur  admitted
          into the hospital, in which after the employment for some time of the
          ordinary Desault's  apparatus, a shortening of the limb to the extent
          of three-quarters of  an inch existed, the  extending screw  of  Dr.
          Bache was applied with the utmost  success.   The patient recovered,
          with a shortening of one-eighth of an inch only, as shown by the most
          careful measurement.—Ed.]
            Fractures in the vicinity of the Knee-joint.—The lower end
 of the femur is not unfrequently broken in a transverse direction, both condyles
 being detached.  In other cases again the fracture extends through one of the con-
 dyles, detaching it  from the shaft of the bone.   The readiness  with which crepitus
 can be felt, and the  line of  fracture made out, determines at once the nature of
 this accident.  These cases are sometimes complicated with wound of the knee-
 joint, rendering  amputation necessary.  They are best treated  on the  double
 inclined plane.   I have lately  had a case of  impacted fracture  in this  situation
 under my care, the upper fragment, which was very oblique, being firmly driven
 into the cancellous structure of the lower one (Fig. 85).
  Fractures of the Patella are most frequently met with in men,  not very
 commonly occurring  in women, and very rarely in children.  They may  be  the
 result of direct violence, when  the fracture is often comminuted, or the bone may
 be broken longitudinally, being split, and the joint injured. But most frequently
 they occur as the consequence of  muscular action; the bone being torn across
                                     15
 
226
SPECIAL  fractures.
by the violent effort made by the extensor muscles of the thigh in the attempt
a person makes to save himself from falling when he suddenly slips backwards.
All fractures of the patella from muscular action  are transverse, the lower por-
tion of the bone being fixed by the ligamentum patellae;  the upper segment is
torn off by the spasmodic action of the extensors at the moment  that the knee
is bent, whilst the person is in the act of falling backwards.  It  not unfrequently
happens when one patella has been  fractured that the unsteadiness  of  gait
causes the opposite one to be  broken by muscular action  in an effort to save a
fall.  The same patella may be  broken more than once;  in  those cases that I
have seen, the second fracture has always occurred in the upper fragment, a little
above the line of original fracture.
  The signs of this fracture are very evident.   When transverse, the separation
between the fragments, which is much increased by bending the knee (Fig. 86),
and the inability to stand or  to  raise the  injured limb, indicate what has  hap-
Fig. 86.                     Fig. 87.                    Fig. 88.
pened; when longitudinal or comminuted, the crepitus and mobility of the frag-
ments.  There is usually considerable swelling of the knee-joint in these cases,
perhaps wound of it.
  When the bone is broken  transversely (Fig. 87) it very rarely indeed unites
by osseous matter, in consequence of the wide separation of the fragments; there
are, however, two or three cases on record in which this kind of union has taken
place in these fractures.  In the longitudinal and comminuted fractures, osseous
union readily occurs, the fragments remaining  in close apposition.  In the ma-
jority of cases of transverse fracture the fragments remain separated by an inter-
val varying from one-fourth of an inch to an inch, but in some instances the gap
is much greater, amounting even to four or five inches.  When the separation
does not exceed an inch and  a half the  gap is  usually filled up by fibrous or
ligamentous tissue, uniting the fragments  firmly.   In  some of the cases, how-
ever, in which the separation between  the fragments does not exceed this dis-
tance,  and in most of those in which it extends beyond it, Mr. W. Adams has
found that the fracture is not united by any plastic matter that has been thrown
out, but that the fragments are bound together, simply by the thickened fascia
which  passes over the patella, with which is incorporated the bursa patellae.  Mr.
Adams finds that the aponeurotic structure thus uniting the  fragments may  be
arranged in  different ways.   Thus, it may pass between, and be adherent to the
anterior periosteal surface  of both  fragments; or, the connecting aponeurosis
may be reflected over,  and  be adherent  to, both  the fractured  surfaces; or,
lastly,  and this is the most frequent form  of arrangement, the connecting apo-
neurosis may pass from the periosteal surface of the upper fragment to the frac-
tured surface of the  lower one, to which it becomes  closely and firmly united.
In the majority of cases when united by aponeurotic tissue, the fragments gape
somewhat towards the skin,  coming into better  contact  posteriorly.   Thus, it
would appear that a patella fractured transversely may unite  in two ways, most
frequently by the intervention of thickened aponeurotic structure, and, next, by a 
FRACTURES  of  the  leg.
227
ligamentous or fibrous band.   Of thirty-one specimens in the London museums,
examined by Mr. Adams, it was found that in fifteen  aponeurotic union  had
taken place, in twelve ligamentous union,  and in the remaining four the kind of
union could not be determined.
  The aponeurotic union always  leaves a weakened  limb and  an unprotected
joint, for in consequence of the separation of the fragments, the folding in  of the
fascia, and its adhesion to the  capsule of the joint, the fingers  can be thrust in
between the articular surfaces  of the knee.
  In the treatment of a fractured patella,  the principal point  to be  attended to
is to keep the fragments in sufficiently close  apposition for  ligamentous union
to take place  between  them.   With this view, the  upper fragment, which is
movable, and  has been retracted by the extensor muscles of the thigh,  must be
drawn down, so as to be approximated to the lower one, which is fixed by the
ligamentum patellae.   This approximation  of the fragments may  be  effected
either by position and relaxation of the muscles, or by mechanical contrivance.
By placing  the  patient in a semi-recumbent position, and  elevating the leg
considerably, so as to  relax the muscles  of the  thigh  completely, the  upper
fragment may be brought down to the lower one, and, if necessary, may be retained
there, after any local inflammation that results from the accident  has been sub-
dued, by moulding a gutta-percha cap accurately to and fixing it firmly upon
the knee,  or by the application of pads of  lint and broad straps of plaster.1   This
position must be  maintained for  at least six weeks, at the   expiration of
which  time  the  patient may be allowed  to walk  about, wearing, however, an
elastic knee-cap, or, what is better, a straight leather splint in the  ham, so as to
prevent the knee being  bent  for at least  three months.  If this  precaution be
not taken, the union between the fragments, which at first appear to be in very
close contact, will gradually lengthen, until  in  the course of a  few months an
interval of several inches may be  found  between  them.  In these  cases, how-
ever, even  though the  separation  between the fragments be  great,  it  is  re-
markable how well the limb may be used, especially on level  ground; and with
the aid of a knee-cap but little inconvenience is experienced by the patient.
  In these fractures M. Malgaigne  uses, with considerable success, two double
hooks, one of which is fixed above,  the other below the upper and lower frag-
ments  respectively, and being approximated by means  of a screw, enable  the
bone to be brought into perfect contact, and  thus firm  union to be obtained.
Compound and comminuted fractures of the patella, especially if occasioned by
bullet-wounds, and injuring the knee-joint, are usually cases for  immediate  am-
putation.
  In most cases of fractured patella the starched bandage will, I think, be  found
a very useful mode of treatment, the patient being  with it enabled  to walk  about
during the whole of the treatment.   A back splint of pasteboard is  required to
fix the knee, and a good pad of lint with a figure of 8 bandage should be applied
above and below the fracture, to keep it in  position.   In several  cases I have
obtained very close and firm union between the fragments in this way,  without
confining the patient to bed after the third  day.
  Fractures of the Leg.—The bones of the leg are frequently broken.   The
tibia, though  a stronger bone than the  fibula, is most frequently fractured,
owing to its  being more exposed and less protected by  muscles, and receiving
more directly all shocks communicated to the heel.  The fractures of the upper
part of this bone are usually transverse, and  result from direct violence;  those of
the lower extremity oblique, and proceed  from  indirect  violence.   When both
bones are broken, the usual signs of fracture, such as shortening, increased mo-

 1 [Two cases of the treatment of this fracture by the application of strips of adhesive plaster, in the form
of the figure of 8, above and below the fragments, are  reported by Dr. Neill of the Pennsylvania Hos-
pital.  See Medical Examiner for January, 1854.—Ed.]
I 
228
special  fractures.
bility at the seat  of injury, and crepitus, render the diagnosis easy; but  when
one bone alone is broken, it is not always a very simple matter to determine the
existence  of the fracture;  the sound bone, acting as a splint, preventing dis-
placement, and keeping the limb of a proper length  and steady.  If it be  the
tibia alone that has been  broken, the fracture  may be detected by running  the
finger along the subcutaneous edge, until it comes to a point  that is somewhat
irregular,  puffy, or tender,  where  by accurate  examination some mobility and
slight crepitus  may be  detected.   When the fibula  alone  is  broken, the  thick
layer of the peroneal muscles, overlaying its upper two-thirds,  renders the detec-
tion of the fracture difficult, but in the lower third it is easy, by attention to the
same signs that occur in fractured tibia.
  In the  treatment of fractures of the leg, M'lntyre's splint will usually be found
of great service during  the  earlier periods,  more  especially  if there  be much
ecchymosis or extravasation,  as it keeps the limb in an easy position, and admits
of the ready  application of evaporating lotions.   After  the  swelling has  sub-
sided, the starch bandage should be applied,  and the patient be allowed to  move
about on crutches.  In some cases  of fracture of the  bones  of the leg, however,
M'lntyre's apparatus is  not applicable.   This is more particularly the case when
the fracture is very oblique, from above downwards, and from  before backwards;
under these circumstances the fragments cannot be got into good position so long
as the limb is  kept extended and  resting  on its  posterior surface; the bones
riding considerably, and  one or other of the fractured ends pressing  upon the
skin in such a way as often to threaten ulceration.  In  these cases it is  that
division of the tendo Achillis has been practised, with a view of removing the
influence  of muscular contraction.  This appears  to me, however, to be an un-
necessarily severe procedure, and  certainly was not a very successful one in two
cases in which  I practised it; for although  the  tendon was  exceedingly tense,
but temporary benefit resulted, the  displacement returning under the influence of
the other  muscles inserted into the foot.   In these cases the  bones may usually
be got into excellent position by flexing the thigh well upon the abdomen, and
the  leg upon  the  thigh, so that  the heel  nearly touches the nates, and then
laying the limb on  its outer side on a wooden leg splint, provided with a proper
foot-piece, and  keeping it fixed in this position.   In some  cases the swing box
will be  found  a useful and  very easy  apparatus.   In  some fractures of the
leg, the lower end of the upper fragment projects  considerably,  and cannot be
got into proper position  so  long  as the knee  is  kept bent;  but if it be  ex-
tended, so as to relax the extensors of the thigh, the bone  is readily brought
into good  position.  In  fractures  of the leg, however, as  in all  injuries of a
similar kind, no one plan of treatment should be adopted  exclusively, but the
means had recourse to should be varied and suited according to the peculiarities
of each individual  case.
              Fig. 89.                   [In fractures of  the leg, attended with
                                    little  or no  displacement  the application
                                    of the fracture box (Fig. 89), will be usu-
                                    ally sufficient.   The limb should  be placed
                                    upon a pillow, laid  in  the box.  The foot
                                   should  be  attached  to  the footboard by
                                    means of a stirrup-bandage, and the sides of
                                    the box then being elevated, sufficient lateral
                                   pressure will be exerted to prevent displace-
ment taking place.   In case  the  fracture be a compound one, bran, as proposed
by Dr. Barton,  may be substituted  for the pillow.   If, however, the displacement
be  considerable, and extension and counter-extension be required, the modified
apparatus  of Desault, before described, may be employed.—Ed.]
   Compound fractures of the leg are best treated on M'lntyre's splint, which 
fractures  of  the  leg.
229
admits of proper dressings being applied to the seat of injury more readily than
any other  apparatus.  The details of the treatment  of these  injuries must  be
conducted in accordance with  those  general  principles that were  discussed in
speaking of compound fractures.
  In fractures of the leg, the starch  bandage is especially applicable.  It should
be applied as follows.  A dry roller having been put on to the limb, well covered
with wadding, a strong pasteboard splint, four inches broad, and long enough to
extend from the back of the knee to  six or eight inches beyond the heel, should
be applied to the back of the leg.  The  projecting terminal piece is now to  be
turned up along the sole of the foot,  and two lateral slips adapted to either side
of the limb.   Over this the starch bandage,  single or double, according to the
size of the limb, must be tightly applied.  After it is dry,  about the end of the
second day, it must be cut up, as represented in Fig. 65, and re-adjusted, and the
patient may then walk on crutches with  perfect safety.   In compound fractures
of the leg, a trap may be cut in the bandage,  as represented in Fig. 66,  through
which the wound can  be dressed.
   Fractures  in  the  vicinity of the Ankle-joint are amongst the most
common injuries of the bones of the lower  extremity.   They are usually occa-
sioned by twists of the foot, by catching it in a hole whilst  running, by jumping
from a height to the ground, or off a carriage in rapid motion.   These fractures
are usually associated  with severe strain, or even dislocation, of the ankle.  The
twist of the foot is almost invariably  outwards, the sole  remaining slightly turned
in this direction, though not always to the extent that Dupuytren states, and the
inner malleolus projecting under the skin; most  commonly the toes are turned
somewhat out, and the heel in.
   Fractures  of the lower ends of the  Tibia  and Fibula present four  distinct
varieties.
   1st. The fibula may be broken at from two to three inches above the malleolus
externus, the deltoid ligament being  either stretched or torn.
   2d.  The fibula  may be fractured  about three inches above the ankle, the tip
of  the malleolus internus being splintered off as well.   This
constitutes the form of injury called " Pott's fracture,"  and  is
perhaps the most common fracture in this situation.
   3d.  The  fibula  may be  fractured at  about three inches
above the ankle, and  the lower end of the tibia at the same
time be splintered off in an oblique  direction from without,
downwards and inwards (Fig. 90).   And, lastly, the internal
malleolus may alone be broken off, the fibula remaining sound,
but one of the divisions of the external lateral ligament being
torn through.
   The signs of these fractures vary somewhat according  to
the bone that is injured.  When the fibula alone is broken,
there is but slight displacement of  the foot, but great pain
and much swelling, with perhaps indistinct crepitus and ir-
regularity of outline at the seat  of  fracture.  If the  tip  of
the inner malleolus is broken off as  well, this may be  ascer-
tained by feeling the  depression above the detached fragment.   In those cases
in which the lower end of  the tibia  is  obliquely splintered, as well as the fibula
broken, there are not only the  ordinary signs of fracture,  with  eversion  of the
toes, and a corresponding turning inwards of  the heel, and some rotation  of the
feet outwards, but the  malleoli are  widely separated,  giving  an appearance of
great increase in breadth to the joint;  crepitus is very readily felt, and a depres-
sion can be perceived corresponding  to the line of fracture.
   In these cases there  is always a good  deal of swelling from  ecchymosis and
inflammatory action, which requires  to  be subdued by the continuous application
of cold before any apparatus can be applied.   If there  is not much  displacement
 
230
SPECIAL  FRACTURES.
of the foot, the treatment may besf be conducted by splints with good foot-pieces,
and the starch bandage.  If the foot be much twisted, Dupuytren's splint should
be applied on the opposite side to that on which the twist of the foot has taken
place, the pad being thickly folded  at its lower end, and not  descending below
the ankle.   Much stiffness is always felt after union has taken place, the ankle
remaining weak and useless for a long time.
   Compound Fractures of the ankle-joint are very serious injuries, commonly
requiring amputation, if associated  with  dislocation and extensive wound of the
soft  parts.  If, however, the wound be  of but moderate extent, clean  cut, and
the tibial arteries uninjured,  the fracture should  be reduced, a portion of bone
being perhaps sawn  off in order to accomplish this, and the  limb then placed
upon a leg splint, with the foot well supported.
  Fractures  of the Foot almost invariably result from direct violence, and
are usually accompanied by much bruising and injury of the soft parts; hence
there is usually but little displacement, and when the fracture is simple, rest and
position alone are necessary.  Compound fractures of the foot, attended by much
bruising, often require partial removal of the part, or amputation of the leg.
  The only special fractures  of the foot,  requiring particular attention, are those
of the calcaneum and the neck of the astragalus.
  The calcaneum may be broken  either by direct  violence,  as when a person
jumping from a height alights forcibly on his heel, and thus fractures the bone;
or else by the powerful action of the muscles of the calf tearing off a portion of
the bone.
  When the os calcis is broken through at its posterior part, beyond the inser-
tion of the lateral ligaments, the  detached  fragment will be drawn up by the
                            action of the strong muscles of the calf.  But when
                            the fracture occurs across the body of the bone, no
                            displacement can take place, owing to the lateral
                            and  interosseous ligaments keeping the posterior
                            fragment   in position,  and  preventing its being
                            drawn away.
                               In the first form of fracture, the pain, swelling,
                            flattening  of the  heel, and prominence of the
                            malleoli, indicate the nature of the  injury, even
                            though crepitus be wanting.  In the second variety,
                            the mobility of the fragment,  and its projection
                            posteriorly by the muscles of the calf, point to the
                            existence   of the fracture, which is  confirmed by
                            the occurrence of crepitus.
                               In the treatment of these injuries, subduing in-
                            flammatory action, keeping the part fixed, by means
                            of bandage  and gutta  percha  splints,  with due
                            attention  to the relaxation of the muscles, is all
                            that can be done.  Union probably occurs by bone
                            in some cases, though very commonly  by fibrous
                            tissue.  [In Fig. 91, the simplest  treatment of
                            fracture of the  os calcis is represented, the leg
                            being flexed upon the thigh, and  the foot ex-
                            tended upon the leg, by means of a slipper, attached
                            by a  cord  to a  band encircling the lower part of
                            the thigh.—Ed.]
                               Fracture of the  Ribs  and Costal  Car-
tilages.—These injuries commonly occur from direct violence, the part that
is struck being driven in towards  the  thoracic cavity, and thus broken.  In
other cases, again, the fracture occurs by indirect violence, the fore-part of the
chest being forcibly compressed, so  that the rib is bent outwards, and thus snaps.
 
FRACTURES OF  THE RIBS.
231
When  the injury is the result of direct violence, the pleura, lung, liver, or dia-
phragm, may be wounded, thus giving rise to the most serious and fatal conse-
quences, such as hemorrhage, emphysema, and inflammation of the parts injured.
When it is occasioned by indirect violence, the thoracic organs may be contused,
and thus injured, although, as the  fracture takes place in a direction Outwards,
they are not, under the  circumstances, liable to be punctured by the fragments.
In some rare cases, the ribs have been known to be broken by the violent con-
traction of the abdominal muscles during parturient efforts.
  Any one of the ribs  may be broken, and frequently several are  fractured at
the same time.   The middle true ribs are those that most frequently give way,
being most  exposed, and at the  same time fixed.   The first and second ribs are
seldom broken, being protected  by  the  clavicle and shoulder; when fractured,
the injury is always a very dangerous one, on account of the importance of the
subjacent  structures.   The  lower ribs, being less firmly fixed than the others,
commonly escape, unless very great  and direct violence be inflicted  upon them.
Any part of a rib may be broken by direct violence; but when the fracture is
the result of compression of the chest, it is usually the convexity, or the neigh-
borhood of the angle of the rib that  gives way.  These  fractures most commonly
occur in  elderly people, in whom  the  elasticity of the thoracic  parietes  has
lessened as the result of age.
   Symptoms.—The  chief  symptom  complained of is a sharp  pricking and
catching  pain at the  seat of injury, in breathing deeply, or in coughing.  In
order to avoid this, the inspirations are shallow, and the breathing principally
abdominal.  On laying the hand  over  the seat of injury, and  desiring  the
patient to cough, a crepitus may often be felt; and in most cases this is audible
on  applying the ear to the chest.   Occasionally the outline of the rib  will be
found to be  irregular, and in some instances, where several ribs are broken, the
whole side of the chest  is flattened  and depressed.
  In treating fractured ribs, the surgeon  need not concern  himself so much
about the union of the fracture as  about the prevention of pain to the patient
in breathing, and the subsequent occurrence of serious inflammation or other
mischief within the chest.
  Any displacement that may exist  usually remedies itself without the necessity
of the surgeon interfering.  If, however, a portion of the rib continues depressed,
it had, I think, better be left  so; the  suggestions that have been made for
elevating these fractures by means of sharp hooks and  screw probes being more
likely than the continuance of the depression to occasion serious mischief to the
contents of the thorax.   In order to prevent undue motion of the broken bone,
and  consequent  irritation produced by its  puncturing  the  pleura or lung, the
movements of the chest may be restrained by the application of a broad  flannel
roller, or of  a laced napkin round it.   Instead of these means, I have for some
years past found it more useful to apply a roll of adhesive plaster round  the
chest.  The plaster must be at least a foot in width, and should be  sufficiently
long to make one and a half turns round the body.  It should be applied very
tightly, and  may be left on for  ten days or a fortnight, when it may require
reapplication.   It supports the chest more firmly and evenly than an ordinary
bandage,  affording the patient great comfort.
  The prevention of inflammatory action must be attempted by the employment
of bleeding, if necessary, but certainly by the adoption of a spare diet and com-
plete rest.   Any complication that may occur, such as emphysema, inflammation
of the  lungs or pleura, must be  treated in accordance with  the principles that
will be laid down in speaking of injuries of the chest generally.
  It occasionally happens that one  or more of the costal  cartilages, especially
the  fifth, sixth, seventh, or  eighth,  is broken by direct violence.   This injury
requires the same treatment  as a  fractured rib; the broken cartilage most
commonly uniting by a bony callus  which surrounds the fractured end. 
232
INJURIES OF JOINTS.
                           CHAPTER XVI.

                        INJURIES OF  JOINTS.

  Joints  are  often  contused  by kicks,  falls, or blows, so as to be  severely
injured, with much pain, and consecutive inflammation of the capsule, synovial
membrane, or other structures  entering  into their  formation.  The treatment
should be  actively antiphlogistic, with complete rest  of the part.  In a later
stage, an elastic bandage, cold douches, and friction, are useful.
  In some cases the bursa,  situated in the neighborhood of a joint, is seriously
bruised, and becomes inflamed  in consequence;  often giving rise to troublesome
suppuration and some sloughing.   When this takes place, free incision into the
inflamed part, in addition to the ordinary antiphlogistic treatment, will afford
speedy and effectual relief to the patient.
  Sprains.—When a joint is twisted violently, so that its ligaments  are either
much stretched or partially torn, though there is no displacement of the  osseous
surfaces, it is said to be sprained.  These injuries are exceedingly troublesome
and most frequently occur  to the wrist and ankle-joints.   The pain attending
them is very severe, and often of a sickening  character, and the sprain is rapidly
followed  by swelling and inflammation of the joint  and investing tissues, often
of a very chronic and tedious character.   As the inflammation subsides, stiffness
and pain in using the part continue for a  considerable length of time, which, in
some cases, give way to a kind of rigidity and wasting of the limb.  In others,
again, a rheumatic tendency appears to be set up by injuries of this description,
and occasionally it happens that in strumous  subjects destructive disease of the
joint is induced.
  If the sprain is  slight, rubbing the part with a stimulating embrocation, and
giving  the support of a bandage, is  all that  need  be  done.   But if it be at all
severe, more active measures must be had recourse to.   The best mode of avert-
ing the inflammation, which is the thing to be dreaded in these cases, is to keep
the parts  for several hours in cold  water, or well moistened with an evaporating
lotion, or wet by means of irrigation.   Should this not check the inflammation,
leeches  should  be freely applied, and  when the swelling has somewhat subsided,
the joint should be supported with an elastic roller or stocking, a starch bandage,
or a leather splint, and  be well douched with  cold water twice a day, and after-
wards rubbed or kneaded with soap liniment, until its usual strength and mobility
are  restored.  This, however, very commonly does  not  occur in sprains of the
knee and ankle for many weeks;  a degree of stiffness,  combined with inflamma-
tion, being left until the stretched and lacerated ligaments have regained their
normal condition.
                            WOUNDS OF JOINTS.
  A joint is known to be wounded when  synovia escapes from the aperture, or
when the interior of the articulation is exposed.   If there is any doubt  as to the
wound penetrating  the synovial membrane, no means, by probing or otherwise,
should be taken to ascertain  this, as in this way the very occurrence that is to be
dreaded may be induced by the  surgeon.   The fact of  the  wound  penetrating
the  joint will speedily be cleared up by the symptoms that occur.
  The severity of the wound of a joint depends chiefly on the size of the articu-
lation, but partly on the nature  of the wound.
  When a small joint, as of one of the fingers,  is opened,  the injury may often
be  recovered from without destruction of the  articulation.   When a large joint 
SPRAINS AND  WOUNDS  OF  JOINTS.
233
is  opened, even  by a small incised  or  punctured wound, there is great danger
lest such extensive local mischief and constitutional disturbance ensue as to lead
to  the destruction of the articulation, with loss of the patient's life.   When the
wound is large, lacerated,  or contused with fracture of the articular ends of the
bones, one or other of these consequences certainly results.   It is especially in
grown-up persons that these unfavorable consequences ensue;  in children, exten-
sive injuries of large joints may heal  favorably, though if  the child  be of a
strumous habit of body, destructive action is apt to be set up.
   The source of danger in a wounded joint is the inflammation set up in the
articulation (traumatic arthritis).  A few hours after the infliction of the injury
the joint swells, becomes hot, painful, and throbs.   The pain increases, becoming
tensive and excessively severe.   If the  aperture be large, synovia freely escapes,
which soon becomes mixed with pus.  If it be small, but little more than a punc-
ture, the joint swells and fills  with  fluid, which will either escape through the
original wound or find an  outlet for itself through a new situation.  The consti-
tutional disturbance becomes very severe, the patient being occasionally carried off
by the violence of the symptomatic fever.   In other cases symptoms of purulent
absorption come on, and death results from pyemia.
   If the patient survive this period of acute action, abscesses will form around and
above  the  articulation, the discharge  from which, as well as  from the joint,
induces'irritative  fever and hectic.    Should this danger be passed through, and
the patient survive, it will be with  a  partially anchylosed limb, the utility of
which is greatly impaired.
   The severity of  the symptoms in the  wound of a large  joint is  evidently
dependent on the extent and depth of the synovial membrane which  suppurates,
and to the pus thus formed being pent up in the midst of tense and unyielding
tissues, from which  it has not a free exit.  It is the admission of air into the
joint that occasions the suppuration, for  we find that  in the most extensive subcu-
taneous wounds and lacerations of joints, as occur in  dislocations and fractures,
suppuration scarcely ever takes place.   The presence  also of  the air  appears to
exercise an injurious influence  upon  the pus that is collected in the depth of the
joint, causing it to become  putrescent and acrid, and thus increasing the local
irritation greatly.   It  is also this retention of acrid and  putrescent pus, in con-
tact with a large inflamed  surface, that gives rise to ataxic fever and pyemia, that
so frequently prove fatal in these injuries.
   In  the treatment of wounded joints,  the first point to be determined must be
whether amputation should be performed, or an attempt made  to save the injured
limb.   If the  joint be small there  can be  no doubt  that we  may attempt, and
shall usually succeed in saving  it.  But if it be one of the larger articulations,
the line of practice must be  determined by the extent of the injury to  the soft
parts, and the constitution of the patient.  If the  wound be but small and  is
clean cut, no surgeon would be justified in having recourse to immediate ampu-
tation, even though it be the knee that is injured.  But if the part is extensively
laid open, with much contusion and laceration, perhaps dislocation, or fracture
and splintering of the bones, the case is different.  Under these unfavorable cir-
cumstances, however, in the upper extremity, and even  in the  ankle, the limb
may not unfrequently be  saved.  If the bones be comminuted, the removal of
splinters and partial resection of the  articular ends may advantageously be  prac-
tised in many cases, more particularly if the patient's constitution be young and
sound, and the soft parts not too extensively damaged.  But if these  be largely
lacerated and widely contused, and the patient aged  or broken in health, amputa-
tion is imperatively called for.   This is more especially the case, when the knee
is the articulation injured; extensive lacerations of  this joint, more  particularly
complicated with dislocation or comminution of the bones, being cases for early
amputation. 
234
INJURIES  OF  JOINTS.
  If it be determined to make an attempt at saving the limb, the principal point
is, if possible, to close the wound by the first intention, and thus to prevent the
occurrence of suppuration.   If it be a  puncture, or clean cut wound, this may
occasionally be done by bringing its edges together and placing a piece of lint
soaked in collodion upon it, or a strip of plaster washed over with  resin varnish,
the inflammatory action being subdued by continuous irrigation with cold water;
no  poulticing or warm fomentations should ever be allowed during this stage.
Union may take place under this dressing, but in the majority of cases the
inflammation that is set up in the joint,  causes so abundant a secretion of synovia
that it becomes loosened by the tension and outward pressure of the accumulated
fluid which escapes from under it.
  If suppuration have come on,  free incisions should be made into the joint, so
as to procure an early outlet  for the pus ; the part must be well poulticed, and an
attempt  made at procuring anchylosis by the granulation and cohesion through
fibrous tissue of the articular surfaces.  By  making free and early incision into
the joint after  suppuration  has once been set up, the dangers  resulting from
decomposition  of the  pus,  and  its absorption  into the system are  in a  great
measure lessened, and the constitutional irritation produced by the tension of the
parts at  once removed.  The joint  itself  is not put  into a worse  condition by
being more freely opened, for when once suppuration  has been set up in it even
to a limited extent, destruction of its tissues must ensue; and the most favorable
termination that can be expected is the production of anchylosis.   At the same
time  constitutional treatment must  be  employed, with the  view of lessening
febrile action and removing irritation,  the  administration of antimonials, with
calomel and opium, being especially serviceable,  but  free purging and all other
sources of irritation should be avoided.
  If the case proceed favorably the discharge will gradually lessen, and the con-
stitutional disturbance subside.  The joint must then be placed in such a position
that when anchylosis results the limb may be most serviceable to the patient.
  If, however,  as very frequently happens when the larger joints are wounded,
the  suppuration within the  articulation, and the abscesses that form outside it,
reduce the patient into a hectic state, secondary  amputation speedily becomes
inevitable.
   When the wound in the joint is too extensive for union by the first intention
to be effected, and yet it be thought proper to make an effort to  save the limb,
the continued application of ice or of cold  irrigation,  with active antiphlogistic
treatment, must be had recourse to, with free and early incisions to relieve tension
and let out matter, so as to lessen the intensity of the suppurative inflammation
that will be set up.  In the great majority of these cases, however, where the larger
joints of the lower extremity especially, are implicated, amputation will  even-
tually be required, the instances of recovery under  these circumstances being
altogether exceptional; and  indeed the  patient not unfrequently sinking during
the attempt at saving the limb.

                               DISLOCATIONS.

  By a dislocation is meant  the more or less complete displacement of the bony
structures of a  joint.   In the orbicular joints, as the hip  and  shoulder, the
osseous structures may be  completely separated from one another, the dislocation
then being complete.   In the hinge  joints, as the elbow and knee,  the  osseous
surfaces commonly remain partially in contact though displaced from their normal
relations to one  another: here the dislocation is incomplete.  In most dislocations
the integuments covering the displaced bones are put greatly on the stretch, but
in some  they are ruptured, and then the dislocation is compound.  Besides these
varieties, surgeons recognise spontaneous dislocations,  in which the displacement
does  not occur from external violence.  In other cases  again,  the dislocation 
REDUCTION  OF  DISLOCATIONS.
235
arises from congenital malformation of the joint, in  consequence of which the
bones cannot remain in proper apposition.
  Dislocations  are  predisposed  to  by various conditions,  amongst which  the
arrangement of the joint  appears to exercise  most influence; orbicular joints
being more liable to dislocation than any of the other articulations, whilst in some
of the synchondroses they never occur.   Malgaigne  finds  that of 491  cases of
dislocation, 321 occurred in the shoulder, 34 in the hip, 33 in the clavicle, 26 in
the elbow, 20 in the foot, besides others in the thumb, wrist, and jaw.
  Dislocations are seldom met with in children, in whom fractures more readily
occur.  Travers, however, has seen the hip dislocated in a boy five years of age.
In old people the bones are so brittle,  and the ligaments so tough,  that violence
causes fracture rather than dislocation.  Hence  it is principally in young  and
middle-aged subjects that dislocations are met with.  They are necessarily more
common in men than in women, from the nature of their respective occupations.
   It  is well  known that it  is rather owing to  the  continuous  tension of the
muscles than to  any arrangement  of their osseous and ligamentous  structures
that the articular ends of the bones of the extremities are  kept in their proper
positions,  and that  considerable external   violence may be applied to  a  limb
without dislocating it.   If, however, the muscles be taken by surprise, or if they
have been weakened by previous injury of any kind,  the  joint becomes predis-
posed to dislocation,  and may be displaced under the  influence  of very slight
causes.  In this way the same joint may be repeatedly dislocated.   Thus I  have
seen a man whose humerus had been dislocated between 40 and 50 times owing
to a weakened state of the deltoid.
   The direct causes  of dislocation are external violence and muscular action.
The  external violence may act either directly upon a  joint, forcing or  twisting
the articular  ends asunder, as happens when the  foot is displaced  by the  twist
of the ankle, or when the thumb is dislocated  backwards by a blow.   But  more
 commonly the force acts at a distance from the  joint that  is displaced, and the
head of the bone is thrown out of its socket by the " lever-like movement of the
shaft," as happens when the head  of the humerus is dislocated by a fall on the
hand.
   Muscular action  alone may cause the dislocation of a bone even though the
part  be previously in a sound  state.   Thus, the lower  jaw has been  dislocated
by excessive  gaping,  and the humerus by  making a violent muscular effort.  If
the joint  have already been weakened by previous injury or disease, muscular
 action is especially apt to occasion its displacement.  The congenital dislocations,
in all probability, arise from irregular muscular contraction in the foetus by which
the bones are displaced, and the normal development of the  joint interfered with.
 In dislocations  of the orbicular joints, after the head of the bone has been thrown
out of its articular cavity, it is  often still further  displaced  by the contraction of
the muscles, which continue until they have shortened themselves to their full
 extent, or until  the dislocated bone comes in contact with  some osseous promi-
 nence that prevents its further  retraction.
   The existence of a  dislocation  is  rendered  evident by the  change in the
shape of the joint, and in the altered relation of the  osseous prominences to one
another; by the articular end of the displaced bone being felt in a new position,
and by an  alteration in the length of the  limb, and in the direction of its axis.
Besides this, there is after a time, if not immediately on the  occurrence of the
accident, impaired motion of and pain in and around the injured  articulation.
   The effects of  dislocation  on the structure of a joint are always of a serious
character.   The  bones that enter into the  formation of the articulation are not
unfrequently fractured as well as displaced, more particularly in hinge joints; the
cartilages may be injured, and the ligaments are always much stretched, and
more or less*torn, the capsule of the joint suffering  especially.  In  many cases 
236
REDUCTION  OF  DISLOCATIONS.
the muscles and tendons in the immediate  neighborhood are lacerated as well as
displaced, and  the vessels  and  nerves  compressed.    The  skin  is  commonly
stretched, and sometimes  ruptured, when  the  dislocation becomes a  compound
one.  If the dislocation be a  simple one, and if the reduction be speedily effected,
these injuries are soon repaired;  and although a  good deal of stiffness may
continue about  the joint,  its  functions are not usually permanently interfered
with.
  If the dislocation be left unreduced, important changes take place within and
around the joint.   Its cavity becomes filled up by a kind of fibrinous material,
almost cartilaginous in structure.   The ligaments are shortened and wasted, and
a false joint forms around  the articular end of the bone in its  new situation.   In
some cases the bone  upon which  the  dislocated head rests becomes depressed
into a shallow cup-shaped  cavity,  so as to  receive it.   In  others the  depression
is formed by the elevation of a rim of callus upon  the subjacent bone, and  in
both instances the cellular tissue  in the neighborhood becomes consolidated into
a capsule of a fibroid character, surrounding and fixing the bone in its new situa-
tion, and usually admitting  of but a limited degree of motion.  The  soft struc-
tures that have  been lacerated at  the time  of the dislocation become  matted
together by plastic material, the  muscles  shorten, atrophy, and at  last undergo
fatty degeneration from disuse; the neighboring vessels and nerves may  become
attached to the new joint, or their sheaths become incorporated with the altered
structures in contact with  them.
  In the treatment of  dislocations, the first and principal  indication  consists in
replacing the bone in its normal situation as speedily as possible.  In doing this,
the surgeon has two great difficulties to overcome : in  the first place, the con-
traction of the muscles of the part; and, secondly, the anatomical structure of
the joint.
  The great obstacle to reduction is the tonic contraction of the muscles inserted
into or  below the displaced  bones; and in the reduction of the dislocation the
surgeon's efforts are chiefly directed to overcome this  contraction.   The longer
the dislocation is left unreduced the more powerful does this become, being less
at the moment of the accident, and immediately afterwards, than  at any subse-
quent period.   Hence reduction  should  be attempted as soon as possible after
the occurrence of the accident, and if the patient be seen at  once, the bone may
sometimes  be replaced without  much difficulty  by the unaided  efforts  of the
surgeon.  Thus Liston reduced a dislocated hip by his own  efforts immediately
after the accident occurred.   If a few hours have elapsed, the muscular  tonicity
becomes so  great that special  means must be adopted  in  order to diminish  it;
and if some weeks  or months have been allowed to pass by, the dislocation may
have become irreducible, partly owing to permanent contraction of the  muscles
which have been shortened by  the  approximation  of  their  attachments, and
which it is impossible  to overcome, but chiefly by the cohesion of the surround-
ing tissues, and  the formation of adhesions about the head of the bone.
  In the reduction of a recent dislocation, advantage may sometimes be taken
of the occurrence of faintness, or  of the patient's attention being distracted to
other matters, in order to effect the  return,  the  muscles being  then taken  by
surprise, and the bone readily slipping into its  place.   Such measures as these,
however, cannot be depended upon, and  muscular relaxation  should be induced
by  the  administration of chloroform  or  ether.   By  the employment of  these
valuable agents, the  muscles  of the  strongest  man  may be   rendered perfectly
flaccid and powerless in a few minutes so as to oppose no action whatever to the
reduction of the dislocation,  which  has  thus been wonderfully simplified and
facilitated.  In  no department indeed of practical surgery has the administra-
tion of  anaesthetic  agents been attended  by more advantageous results than in
this. 
REDUCTION  OF DISLOCATIONS.
237
  Mechanical contrivances are.  much less frequently had recourse to for the re-
duction of dislocation now than formerly.  It is, however, occasionally necessary
to employ apparatus calculated to fix the articular surface from which the bone
has escaped, and to draw down the displaced bone to such an extent that it may
be replaced on the surface on which it  should be lodged.   If the patient have
not been anaesthetized, it will be found that  so  soon  as the bone is well brought
down by the extending force so as to get opposite its  articulation, being  disen-
tangled from osseous  points  upon which it may have hitched, it will  be  drawn
at once into its proper position by the action of its own  muscles, with a sudden
and distinct snap ; the muscles of the part being the most efficient agents in the
reduction so  soon as the  bone is placed in a  position for them to act upon it.
When, however, the  patient has been placed under the-influence of chloroform,
the muscular system  being throroughly relaxed, the bone will  not slip into its
place with a snap or sudden  jerk, but is reduced more quietly, and rather by the
efforts of the surgeon than by any sudden contraction of its own muscles.  It is
important to  note these  differences in the mode of reduction, lest the surgeon,
expecting to hear the snap or feel the jerk when chloroform has been fully ad-
misistered, and, not  doing so, should imagine  the bone not to  be reduced, and
 continue an improper degree of extension.
   The purely mechanical means for the reduction of dislocation are sufficiently
 simple : the patient's body, and  the articular cavity              Fig. 92.
 into which the luxated  bone is to be replaced, are
 fixed by a split sheet, a jack towel, a padded belt or
 some  such  contrivance,  by  which  counter-extension
 is practised.   In some cases  the hands of an  assistant
 or of the surgeon himself, or the pressure of his knee
 or heel, constitute the best "counter-extending means.
    Extension may now be made  either by the surgeon
 grasping the limb to be reduced  and  drawing it
 downwards, or else by means of a bandage or jack-
 towel fixed upon  the part, with a clove-hitch knot
 applied in the way represented in the  annexed cut
 (Fig. 92).   If more force be required, the multiply-
 ing pulleys (Fig. 107),  or the dislocation tourniquet
 invented by Mr. Bloxam (Figs. 109, 110), may be
 used, by which any amount  of  extending force that
 may be required can readily be set up and maintained.
 The " extender" invented by Mr. Jervis is a  useful
 and  powerful instrument for   the  same  purpose.*
 These contrivances, however, are much less frequently
 required now than formerly,  owing to surgeons taking
 advantage of the paralysing  effects of chloroform upon the muscular system, and
 consequently not requiring so much force to overcome their contractions.  When
 any powerful extending force is applied, the skin of the part  should  always be
 protected from being chafed by  a few turns of a wet roller.   The extension must
 be made slowly and gradually without any jerking, equality of  motion as well as
 force being attended to.   In this way the contraction of the muscles is gradually
 overcome, whereas sudden  and forcible extension might excite^ them to react
 against it.   The traction is most advantageously made in the axis that the  limb

   » [The " extender" referred to in the text is probably the apparatus known in this country as " Jarvis's
 Adjuster," invented by Dr. Jarvis, of Portland, Connecticut. This is a most powerful instrument, and is by
 far the most perfect of all the contrivances, which have been invented for the reduction ot luxations.
 The extending power can be rendered very great, and is completely under the control ot the surgeon.
   tv,.. „„*.„...,?.,., ;„ .„..»i;kL «<■ h»;n,r nnni;«.i «« »tprv rlisWntinn in which a resort to mechanical ex-
is a patented instrument.—Ed.] 
238
INJURIES  OF  JOINTS.
has acquired in  its new position without reference to its normal direction or to
the situation of the joint.  In this way the head of the bone is replaced by being
made to pass along the same track that it has torn for itself in being dislocated,
and thus is replaced without the infliction of any additional violence to the tissues
around the joint.
   The question as to whether the extending force should be applied to the bone
that is actually displaced, or to the further end of the limb, has been much dis-
cussed, and appears to me to have received more attention than  it deserves.  It
is  true that by  applying  the extending force  to the displaced bone itself the sur-
geon has greater command over its movements, with less chance of injury to the
intervening bones; whilst, by applying the extending force  to the lower part of
the extremity, he  has  the advantage of  a longer lever for  the reduction of the
head of the bone.   This  lever, however, it must be remembered,  is in many cases
a broken one, and cannot be made  to act if  the bone has to be  replaced in the
direction of the flexion of the  joints that enter  into its  composition.   For this
reason we find  that some dislocations are best reduced by applying traction to
the bone itself that is displaced, as in luxations of the femur and of the bones of
the forearm, whilst, in other cases, as in the dislocations of the humerus,  most
advantage is gained by applying the extending force to the end of the limb.
   But I look upon these points as of comparatively little consequence, believing
that when  the  patient is not anaesthetized, the muscles of the limb themselves
effect the reduction without the  necessity of  the surgeon employing any very
powerful lever-like  action of the bone, and that when the patient is paralysed by
chloroform, the bone is in most cases readily replaced by the simple movements
impressed directly upon  it,  or even upon its articular end, by the hands of the
surgeon.
   In reducing a dislocation, it  is of especial  importance to attend to the relation
of the osseous points in the neighborhood of the joint, and to disentangle the dis-
placed bone from any of  these upon which it may be lodged.   This is especially
the case in such hinge-joints as the jaw and  elbow, in which the arrangement of
the articulation is somewhat complicated.
   After the dislocation has been reduced, the bone must be retained in position
by proper splints and bandages, if necessary, the joint being kept quiet for two
or three weeks,  according to its size, so as to allow of proper union taking place
in the capsule and neighboring structures.  Any consecutive inflammation may
often be  prevented by the continuous application of cold;  and, if set  up, must
be treated by local antiphlogistic means.
   In dislocations of old standing,  reduction is opposed not only by the powerful
contraction of shortened muscles, and by a kind of rigid atrophy of the neigh-
boring structures, but  also by the existence  of adhesions between the displaced
bone and surrounding parts.  If the dislocation have existed for several months,
these  obstacles will in general be sufficiently  powerful to render  it impossible to
effect the reduction  at all, or without the  employment of such  force as to  occa-
sion dangerous  laceration of the tissues  about the displaced bone and serious in-
flammation of them; as  happened in the cases related by Mr. Gibson, in which
rapture of the axillary artery followed attempts at reducing old dislocations of
the shoulder. ^  If itbe determined to attempt the reduction, the  pulleys must be
used, the patient being put under chloroform; but every precaution must be taken
not to allow the traction  to be carried  to too  great an extent, lest sudden lacera-
tion of the parts occur.
   The latest period at which reduction should be attempted varies much accord-
ing to the nature of the dislocation.  It  may be successfully practised at a much
later period in luxations of the orbicular than of the hinge-joints;  and it is especially
in the shoulder that these late attempts may be successfully undertaken.  Accord-
ing to Sir A. Cooper, however, the latest period  at which reduction even in this 
          COMPOUND AND COMPLICATED  DISLOCATIONS.       239

articulation can generally be successfully effected does not exceed  three months,
and eight weeks for the hip : but within this time it may often be safely accom-
plished.  Thus Dupuytren reduced twenty-three  cases  of dislocated shoulder
between the fifteenth and  eighty-second day after the accident; and Breschet
reduced  the hip on the seventy-eighth day.   At a considerably later period,
however, than  this the  luxated bone has been put into place.  Thus Smith, of
the United States, reduced one dislocation of the shoulder at the seventh month,
and another at ten and  a half  months.  In the reduction of some of these old-
standing dislocations, it  has been proposed to divide by the subcutaneous section
those muscles which appear to offer the greatest  obstacle  to  the return of the
bone.  In this way Dieffenbach has succeeded  in reducing a dislocation of the
humerus two years after its occurrence.   In some cases, however, as I have more
than once witnessed, this plan does not succeed,  owing evidently to the existence
of contractions in, and adhesions between, other tissues than  the muscular, and
to the changes that  have taken place  in the articular surfaces preventing the
head of the bone being replaced or retained in its new position.
   Compound  dislocations  are  amongst the most  serious injuries  to which the
limbs can be subjected.   For not only is there  such extensive laceration of the
soft parts that  cover and enter into  the formation of the  joint as to give rise to
the most severe forms of traumatic arthritis, but the bones are often fractured,
and the main vessels of  the limb perhaps greatly stretched or torn.
   The treatment of a compound dislocation must be conducted on the same prin-
ciples that guide the surgeon in the  management of a  wounded joint;—getting
union if possible by the  first intention,  subduing inflammatory action, and letting
out matter as it forms.   Owing to the rupture of the ligaments and of the mus-
cular attachments, there is  usually no difficulty in the reduction, the bones being
readily replaced : but the danger consists in the destructive inflammatory action
that will be set up in the joint and limb from the extensive injury inflicted upon
them.   This varies  greatly, according to the size and situation of the joint, and
the state of the soft parts.  If it be small, as one of the phalangeal articulations,
the dislocation may be reduced, and the parts covered with cold lint.  If it  be
one of the larger joints,  the line of  practice will vary according to other circum-
stances than the mere dislocation.   Thus, if it be in the upper extremity, the
patient being healthy, and the soft parts not very extensively contused or torn,
the  bones may be  replaced, cold  irrigation assiduously applied,  and antiphlo-
gistic treatment pursued.  If there be fracture conjoined with the dislocation,
perhaps resection should be done, as was successfully practised by Hey in several
cases of injury of the elbow of this description; but if the soft parts be greatly
injured as well, and especially if the bloodvessels  and nerves of the limb have
suffered, amputation must be performed.
   In the lower extremity amputation is more frequently necessary;  in the knee
almost invariably so.  Sir A. Cooper states that he knows no accident that more
imperatively demands amputation than compound dislocation of this joint.   Yet
there are exceptions to this rule;  thus, Mr. White had a case of compound dis-
location of the knee-joint  in  a boy,  nine  years  of age,  at the  Westminster
Hospital, in which  he  saved the limb by sawing  off the condyles of the femur
and reducing the bone.   In the compound dislocations of the ankle and the as-
tragalus an attempt should generally be made to save  the limb, in the way that
will be more specially pointed out when we come to treat of these injuries.
   After recovery from compound dislocations the joint will remain permanently
anchylosed; hence attention to position during the treatment is  essentially re-
quired.   But in many cases very good motion is ultimately obtained, though the
stiffness may continue for some length of time.
   The complication of fracture of the shaft of one of the long bones with dislo-
cation of its head increases  considerably the difficulty of reduction.    Under these 
240
INJURIES OF JOINTS.
circumstances, it  has been recommended to consolidate  the fracture first, and
then to attempt the reduction.   But to do this is only to  defer and increase the
difficulties.   At least seven or eight weeks would elapse before the fracture were
sufficiently firmly united to bear the requisite traction to reduce so old a disloca-
tion, and then there would be great chance of rupture of the callus, and at least
extreme difficulty in  the  reduction.  It therefore  appears to me much safer,
under  all circumstances, to reduce the dislocation at once and afterwards to treat
the fracture in the  ordinary way.   In reducing a  dislocation complicated with
fracture of the shaft of the displaced bone, the fracture must first be put up very
firmly  indeed, with wooden  splints completely encasing the limb.   The patient
must then  be put fully under the influence of chloroform, which is of the most
essential service in  these cases,  and when the muscles are  completely relaxed,
extension and counter-extension being made in the  usual way, the reduction may
be effected.  The extending means should always be applied upon the splints, so
that there  may be no dragging upon  the fracture.   In this way I reduced last
winter, without any difficulty, a dislocation of the head of the humerus into the
axilla,  complicated  with comminuted fracture of the shaft of the bone, in a re-
markably muscular man to whom I was called by Mr. Byam, and about the same
time I had a case of dislocated elbow, with fracture of the shaft of the humerus,
under  my  care, at the Hospital, that was reduced with ease in the same way.
After the bone has been reduced the fracture can be treated without difficulty.
   When a simple fracture extends into the articular end of the bone, as in some
dislocations about the elbow and ankle, there is no material increase in the danger
of the  case or in the difficulty of its management.
   In compound dislocation with fracture of the articular ends, removal of splin-
ters, partial resection, or amputation will be  required, according to  the seat and
extent of injury.
   Spontaneous dislocations may occur either suddenly or gradually according to
the nature  of the cause that gives rise to them.
   In many cases they result from the destruction of the joint by old disease; the
ligaments and cartilages being destroyed by suppuration, the head of the bone
becomes carious and absorbed, the articular  surfaces  are  displaced by ordinary
muscular action.   This we commonly see in old cases of hip disease.
   There is, however, another and  more rare  form of spontaneous dislocation to
which  the  hip and shoulder are liable, and which has been especially studied by
Mr. Stanley.  In these dislocations the head of the bone slips out of the articu-
lation  without any  very marked sign of disease  about the  joint, and certainly
without any previous destruction of it.   In these cases there is either a paralytic
condition  of the capsular muscles, as has  been observed several  times in the
shoulder, the deltoid having become paralysed and thus allowed the bone to slip
out of place ;  or, as has been noticed  in  the hip, obscure  rheumatic or neuralgic
pains have for some time been seated in the joint.   This dislocation may not be
confined to one joint, but may affect several.  Thus some time ago there was  a
case in University  College Hospital, in which both shoulders and hips were dis-
located spontaneously.   In many cases it occurs suddenly, and often without any
pain to the patient, the deformity of the  limb attracting attention to the accident,
though in  others it has been preceded by rheumatic affection of the joint.  The
treatment  of these  cases is not very satisfactory.    Reduction in many cannot be
 accomplished, but in others it may be effected readily enough; though the bone
 cannot be  fixed in the joint, out of  which it slips again.   In  a case of sponta-
 neous dislocation of the hip, without any apparent disease of the joint, occurring
 in a young woman  who was  placed  under my care by Mr. Ashton, I readily
 effected reduction by the pulleys three weeks after the occurrence of the displace-
 ment.   The limb was then fixed with the long splint, and maintained at a proper
 length for two or three weeks : when, in consequence of a severe bronchitic at- 
                DISLOCATIONS OF  THE LOWER  JAW.             241

tack, it became necessary to remove the apparatus, and the displacement speedily
returned.   Whilst convalescent from this attack she fell and fractured the dis-
placed femur in its upper third, thus rendering it impossible to replace the bone
again.   In another case of spontaneous dislocation of the knee, occurring in the
same painless manner, the joint could not be  replaced, and permanent deformity
was left.  After reduction in similar cases, a splint  or starched bandage should
be worn for a  considerable length  of  time, so as to  give a chance for the liga-
ments of the joint to recover themselves.  If there be  a rheumatic tendency,
that should be removed by suitable treatment, and if there be a paralytic condi-
tion of the muscles, electricity, the endermic  application of strychnine and cold
douches with friction, may be advantageously employed.
   Congenital dislocations are occasionally met with  in the hip, shoulder, wrist,
and jaw, and have of late years attracted the attention of  surgeons through the
labors of Guerin, Smith, Chelius, Robert, and  others.  These dislocations are
closely allied in cause and nature with other congenital deformities of the limbs,
such as  club-foot, &c.   In them there is usually  found imperfect development of
some  portions of the osseous articular apparatus.   Whether this is so originally,
thus causing the displacement of the bones, or consecutive upon disuse occasioned
by spasmodic action of the one set of muscles or  paralysis of another, dependent
on some irritation in the nervous centres, is scarcely worth inquiring here.   In
some  cases it would appear as if faulty position  of the foetus in utero, or undue
violence during birth, may have  occasioned  the displacement.   These disloca-
tions  are probably incurable, as  there is  always congenital defect of structure in
the articular ends of the bones.
                         CHAPTER  XVII.

                      SPECIAL  DISLOCATIONS.

  Dislocations  of the Lower Jaw are of rare  occurrence, and when met
with are frequently occasioned by spasmodic action  of its depressor muscles,—
opening the mouth too widely, as  in fits of laughing, of gaping, or in attempting
to take too large a bite.   Occasionally this accident  has resulted from blows  or
kicks upon the chin, or from the violent strain upon  the part in tooth-drawing.
The mechanism of the dislocation is
simple  (Fig. 93); when the mouth is
opened the interarticularfibro-cartilage
with the condyle glides forwards on  to
the eminentia articularis.  If this move-
ment be  continued too far,  and the
external pterygoid  contracts forcibly
at the  same time,  the  condyle slips
forward into the zygomatic fossa, the
coronoid process hitching  against the
malar bone, the  axis  of the  ramus
being directed  obliquely  backwards,
and  the dislocation being thus com-
plete.  In this way both condyles  may
be displaced, or only one.
  The signs of this dislocation are evi-
dent from the nature of the accident.   The mouth is widely opened and cannot
                                     16
Fig. 93.
 
242
SPECIAL  DISLOCATIONS.
be closed;  deglutition and speech are impaired, the labial  consonants not being
pronounced ; there is dribbling of saliva over the lower lip ;  the chin is length-
ened, and the lower line of teeth advanced before  those of the  upper jaw; the
cheeks are flattened, and there is a depression in front of  the meatus externus.
There is also an oblong prominence  in  the temporal fossa  between the eye  and
the ear.  If the dislocation is left unreduced, the  patient slowly regains some
power of  movement  over the jaw; he gradually approximates the lips, and,
after a length of time, may even be enabled to bring the lines of teeth into ap-
position.
  When one condyle only is dislocated, the  axis of the  lower jaw is directed
towards the opposite side to that on which the displacement exists, and the gene-
ral signs are the same, but in a less marked degree, as those that are met with
when both sides are dislocated.   The hollow before the meatus on the injured
side is, however, well-marked, and serves to point  out  the seat and nature of
the displacement,  the diagnosis of which is not always readily made; indeed,
R.  W.  Smith states that he has seen attempts at reduction applied to the unin-
jured side.
  Sir A.  Cooper has  described a subluxation of the jaw, which is  most  fre-
quently met with in young and delicate  women,  in which the head  of the bone
appears to slip before the interarticular  cartilage,  so as  to prevent the mouth
being closed.  Most commonly the natural efforts  of  the  part  are sufficient to
return the head of the bone into the glenoid cavity with a loud snap, or a crack-
ing noise.
  The reduction of a  dislocated jaw is easily effected, it being only necessary to
push the angle of the bone downwards and backwards, so as to disentangle the coro-
noid process from under the zygomatic arch, at the same time that the chin is
raised by the surgeon's fingers, in order that the  temporal and pterygoid muscles
may draw  the head of the bone into its  proper position.  The reduction is best
effected by the surgeon standing before the patient and applying his  thumbs,
well protected with a  thick napkin, to,the molar teeth on  either side, and thus
depressing  the angle of the  jaw forcibly  at  the  same  time,  that  he  raises
the  chin by means of his fingers spread out  and placed  underneath it.   The
bone is then returned into its place with so forcible a  snap, that unless care be
taken, or the thumbs be well covered up, they may be severely bitten.  When
only one condyle is luxated, the  efforts at reduction  should  be applied to  the
injured side only.   In the cases of subluxation, Sir A.  Coopfer recommends a
tonic plan of constitutional treatment, such as iron, valerian, and shower-baths;
to this I have found the application of a series of blisters over the articulation a
useful addition.
  After the  reduction, the  four-tailed bandage should be applied, as in cases
of fracture of the jaw, and for several  days the patient must not be allowed to
talk, or  to eat any solid food, lest the displacement return, which it always has
a great tendency to do.  Very old dislocations of this  bone may in this way be
reduced.  Thus Stromeyer  replaced  one at the  end of  twenty-five days,  and
Donovan at ninety (Nelaton).
  The congenital dislocation of the condyle of the lower jaw is a remarkable and
rare condition, for an acquaintance with which we  are chiefly indebted to  Mr.
Smith.  In this condition  there is a  singular distortion of countenance.   The
osseous and muscular structures on the  dislocated side are atrophied, the teeth
of the upper jaw projected beyond those of the lower, contrary to what occurs
in the accidental dislocations, the  mouth can be  closed, speech is perfect, and
there is no dribbling of saliva.   Congenital dislocation of both condyles has not
yet been observed.
  Dislocations of  the Clavicle are rarely met with  in comparison  to the
frequency of fractures of this bone, owing doubtless to the short and firm liga- 
DISLOCATIONS OF THE  SHOULDER.
243
ments by which it is attached to the  sternum and  acromion, and to  its usually
receiving any force that is applied to it in a line  that  corresponds to its axis,
thus causing it to be rather bent and  broken than luxated.
  Either the sternal or the acromial end of the clavicle may be dislocated, and
the simultaneous displacement of both has even been observed.
  The sternal end of the clavicle may be luxated in a direction forwards, back-
wards, or upwards, being thrown before, behind, or above the sternum.
  In the dislocation forwards (Fig. 94), the
end of the bone can be felt in its new position,
the point of the shoulder is approximated to
the mesial line, and the depressions above and
below the clavicle are strongly defined.  It
is occasioned by blows upon the shoulder, by
bending this part forcibly backwards, or by
violence applied to the elbow whilst the arm
is raised from the side.
  This dislocation, which is amongst the most
frequent to which the clavicle is subject, may
readily be reduced  by pushing the  shoulder
outwards and  bending  it  backwards.  The
principal difficulty in  the treatment consists
in preventing the return of the displacement,
owing to the shallowness of the articular sur-
face upon which the clavicle lodges.  With this view a pad and figure of 8 ban-
dage must be firmly applied upon the  displaced end of the bone.
  The dislocation upwards is of extremely rare occurrence.  The signs in the
two recorded cases were so evident  as not to lead to any difficulty in  the diag-
nosis of the accident, the projection of the sternal end  of the clavicle  in its new
situation  being  subcutaneous, and at once cognizable to the touch.   In the
treatment, a bandage and pad, with elevation  of the  elbow, brought  the  bone
into good position.
  The dislocation backwards is  not  of common occurrence, though, according
to Nekton, there are  at least ten  or a dozen cases  on record.   This luxation
appears generally to have resulted  from the point of the shoulder having  been
driven upwards,  or by the  hand being  violently drawn  forwards.  It has also
been observed to result from the direct pressure of the clavicle backwards, as by
the kick of a horse.
  The signs are  those that usually attend a dislocated clavicle, shortening of the
shoulder, and deformity about the upper part of the sternum; but besides these
a special train of symptoms is occasioned  by the pressure of the displaced  bone
upon the trachea, oesophagus, and vessels of the neck; in consequence of which
so much congestion of the head, with difficulty in breathing and swallowing may
result as to require the removal of  the end of the  bone,  as happened  in a case
related by Sir A. Cooper, in which  the  surgeon was obliged to  saw off the dis-
located end.   In some cases the end  of the bone is thrown  upwards as well as
backwards; in others it takes rather a  downward direction.   In the treatment of
this dislocation, it is easy to effect the reduction of the bone by making' a fulcrum
of the fist in the axilla, and then bringing  the  elbow well  to  the side; but it
is difficult to retain  it in proper position.  With this view, the figure of 8  ban-
dage tightly applied to the points of the shoulders, and crossed over a large pad
placed in the middle  of the back, will give  the most efficient support to the
part, the elbow being at the same time well fixed to the side and drawn back.
  The dislocations  of the outer end  of the clavicle are more commonly met  with
than those just described.  The most frequent accident  of this description is that
in which the bone is  thrown upon  the upper  surface of  the  acromion, or upon
 
244
SPECIAL  DISLOCATIONS.
the anterior part of the spine of the scapula (Fig. 95). In several cases of this acci-
                             dent which have of late years presented themselves
          Fig. 95.              at University College Hospital, there has been no
                             difficulty whatever in  the  diagnosis ; the promi-
                             nence formed by the displaced  bone, the narrow-
                             ing of the distance from  the mesial line to the
                             point of the shoulder, the facility of the  reduction
                             of the dislocation,  and the tension of the clavicu-
                             lar portion of the  trapezius  muscle, indicate  the
                             nature of  the accident.  The treatment may in
                             general be  successfully conducted  on the same
                             principles as those on which a fractured clavicle
                             is managed.  In  some cases, however, the  dis-
                             location has a tendency to return.   Under these
                             circumstances, M.  Laugier has found that Petit's
                             tourniquet strapped from the shoulder to the elbow
                             and  properly tightened, keeps  the bone in good
                             position.
                                The outer end of  the  clavicle has been found
                             dislocated under the acromion by the application
                             of direct violence to  the end of the bone.  This
form of displacement is so rare that Nelaton states that there are only  three
cases on record; several instances have, however, of late been mentioned in the
journals.  The diagnosis must be easy, simple digital examination pointing out
the nature of  the accident, and the treatment must be  conducted  in  the same
way as that of fractured clavicle.
   The acromial end of the clavicle has been known to be displaced underneath
the coracoid process.  Here also simple examination and the clavicular bandage
suffice  for diagnosis and treatment.  The only instance  of simultaneous disloca-
tion of both ends of the clavicle that I am acquainted with, has  been reported by
Richerand.
   Dislocations of the Shoulder occur far more frequently  than those of any
other joint.   Their pathology and treatment have been so clearly elucidated by
Sir A. Cooper, that there is  little left for subsequent writers but to follow the
descriptions given  by that great surgeon; though several of the modern French
surgeons, especially Velpeau, Malgaigne, and Goyrand, have thrown some  new
light on the subject.  The reason of the frequency  of these dislocations is to be
found in the shallowness of the  glenoid cavity, the large size and rounded shape
of the head of the humerus, and the weakness of the ligaments; but, above all,
in the extent and force of the movements to which the joint is subjected.  These
displacements indeed would be much more frequent than they  even are, were it
not for the protection afforded to the joint  by the osseous and  ligamentous arch
formed by the coracoid process  and acromion with their ligaments, the  great
strength and  close connexion of the capsular muscles with the  joint, and" the
support given by the tension of the long head of the biceps  over  its weakest
part;  but the principal obstacle  to dislocation  is the mobility of the scapula
enabling all movements communicated to the hand  and arm to react upon  that
bone.
   The shoulder joint is susceptible of four dislocations.  Of these, according to
Sir A. Cooper, three  are  complete, and  the fourth  partial.  I think, however,
that on examination, it will be  found that so-called partial  dislocation is in
reality a complete one. ^ The directions in which  the head of the bone is thrown
are downwards and  slightly inwards under the  glenoid cavity; forwards  and
inicards beneath the clavicle ;   backwards and  downwards under the spine of
the scapula; and inwards and slightly downwards beneath the coracoid process.
 
                 DISLOCATIONS OF THE SHOULDER.              245

Thus  three dislocations are more or less inwards, only one  being backwards or
outwards.
  In the dislocation downwards, or the subglenoid, the head of the  bone lies in
the axilla, resting against the inferior costa of the scapula below the  glenoid
cavity, and lodged between the  subscapular muscle and  the long portion of the
biceps.  This  dislocation is the  most frequent of  all, and is an accident of ex-
tremely common occurrence.   In it  the axillary artery and  plexus of nerves are
compressed and stretched by the dislocated head of the bone; the tendon of the
subscapular muscle is commonly torn near to its insertion to the lesser tubercle
of the humerus, and  the capsular ligament largely
lacerated.   The  supraspinatus muscle may  also  be
torn through,  and the rest of the capsular muscles
put greatly on the stretch.
   In the dislocation forwards, or the subclavicular,
the head of the bone  is thrown on the inner side of
the coracoid process, lying upon the second and third
ribs under the pectoral muscles, and  immediately
below the clavicle (Fig. 96).   In a case recorded by
Mr. Curling,  the infraspinatus and  subscapukris
muscles were  torn away from the  tubercles of the
humerus, and  the teres minor partially lacerated, the
capsule being  completely separated  from the neck of
the bone, which  pressed forcibly upon the  axillary
vessels and nerves.
   In the dislocation backioards, or the subspinous,
the head of the humerus lies behind the glenoid  cavity, and below the spine of
the scapula, between the infraspinatus and teres  minor muscles.  Mr. Key has
found the tendon of the subscapukris torn across, together with the internal
portion of the capsular ligament; the supraspinatus and long head of the biceps
being stretched, but not ruptured.
   In the case  of incomplete dislocation reported by Sir A.  Cooper, the  head of
the bone was found to  be  thrown  out  of the glenoid  cavity, lying under  the
coracoid process upon the anterior part of the neck of the scapula; the capsular
muscles were not torn, but the long head of the biceps had been ruptured.   The
description given by Sir A. Cooper of this case, and reference to the illustrative
plate  in his work on " Dislocations," appear to point to a form of injury of the
shoulder-joint  which  has of late  years been specially described by  the  French
surgeons as a variety of the dislocation  downwards; that form of displacement,
indeed, which by Boyer has been described as the dislocation inwards, by Mal-
gaigne the "subcoracoid" luxation, and by Velpeau as  the  "subscapular" dis-
location ; in which the head of the humerus is placed in front of the  neck of the
scapula, and underneath the subscapular muscle.   Why Sir  A. Cooper described
this as a partial dislocation, I do not understand; for not only was there rupture
of the capsule and of the long tendon of the biceps, but the wood-cut  at page
401 of the last edition of his work, shows clearly that the head of the bone had
formed a new articular cavity for itself, in the subscapular fossa, being apparently
completely thrown out of the glenoid cavity.
   It appears to me that the only dislocation of the humerus to which the term
partial is  strictly applicable is that which has been described by Mr. Soden, in
which  the long tendon of  the biceps is displaced from its groove or ruptured,
and the head  of the bone thrown upwards and forwards under the coracoid pro-
cess, but not out of the glenoid cavity.  It is to this form of displacement also
that Mr. Callaway seems disposed to confine the term partial.
  Dislocations of the shoulder-joint are almost invariably the result of falls upon
the hand  or  elbow,  the particular variety  of dislocation depending  upon  the
 
246                    SPECIAL  DISLOCATIONS.
          t

direction of the shock communicated to the arm, and the position of the limb at
the time of receiving it.   On this account wc almost invariably find the displace-
ments in a direction inwards and downwards.   When a person saves himself in
falling with his arms widely stretched out, the head of the bone is driven with
all the force of a long lever against the lower and inner  portion of the capsule,
which, being  ruptured  in  this its weakest part, allows the bone to be thrown
upon or to the inside  of the  inferior  costa of the scapula, and thus into the
axilla.  When the patient falls upon his elbow, the  inner part of the joint is
still acted on; but the  leverage not being so great, the head  of the  bone is
thrown upwards or forwards under the clavicle.
   The dislocation backwards can only take place when the arm happens to re-
ceive the shock at  the time that it is stretched across the chest.   As this is an
unusual position for any injury to be received  in, this  dislocation is proportion-
ately rare.  An obstacle  to  this displacement may also  be found in the great
strength of the outer portion of the capsule of the joint as compared with the inner.
   Amongst these various dislocations those into  the axilla are by far the most fre-
quent, and that under the clavicle next.   The displacement of the head of the
bone under the spine of the scapula is so rare, that Sir A. Cooper only met with
two  cases of it; one  case  occurred some years ago at  the University  College
Hospital, which was reduced without difficulty by that excellent surgeon the late
Mr.  Morton.
   The signs of dislocation of the humerus are sufficiently obvious, varying, how-
ever, according to the nature of the injury.  In all cases there are six common
signs, viz., a flattening  of the shoulder;  a hollow under the acromion; an ap-
parent projection  of this process; the presence of the head of the bone in the
abnormal situation; rigidity; and pain about the shoulder.
   In the dislocation downwards the head of the bone can always readily be felt
in the axilla, at its anterior and under part; the arm is  lengthened to the extent
of about an inch, the forearm  is usually somewhat bent, and the fingers often
numbed, in consequence of the pressure of the head of the bone on the axillary
plexus.   The  elbow is separated from the trunk and carried somewhat backwards,
but can be approximated to the side.   If the head of the bone cannot be felt in
the axilla, its presence there may be ascertained, as Cooper directs, by raising the
elbow from the side, when  it at once becomes perceptible.
   In the dislocation forwards the head  of the humerus can  be felt  and seen
under the clavicle;  the arm is shortened,  the axis of the limb being directed to-
                              wards its head, and  the elbow  is a good  deal
                              separated  from  the side and thrown back.
                                When the head of the bone is dislocated below
                              the spine of the scapula (Fig. 97), it can be felt
                              and seen there, more especially when the arm is
                              rotated; the axis of the limb is likewise altered,
                              being directed backwards.
                                In  the  dislocation  inwards  there is less de-
                              formity  about  the shoulder than  in  the  other
                              luxations,  the acromion not  forming so distinct
                              a projection.  The limb is somewhat shortened,
                              the elbow being carried backwards and  slightly
                              away from the side; the head of the bone is placed
                              deeply in  the upper and inner part of the axilla,
                              and cannot be  very  distinctly felt, owing to its
                              being thickly covered with soft parts; rotation of
                              the arm and elevation of the elbow being usually
                              required in order that it may be detected.
  In the partial dislocation the signs do not appear to be very evident.   In Mr.
 
DISLOCATIONS OF THE SHOULDER-JOINT.          247
Soden's case there was slight flattening of the outer and posterior parts of the
joint, and the head of the bone appeared to be drawn higher up in the glenoid
cavity than  usual.  There was  great  pain, induced  by any movement  of the
biceps  muscle, and on  attempting any overhand motions the head of the bone
became locked by the acromion.
  Dislocations of the humerus may readily be  diagnosed from fractures of the
anatomical and surgical neck of the bone by the existence of the signs which are
common to all the luxations,  and by the  absence  of crepitus.   In fractures in
this situation also the glenoid cavity always continues to be occupied by the head
of the bone.   The existence of crepitus, of slight shortening but little alteration
in the  axis of the limb, and no correspondence  between this and the position of
its head, are additional signs of value in establishing the diagnosis.  Paralysis of
the deltoid from a blow may simulate a dislocation, the  shoulder being flattened
and the acromion  projecting;  but here the mobility of  the joint, and the pre-
sence of the head of the bone in the glenoid cavity, establish the  absence of dis-
location.
  The  reduction of a  dislocated humerus may be  conducted on three different
plans:  by the heel in the axilla, by the knee, or by drawing the arm  upwards.
Whichever plan is adopted the patient should, if strong, be  put under the in-
fluence of chloroform;  when his muscles  are paralysed by this agent, but little
force is required to effect the reduction, the surgeon's unaided strength usually
sufficing for  this purpose.   If more power, however, should be required than he
can exercise, extension may be made by assistants drawing upon a towel properly
fixed round the lower end of the humerus, or else by the pulleys attached to the
same part of the limb.
  The  reduction of the  dislocation by the heel  in the axilla is certainly the
easiest  procedure in ordinary cases.  In adopting this plan, the  patient is laid
upon his  back upon a low bed or couch; the surgeon seating himself upon the
edge of this on the same side as the dislocated arm, takes the limb by the wrist,
and fixing one foot firmly upon the ground places the other, merely covered with
the stocking, well up into the axilla, so that the heel may press against the lower
border  of  the scapula, and the ball of the foot act  upon the  humerus  (Fig. 98).
He then  draws the limb  steadily downwards, and when it is disengaged to a
                                  Fig. 98.
sufficient extent, brings the hand across the patient, using his foot as a fulcrum,
by which the  head of the  bone may be reduced by being pushed upwards and 
248
SPECIAL  DISLOCATIONS.
outwards.   This mode of reduction is especially serviceable in ordinary disloca-
tions into the axilla, and in those under the clavicle.   In the latter, however, it
will be necessary to draw the arm more obliquely downwards and backwards, and
to press the foot somewhat forwards upon the head of the bone, after it has been
disengaged by being brought below the coracoid process.
  The reduction by the  knee in the axilla is precisely the  same in principle as
the last, though not by any means so good a plan; the knee being too large and
not following the movements of the humerus so readily as the foot.  In effecting
the reduction by this  means, the  patient should be seated on a chair, and the
surgeon standing by his side, and  resting one foot upon the seat, place his knee
in the axilla.  He then seizes the patient's arm about the elbow with his right
hand, and steadying the acromion  with his left, draws the limb well down; then
bringing it across the knee the head of the bone is reduced.
  In some cases reduction is easily effected by laying the  patient on his back,
when the surgeon sitting behind him  raises the arm perpendicularly by the side
of the head, at the same time that he fixes the  acromion.  In this way the head
of the bone is brought directly upwards into the glenoid cavity.
  If the patient is very muscular, or the dislocation of  old standing, it may be
necessary to have recourse to the pulleys in order to effect reduction.  In applying
these  the  scapula must be firmly fixed, the counter-extension being made  by
passing the patient's arm through a slit in the middle of a  jack towel, which should
be fixed firmly to a hook  or staple in  the wall.   The extending force  may then
be applied immediately above  the elbow;  and traction  being made  slowly and
steadily in the direction of the axis of the limb, the head of the bone should be
directed to the  glenoid cavity by the pressure of the surgeon's hands,  so soon as
it has come on  a level with it.  In this way dislocations  of the humerus of many
weeks or even months standing have been successfully reduced; but in employ-
ing these powerful means, especially under the influence of chloroform, the sur-
geon should always bear in mind that unless care be taken, serious mischief, even
laceration of the axillary  artery, may result.   After dislocation of the humerus
has been reduced, the  limb should be bandaged to the side and supported in a
sling; and if inflammation occur about the joint, leeches and evaporating lotions
may be had recourse to.   In compound dislocations of the humerus, the bone
must be reduced as speedily as possible and the wound closed, the local inflamma-
tion being combated by irrigation and other appropriate means.
  After reduction, there  is a tendency  for  the  head of the bone to be drawn
upwards and outwards under and against the acromion, owing evidently to the
deltoid and coraco-brachialis muscles not being any longer counterbalanced in
their actions by those that have been separated from the head of the bone.  Com-
pound dislocation of the  head of  the humerus  is  a rare accident.   In it, even
though the injury be extensive, it  is better not  to amputate if the brachial vessels
and nerves be uninjured.   If they be so, however, the limb cannot be saved, and
must be removed at the joint.  In many cases the limb  may be saved by reduc-
ing the bone at once, and  after this the wound  should be closed and dressed
lightly,  kept cool by constant irrigation, and allowed to suppurate.
  When the dislocation is complicated with a fracture of the shaft of the bone,
it should  be reduced  at  once by  putting  the  fracture up very firmly, and then
attempting the reduction by one of the usual methods.  In the case  to which  I
have already referred, I succeeded without difficulty by means of the heel in the
axilla.  The fracture must then be treated by lateral splints.
   Congenital dislocations of the shoulder-joint have only of late years attracted
attention.    Mr. Smith has ascertained, by post-mortem examination, the existence
of  two  varieties  of this  condition—the subcoracoid and  the subacromial luxa-
tions.  In  these there is  wasting  of the muscles of the shoulder  and arm,  the
motions of which are extremely limited,  whilst those of the scapula  are  prefer- 
DISLOCATIONS  OF  THE  ELBOW.
249
naturally great.  The condition of the bones is also  remarkable.   In a case of
congenital subacromial luxation of both shoulders there was no trace of a glenoid
cavity, but a well-formed socket  existed  on the outer side of the  neck  of the
scapula, receiving  the head  of the humerus,  which  was small  and distorted.
These  dislocations, though existing from  birth, usually become more marked as
age advances, but are necessarily irremediable  in  consequence of the malforma-
tion of the osseous structures and the wasting of the muscles.
  Dislocations of the Elbow are by no means unfrequent accidents, and as
they are often occasioned by  direct violence,  in  consequence of which  much
swelling speedily sets in, their signs are frequently obscured, and the diagnosis
rendered proportionally difficult; more especially when the dislocation happens to
be complicated with fracture of the articular ends of the bones.   In  these cases,
indeed, it is only by a correct acquaintance with the normal  relations  of the
osseous points,  and by a comparison between  those  of opposite sides, that the
surgeon can detect the true nature of the injury.
   The dislocations  of the elbow-joint  are  very numerous, either both bones of
the forearm or  only one being implicated.  The most common dislocation is
that in which both bones  are thrown backwards (Fig. 99), with or without frac-
ture of the coronoid process.   This injury is readily recognised by the projection
backwards of the olecranon, carrying with  it the  tendon of the triceps.   The
articular end of the humerus also can be felt projecting in front of the elbow.
 When the coronoid process is not  broken off,  it is fixed against the  posterior
surface of the humerus, the
forearm   being  immovably
placed in  its new  position.
When this process  is frac-
tured there is great mobility
about the joint, and crepita-
tion may be felt as  the arm
 is drawn forwards.
   Dislocation of both bones
foricards can scarcely occur
without  fracture of the  ole-
 cranon.  There  are, however, cases on record in which the bones have been so
 displaced without this process being broken.   In this .injury the elongation of
the forearm, the projection of the condyles  of the  humerus, and the depression
of the posterior surface  of  this  bone, render the diagnosis sufficiently  easy.
 When the olecranon is broken off, there is  elongation of the  forearm and great
 mobility, but the detached fragment can be felt behind the humerus.
   The lateral dislocation of the bones of the forearm  is  most invariably incom-
 plete ; either the head of the radius hitching  against the internal  condyle, or
the ulna coming in contact with the external  one; complete lateral dislocation
of the bones of  the forearm  being excessively  rare.   The only  instance that  I
am acquainted with is a luxation outwards, reported by  Nekton, and of which
he has given a wood-cut.
   The ulna or radius alone may be displaced, and, in some cases, both bones are
dislocated, but  in opposite directions, thus complicating considerably the nature
of the accident.
   The only dislocation to which the ulna alone is subject is that in a direction
backwards.   This seldom happens  without  more or less dislocation  of the  head
of the radius.   When it occurs it may be  recognised by the projection of the
olecranon backwards, and by the head of the radius being  felt in its normal
situation during the movements of pronation and  supination.  In the majority
cases the coronoid process would be fractured,  at  the same time  causing  ready
disappearance and recurrence of the dislocation with crepitus.
 
250
SPECIAL  DISLOCATIONS.
  The radius alone may be  dislocated  forwards, backwards, or outwards.  The
dislocation forwards  is certainly the most common.   In the many instances of
it that I have seen, it has resulted from a fall on the palm of the hand, by which
the lower  end of the  radius being  driven  backwards, the upper end  is tilted
forwards with the  whole force of the  leverage of the bone, and in  this way,
rupturing the annular ligament, is thrown against the  external  condyle.  The
signs of this displacement are the following:   The forearm is  slightly  flexed
and in a mid state between pronation and supination; any attempt at  the latter
position occasions great pain, as does also the effort  at straightening  the arm.
The elbow can only be bent  at  an obtuse angle, in consequence  of the head of
the radius  resting against the lower end of the humerus.  On rotating the radius
much pain is experienced, and the head of  the bone  can  be felt  to roll on the
fore part of the humerus.  The whole of the outer side of the  arm is deformed,
                                               being carried  somewhat up-
                                               wards (Fig. 100). The rupture
                                               of the annular ligament in this
                                               dislocation makes it very diffi-
                                               cult to  keep the head of the
                                               radius properly  fixed, so as  to
                                               prevent   a recurrence of the
displacement.   In some cases, and indeed not unfrequently, there is incomplete
dislocation of the radius forwards, arising either  from falls upon the  hand,  or
from  violent twists of the forearm.  In these  we  have  the  preceding  signs,
though to a less marked degree.   The most characteristic symptom, however, is
the inability on the part of the patient to flex the forearm upon the arm.   This
he can never do to a greater extent than to bring the elbow to a right angle. On
being told  to touch  the tip of his  shoulder  with  his  forefinger, he will find it
impossible  to do so.
  The dislocation of the radius backwards (Fig. 101) is of extremely rare occur-
rence ;  it may always be recognised by the head of that bone being felt subcuta-
neously behind the external condyle; the movements of the elbow, and of the radius
especially,  being at  the same  time  very limited and painful.  The dislocation of
the radius outwards is of more  frequent occurrence than the last  form of injury,
                                                the  head of the bone being
                                                thrown on the outer side  of
                                                the  external  condyle,  where
                                                it  is felt under the  skin roll-
                                                ing  as  the  hand  is moved.
                                                The natural motions of the
                                                joint are of  course  greatly
                                                interfered with.
                                                   The  radius  and ulna are
                                                sometimes displaced in oppo-
                                                site directions, the ulna being
thrown  backwards,  and the radius forwards. This injury, of which I have seen
two instances at the  Hospital,  usually results from  heavy falls upon the hand,
with a_ wrench of the limb at the same time, as when a person is thrown out of
a carriage, or  lights upon his  hands, in consequence of which  the  bones are
twisted and displaced in opposite directions.   The deformity is of course great,
but readily recognised by the combination of the characters of the two forms of
displacement, provided an examination be made before the swelling has come on,
which rapidly sets in.
  Dislocations of the elbow-joint are very frequently  complicated with fracture
of one  or  other condyle of the humerus, of the  olecranon, and, as we have
already seen in  displacement of the ulna,  of the coronoid process.   In these
 
DISLOCATIONS OF  THE  WRIST.
251
complicated injuries an exact diagnosis is often extremely difficult, owing to the
looseness and mobility of the parts, and to the great tumefaction that accom-
panies accidents of this description.   It is in these cases that a good knowledge
of the relative bearing of the different  osseous  points, aided  by a comparative
examination of the opposite limb, will alone enable the surgeon to effect a proper
diagnosis of the nature of the injury.
   The mode of reduction in dislocations of the elbow-joint varies according as
the ulna is displaced or not.  When the ulna is dislocated, in  whatever direction
it may be thrown, and whether the radius be displaced at  the same time or not,
we shall find that the great obstacle to reduction is the hitching of the processes
of that  bone  against the articular end  of
the humerus.   If either the olecranon or
coronoid process  be  fractured,  this  en-
tanglement cannot take place, and the joint
then slips  into its  position without  diffi-
culty, though it is very difficult  to main-
tain it there.   The  reduction of the dis-
placed  ulna,   when   uncomplicated  by
fracture, may always be  effected, as Sir
A. Cooper  has recommended, by bending
the arm  over  the  knee.   The patient
being seated on a chair, the surgeon  rests
one foot upon  the  seat, and placing the
knee  in the  bend of the  injured elbow,
grasps  the forearm  with  both hands;
fixing the arm,  he presses the knee firmly
against  the inner aspect of the  forearm so
as to disengage the  ulna  from the  lower
end of the humerus, and at the same time
he bends  or  pushes the forearm  into pro-
per position, into which, indeed, it has a
tendency to  return  by the  action  of  its
own muscles, so soon  as  the  opposing
osseous  surfaces are separated (Fig.  102).
   In dislocations of the radius, this move-
ment across  the knee  is  not  necessary.
All that is required is to fix the upper arm, and then employing extension  from
the wrist to straighten the arm  well, when  by bending the elbow at right angles
 the head of the radius may be pressed into a proper position.
   After reduction has been effected, the limb should be firmly put up in lateral
angular splints, the hand being kept semi-proned.   If the radius have been  dis-
placed,'a pad should be firmly* applied over its head, so as  to prevent a return of
the displacement, which is very apt to occur when the orbicular ligament is torn.
The inflammation which usually  results must be combated by the free  applica-
tion of  leeches and  of evaporating  lotions.  When  this  has subsided, passive
motion  may be commenced, and  frictions and douches had recourse  to, so  as to
remove  the stiffness that is apt  to be left about the joint.
   In those cases in which the dislocation is complicated with fracture of some
part of the articular ends, and  in  which the  diagnosis  of the precise nature
of the injury, owing to the swelling or other causes, has  not been very clearly
made out, the joint should be placed in as good a position as possible by a process
of traction, flexion, and moulding, so as to bring the osseous  points into proper
bearing with  one another;  the  angular splints must then  be  applied, and local
antiphlogistic treatment had  recourse to.  At the end of  a month or five weeks
passive  motion may be commenced, lest permanent rigidity  come on, which is
 
252
SPECIAL  DISLOCATIONS.
Fig. 10.3.
 very apt to supervene.  Compound dislocations of the elbow-joint require to be
 treated on the same principles on which compound fractures of this articulation
 are managed.  Dislocations of both bones have been  reduced some weeks after
 the occurrence of the accident, and of the radius alone at as late a period as two
 years after the displacement.
    Dislocations of the Wrist are of rare occurrence, so much so that their
 existence has been  denied by Dupuytren and other modern surgeons.  Although
 there can be no doubt that fractures of the lower end of the radius, more espe-
 cially of an  impacted character, have often been  mistaken for these displace-
 ments, yet there can  be  no question that they  do occasionally, though rarely
 occur.  Any doubt that  may formerly have existed upon 'this point,Pin conse-
 quence of the want of post-mortem examinations, has been recently cleared up
 by the dissections  of cases  that have been made by Marjolin and Yoillermier.
                          The observations of these  surgeons, together  with
                         those previously made by Sir A. Cooper, tend to show
                         that dislocation of the carpus may  take place either
                         backicards  (Fig. 103),  or  forwards.   In  which-
                         ever direction  the accident  occurs,  a smooth convex
                         swelling, corresponding to the first  row of the carpal
                         bones, is  felt and seen  opposite the  wrist.  There is
                         some shortening  of the forearm, and the styloid pro-
                         cesses of  the radius and ulna form a projection on the
                         opposite side to that in which.the carpal tumor is seen.
                         The facility with which  the  deformity is removed, and
                         the displacement reduced, together with the general
                         laxity of the wrist joint, enable the surgeon to diagnose
                         the injury from impacted fracture of the radius.   The
                         existence  of the swelling points out that it is not a mere
                        sprain of  the wrist that has occurred.
                           The treatment is simple : reduction, which is readily
                        effected, may be maintained by the application  of an-
                        tero-posterior splints.
                           Congenital Dislocations of the Wrist may take place
 either forwards or  backwards.   The  limb is in  either case greatly deformed.
 The bones are shortened and altered in shape, more especially the lower end of
 the radius.   Ihe muscles are also shortened, the extensor  tendons forming a
 sharp angle as they  pass over the carpus.
   Dislocations of single Bones of the Carpus are by no means of frequent
 occurrence.   The bone that is most commonly displaced is  the os magnum.
 This  accident usually  happens from falls, in which the  hand  is violently bent
 forwards, in consequence of which this bone starts out from its articulation, pro-
 jecting as a round hard tumor on the back of the wrist, opposite to the metacarpal
 bone of the middle  finger.  It may be readily reduced by being pressed upon at
 the same time that the hand is extended, thus pushing it into  proper  position.
 There is, however, a great tendency for this bone to slip out again, leaving  con-
 siderable weakness of the joint, so much so,  that in two cases recorded by Sir A.
 Cooper, the patients  found it necessary to wear artificial supports.

 h,i  TM w^     !v? J'f °bserVed t0 be disPlaced h? Evans ™* Fergusson,
 IhLlvri n°tTr\tliat d^Gatr °f "* 0ther of the carPal bones hiS been
 observed.   A case, however, lately occurred to me at the Hospital, in which the

 h^eZl7h\Tf7V7ed  t0 t  1i8l°-Cated-   The Patient in wh™ thilaccident
 hand under bint   n   *  a >eiSH injuring his spine, and  doubling his right
 hand under him.  On  examining the wrist, a small hard tumor was felt  pro-
jecting™ its dorsal aspect  which readily disappeared on extending the hand and
 employing  firm pressure, but started up again so soon  as  the wri_t was forcibly
 
DISLOCATIONS  of THE CARPUS.
253
flexed.   It was evident that this bone belonged to the first  row of the carpus,
articulating  with  the radius, and  from its size, its position  towards the  radial
side of the carpus, and its  shape, which could be pretty distinctly made out
through the integuments, there could be little  doubt that it was the semilunar
bone.
  The only metacarpal bone that admits of  dislocation  is that of the thumb;
and though the articulation between this bone and the trapezium appears at first
not to be of a character to resist much external violence, yet displacement of  it
seldom takes place.  This is probably owing  in a great measure to the powerful
muscles by which the bone is supported in all cases in which the force is applied
upon its palmar aspect, as it most frequently  is,  as well as  to the little leverage
offered by so short a bone.  These luxations, however, have been  observed in
two directions, backwards and forwards.   The dislocations backwards, which are
the most common, are often compound, arising from powder-flask  or gun-barrel
explosions in the palm of the hand, by which the joint is opened,  and the bone
thrown backwards. The reduction is in general easy, extension being made from
the thumb by means of a piece of tape applied round the first phalanx.
   Dislocation  of  the metacarpo-phalangeal  articulations are by  no means of
common occurrence,  though occasionally met  with (Fig.
104).  Most frequently the proximal phalanx  of the thumb        Fis-104-
is the bone that is dislocated, being thrown backwards on
the metacarpal bone.   The signs of  this  accident  are
sufficiently evident, the prominence formed by the articular
surfaces being distinctly marked.   This dislocation of the
proximal phalanx of the thumb, has, owing to the difficulty
of its reduction, attracted more attention than it would at
first appear  to deserve.   So great has this  difficulty been
in some cases as to render the dislocation irreducible, or to
compel the surgeon to have recourse  to  operative interfer-
ence in order to replace  the  head of the  bone.   The
obstacle to the ready reduction of this small bone has been
attributed to different causes.  Thus, Hey supposed that it
was owing  to the constriction of the neck of the  bone between the lateral liga-
ments of the joint;  and Dupuytren  entertained a very similar opinion, looking
upon the position of  these ligaments as  the principal  source  of difficulty.  The
folding  in  of the anterior ligament of the  joint and  the  interposition of a
sesamoid bone between the articulating surfaces has also been looked upon as
giving rise to this peculiarity.
   The more probable explanation, however,  appears to be that the neck of the
metacarpal bone  becomes locked between or constricted  by the two terminal
attachments of the short flexor of the thumb, which must be carried back over
its  head,  together with  the displaced  phalanx.   The  observations of Vidal,
Malgaigne, and Ballingall,  point to this as the cause.
   In many cases  this dislocation may be reduced readily enough by  the surgeon
making extension with his fingers simply, and then pushing the bone into place;
or  better still,  after making  some  traction, by forcibly bending the phalanx
towards the  palm of the hand.   If these means do not suffice,  the hand should
be fixed, and steady traction then be made from the phalanx, to which, previously
protected by a strip of wet wash-leather, a piece of tape has been applied with a
clove-hitch knot, or if more force be required the pulleys may be used. In some
cases the bone may be replaced by passing the ring of a door-key over the thumb,
fixing one side against the projecting head of the phalanx, and then drawing and
pressing this into its  proper  position.   If all these means  fail,  subcutaneous
section  of the opposing muscle may be practised.  If the dislocation be left
 
254
SPECIAL  DISLOCATIONS.
unreduced, Sir A. Cooper says that the patient may still have a very useful thumb.
In compound dislocation of this joint the bone may usually readily be replaced;
                    should there be any difficulty, its head must be removed, the
                    dislocation being then reduced with great readiness, and the
                    wound treated in a simple manner.
                       Dislocation  of the phalanges rarely occurs; when met
                    with, these displacements are  readily recognised by  the
                    deformity they entail (Fig. 105),  and as easily reduced by
                    pressure and traction in proper directions.  In compound
                    dislocation of the phalanges, the bone should  be replaced,
                    the finger supported  by a pasteboard splint, and the wound
                    dressed  lightly.  In some cases  it is necessary to remove
                    the projecting end of bone before this can conveniently be
                    done, anchylosis  then  results, a  sufficiently  useful finger
                    being left.
                       Dislocations of  the Hip.—Notwithstanding the great
                    depth of  the  acetabulum,  the complete manner in which
                    the head of  the thigh bone is received  into its cavity,
the firmness of the capsular  ligament,  and the great  strength of the capsular
muscles  that  surround and  support  the joint, dislocations  of  the  hip are
more  frequently met  with than those of many other  joints  that  appear less
perfectly supported.   This is doubtless in a great measure owing to the  great
length of leverage of the  femur acting  upon its head, when external violence is
applied to the knee, and of that of the whole length of the lower extremity when
it is applied to the foot.
  The different forms  of dislocation of the femur have  been expressed with
great  clearness and precision  by Sir A.  Cooper, who has shown that its head is
most commonly thrown upwards and somewhat backwards, so as to lodge on the
slightly concave surface between the acetabulum and the crista ilii, resting on the
gluteus minimus,  and having the  trochanter turned  forwards;  or it may be
thrown downwards into the  foramen ovale, lying upon the obturator  externus
muscle;  or fur wards and upwards upon the horizontal branch of the pubes under
the psoas and iliac muscles, to the  outer side of  the femoral vessels.   The head
of the bone may also be thrown backwards into the sacro-sciatic notch, resting
upon  the pyriform muscle.  These are the four forms of dislocation of the hip
admitted by Sir A. Cooper, as of the more usual character ; besides these, however,
may be added, as not of very  unfrequent occurrence that form in which the bone
is  thrown  backwards and somewhat downwards behind the tuberosity of the
ischium.   Besides these,  other less common  forms of dislocation have been
noticed;  for instance,  one in  which the head of the bone lies between the
anterior superior and  the  anterior inferior spinous process of the ilium, or that
in which it has been thrown upon the spine of the ischium.  In all these various
forms of dislocation there  is a rupture of  the capsular ligament and of the liga-
mentum  teres, with laceration of the muscles  about the joint and extravasation
of blood  into and around them.
  The signs, causes, and treatment of the different dislocations  of the hip, differ
so greatly from one another,  that, practically, it becomes  necessary to describe
each of these  displacements as a separate lesion.  In considering these we may
reduce the more ordinary dislocations of the hip to four distinct  varieties, besides
which, however, it is necessary to bear in  mind, that other and  less usual forms
of displacement may occur.
  The most common dislocation is that in which the head of the bone is thrown
upwards and backwards upon the dorsum of  the ilium, or rather upon that
portion of the bone which extends between the acetabulum and the sacro-sciatic 
DISLOCATIONS  OF THE HIP.
255
notch.   This displacement differs so slightly in its pathology and treatment from
the dislocation into the sciatic notch, described as a distinct variety of the injury
by Sir A. Cooper, that I think it is more consistent with the true nature of these
accidents to look upon them as essentially the  same, the displacement in both
cases being upwards and backwards, but in different instances partaking more
of one  or other direction.   This dislocation  may therefore be  described as the
ilio-sciatic.
  The  next distinct dislocation  is that in which  the head of the bone is thrown
downwards upon the obturator foramen, hence termed the thyroid dislocation.
  The  third variety is the pubic, where the head of the bone is thrown upwards
upon the pubes ; and lastly,
  The  sciatic dislocation, in which  the  bone is thrown downwards and back-
wards behind the tuberosity of the ischium.
  Thus it will be seen  that in whatever direction the displacement occurs, the
head of the bone has a tendency to sink into some cavity or depression, or to be
upon or behind one of the osseous surfaces in the neighborhood of the acetabulum.
  In the dislocation upivards and backwards or the ilio-sciatic (Fig. 106), if
the head of the bone rest upon the dorsum of the
ilium, the hip will  be  found to be a good  deal
distorted, the gluteal region being somewhat pro-
minent, and the upper part of the thigh enlarged,
in consequence of the approximation of the mus-
cular attachments.  The  head  of the bone  can
be felt in  its new situation, more especially on
rotating the limb; the  trochanter is  less promi-
nent than natural, usually lying close against the
brim of the acetabulum,  and being  turned  for-
wards ;  there is considerable shortening of  the
limb, varying from one and a half to three inches,
and its position is  remarkable, being distinctly
rotated inwards,  with  the  thigh slightly bent
upon the abdomen,  and the leg upon the thigh,
so that the  knee is  semi-flexed, and  raised from
the surface on which the patient is lying.   The
foot is inverted, so that the ball of the great toe
rests on the  ankle  of the sound limb,  and  the
heel is  somewhat raised.   The axis of the thigh
is directed towards the  sound knee.  The move-
ments of the joint are  greatly impaired; abduc-
tion  and eversion are  not  practicable,  but  in-
version, adduction, and some flexion upon the abdomen can be practised.
  When  the  head of the bone slips a little further back so as to become lodged
in the  sciatic notch, we  have  the dislocation backwards  of Sir A. Cooper.   In
this the same symptoms exist, though to a less degree; hence the diagnosis is
proportionately difficult.   There is much less deformity  about the hip in this
variety of the displacement, owing to the head of  the bone sinking into the hollow
of the notch, and thus presenting the trochanter nearly in its  usual position at
right angles with the ilium, though  somewhat  behind and* a little above  its
normal  situation. In  consequence of the head of the bone being received in a
depression,  the  axis of the limb is not altered to the same extent as when it is
thrown  upon  the plane surface of the dorsum ilii;  hence the  inversion of the
knee and foot, though existing, is not so strongly marked.   As  the sciatic notch
is but little above the  level of the acetabulum, the shortening of the limb is
inconsiderable, not exceeding half an inch or an  inch at most.   The  axis of the
 
256
SPECIAL  DISLOCATIONS.
limb also is directed across the middle of the sound thigh in consequence of the
bone being  thrown further backwards.  Thus the signs of these two forms of
dislocation are nearly identical in character, though varying in degree, the prin-
cipal difference  being, as Sir A. Cooper has pointed out,  that when the head of
the bone rests upon the dorsum ilii, the axis of the femur is directed to the sound
knee, whereas when the head of the bone is lodged in the sciatic notch, the axis
of the  limb is directed across the middle of the sound thigh.
  This dislocation  upwards and backwards is that which  is most frequently met
with in the hip.  It  is  occasioned by violence acting upon the limb whilst ab-
ducted; with the body bent forwards upon  the thigh, or the thigh upon the abdo-
men, as when a person is struck on the back with a heavy weight, or thrown for-
wards,  or falls whilst carrying a heavy load upon his shoulders, when the upper
and posterior part of  the joint receives the whole of the strain.  Under these
circumstances, the  capsular ligament is ruptured, and the  bone slips out of its
articulation.
  The diagnosis of this form of dislocation, is  easy in proportion as the head of
the bone  lies high on the dorsum ilii.  The more it sinks towards and into the
sciatic  notch, the more difficult does the detection of the displacement become,
and the greater the risk of its being overlooked altogether  or  mistaken  for a
sprain.  The only severe injury of the hip with which the dislocation upwards
and backwards can be  confounded, are those rare cases in which there is fracture
of the neck of the  femur, with  inversion  of the limb;  here, however, the
increased  mobility, and  the existence of crepitus, will enable  the surgeon  to
effect the diagnosis.  In  ordinary cases of fracture of the neck, the existence of
eversion of the limb at once points out that the head of the bone is not dislocated
on the ilium.
   The reduction of this  form  of dislocation is effected in the  following manner.
The patient having been put under the influence of chloroform, is  laid on his
back upon a strong table  between two staples, one of which  should  be fixed to
the floor and another at  a point  above the level of the  body, in a direct line
with the axis of the limb, and about twelve feet apart.  The  counter-extending
force, consisting of a jack towel or of a padded leather belt, must then be passed
between the injured thigh  and perineum, and fixed  to the staple  in the floor.
The pulleys  must now be attached to proper straps  or to  a towel fixed with a
clove-hitch knot immediately above the knee by one end;  the  other extremity
being  attached  to the staple in the wall, which should be so situated as to be
continuous with the axis of the lower part of the limb.   The knee being then

                                  Fig. 107.
slightly bent and rotated inwards, traction is applied slowly and  steadily until
the head of the bone has approached the acetabulum, when the surgeon rotates 
DISLOCATIONS OF  THE  HIP.
257
Fig. 108.
the limb inwards so that the head may slip into its  socket (Fig. 107).  If diffi-
culty occur in raising the bone over the acetabulum, the plan recommended by
Sir A. Cooper, of passing a towel under the thigh to enable an assistant to lift
the head of the bone over the brim of that cavity may be had recourse to.   The
fact of the reduction being accomplished is  ascertained by comparing the bony
points of the limb with those of the opposite  side, and seeing if they correspond.
A long splint and spica  bandage should now be applied to fix the thigh, and the
patient be kept in  bed for  a fortnight so that reunion of the ruptured tissues
may take place.   In reducing this dislocation, there is some danger of the head
of the bone  slipping downwards into  the sciatic notch, if the limb be too much
raised.  This  accident, which  has happened to some very excellent surgeons,
may be mistaken for reduction of the bone, a serious mistake, that would, unless
corrected, entail permanent lameness  on the patient.
   When the bone is thrown upon the sciatic  notch, the reduction is difficult, and
a slight modification of  the treatment  is required; this consists in laying  the
patient on his sound side  instead of on  his back, and making extension across
the middle of the sound thigh instead of immediately above his knee as in the
last case.  In the reduction of  this dislocation also, Sir A. Cooper gives the very
valuable advice, of  lifting the  femur out of the notch and over the edge of the
acetabulum by means of a round-towel  placed under the upper part of the thigh and
over the shoulders of an assistant,  who at the same  time should rest his limbs on
the patient's pelvis,  and then raising his head draw the bone towards its socket.
   In  the  dislocation downwards into the obturator foramen (Fig. 108), we find
the hip flattened, and the prominence of the tro-
chanter completely absent, or indeed replaced by a
depression.  The limb is lengthened  by about two
inches, advanced before the other, and considerably
abducted.   The knee is bent and incapable of ex-
tension;  the foot usually points forwards, but  is
 sometimes slightly everted, and is widely separated
 from its fellow.  The body is bent forwards in con-
 sequence of the tension of the psoas and iliac mus-
 cles, and in  thin persons the bone  may be felt in
 its new situation.
   This dislocation appears to be occasioned by the
 limb being suddenly and violently abducted,  as by
 falls,  with the legs widely separated;  in conse-
 quence of which the head of the bone is  tilted
 against the inner side of the capsule;  and raptur-
 ing this, is thrown into  the thyroid notch.
   In  the  reduction of this dislocation .the patient
 should be  placed upon his back,  the counter-extend-
 ing girth, or towel, is then placed round the pelvis,
 and fixed  firmly to a staple next the sound side  of
the patient.   A padded girth is then to be placed
between the perineum and the upper part of the dis-
located thigh.  From this, extension is made by  means of the pulleys  or the
tourniquet, which are fixed to  a staple at a little distance  from the  injured side
of the patient.  Extension having then been made to such a degree as to elevate
the head of the bone from the depression in  which it lies, the surgeon passes his
hand  behind  the sound leg, and seizing the ankle  of the injured limb, draws it
backwards and towards  the mesial line, taking care to keep the knee  straight, and
thus throwing the head of the bone into the acetabulum by the action of a long
lever  (Fig. 109).
                                     17
 
258
SPECIAL  dislocations.
  The dislocation vpwards (Fig. 110) on the pubes presents  very  unequivocal
signs.  The hip is flattened; the head of the bone can be distinctly felt lying in
its  new  situation above  Poupart's ligament, to  the  outer side  of the fe-
                                        moral vessels, where it may be made
                                        to roll  by rotating the  limb.   The
                                        thigh and knee are  slightly  flexed,
                                        rotated  outwards, and abducted; the
                                        limb, which  is separated from its fel-
                                        low, is  shortened to the extent of an
                                        inch.
                                           The  cause of this dislocation is
                                        either  direct violence applied to the
                                        back of the thigh whilst the limb is
                                        abducted, or  from the patient making
                                        a false step in walking, and suddenly
                                  :=izn. throwing his  body backwards, in order
                                       Z to avoid a fall, twisting and displac-
                                       _ ing the limb.
                                           With regard to the treatment, Sir
                                        Astley Cooper advises that the patient
                                        should lie upon his back with his legs
                                        widely  separated; and  that counter-
                                        extension being then  made by a girth
                                        carried between the perineum and the
                                        injured thigh, and fixed to a staple in
                                        front of, and above the body, the pul-
                                        leys should  be fixed  upon  the lower
                                        part of the thigh, and the  extension
                                        made downwards an d backwards. After
                                        this has been continued for a sufficient
                                        time, an assistant lifts the head of the
                                        bone by  means of a towel over the
         ^^MMkil^k^i^Ji'm    brim of the  acetabulum  (Fig. 110).
   The dislocation behind the tuberosity of  the ischium  is of  very rare  occur-
 rence.
                                   Fig. no.
  Dislocations of the patella are  not frequently met with.    They may,
however, occur in four directions, viz., outwards, inwards, upwards, and edgeways
or vertically.
  The dislocation outwards (Fig. Ill) is the most common variety of the accident, 
DISLOCATIONS OF  THE  PATELLA.              259
the bone being thrown upon the outer side of the external condyle of the femur,
with its axis directed  some-
what  backwards  and  down-       T,s- hl                        r>e- n2.
wards.   The knee is flattened
in front, and is broader than
usual;  the patella can be felt
in its  new situation,  and the
muscles that form the quadri-
ceps  extensor  are  rendered
tense, more especially the vas-
tus internus; the leg is some-
times  extended,  but  more
frequently the knee is slight-
ly  flexed.    This   accident
usually happens  from  sud-
den muscular contraction  in
persons who  are knock-kneed.
In some cases  it has been
occasioned   by  direct  vio-
lence,  driving the bone out
of its  position.    Most fre-
quently the  dislocation is not quite complete, the patella being only partially dis-
placed outwards, with some rotation of the bone in the same direction.
   The dislocation inwards  (Fig. 112) is  of very rare occurrence; Malgaigne,
who has investigated this subject, being of opinion that there is only one case of
the kind on record.
   In these lateral dislocations  reduction may be  effected by laying the patient
on his back,  bending the thigh on the  abdomen, and raising  the leg so as to
relax the extensor muscles.  The surgeon then by pressing  down  that edge  of
the patella which is furthest from the middle of the joint, raises the other edge,
which being tilted over the condyles, is immediately drawn into position by the
action of the extensors.
   A remarkable form of dislocation of the patella is that in which this bone
becomes twisted upon  its axis in such a  way that it is placed vertically, one of
its edges being fixed between the condyles, or upon the external  one, and the
other projecting under the skin, and pushing this forwards into a distinct tumor.
In some cases the bone is turned almost completely round, the posterior surface
becoming  partly  anterior.   The signs of this dislocation are  evident, manual
examination indicating  the vertical  displacement of the patella,  with a deep
depression on either side.   The limb is completely extended, flexion being im-
possible.
   This peculiar dislocation has most generally arisen from sharp blows or severe
falls upon the edge of the patella, whilst the limb was semi-flexed, in consequence
of which the bone appears to have been semi-rotated and fixed in its  new position.
Violent muscular contraction, however, conjoined with a twist of the leg, but
without any blow, has been known to occasion it in some cases.
   The reduction of this displacement is  always attended  with great difficulty,
and indeed in some  cases has been  found to be quite impracticable; surgeons
having ineffectually attempted by means of elevators  and the section of the ten-
dons to replace it, and the patient having eventually died from  traumatic sup-
puration of  the joint,  with the displacement unrelieved.   The cause of this
difficulty of  reduction  is not  very distinctly made out;  it is certainly much
greater than can be explained by simple muscular  contraction, and  may  not
improbably  be  owing  to the  resistance  offered  by the  aponeurotic  structures
which cover the bone becoming twisted or entangled  under it, or, as Malgaigne
supposes, by the superior angle of the bone being wedged in the  subcondyloid 
260
SPECIAL  DISLOCATIONS.
space.   If relaxation of the muscles of the thigh, and the employment of proper
pressure upon the patella, do not  succeed, reduction may perhaps be effected by
directing the patient to make a sudden and violent muscular effort at extension
of the limb, or by attempting to walk.   In other cases again  it may be readily
replaced by bending the leg, and rotating it on the axis  of the tibia at the same
time that the patella is pressed into position, as Vincent recommends.   Should
these plans not answer,  I do not think it would be advisable to have recourse to
subcutaneous section  of the  tendon of the quadriceps extensor and of the liga-
mentum patellae.  In one case in which both these structures were divided, the
patella remained as firmly fixed as ever, and the patient  eventually died of sup-
purative inflammation of the knee-joint;  and in no case in which it has  been
practised does it appear to have facilitated the reduction of the bone.
   Dislocation of the patella  upwards can only occur as a consequence of the
rupture of its ligament.   This accident, which is always accompanied by much
inflammation of the joint, requires the same treatment as a fractured patella.
   Dislocations of the Knee.—This joint, owing to the breadth of its articu-
lar surfaces, and the great strength of its ligaments, is seldom dislocated.  When
such an accident happens, it usually arises from falls  from a great height, or by
the patient jumping from a carriage in motion.  The tibia may be displaced in
four directions :  forwards, backwards, or to either side.   Besides these displace-
ments, the joint is subject to a partial luxation dependent upon displacement of
the semilunar cartilages.
   The lateral dislocations of the tibia are the most common.  They are always
incomplete,  and  are usually accompanied by a certain degree of rotation of the
limb in an outward direction.  These displacements may either be external or
                                          internal.   In the first (Fig. 113),
                                          the outer condyle of the femur rests
                                          upon the inner articular surface of
                                          the tibia.  In the other (Fig. 114),
                                          the  inner  condyle is placed  upon
                                          the outer articular  surface of the
                                          head of this bone.  In either case
                                          the knee is slightly flexed;  there is
                                          a marked sulcus in the situation of
                                          the ligamentum patella?; the exten-
                                          sor muscles of the thigh are relaxed
                                          and the deformity of the joint indi-
                                          cates at once the nature of the dis-
                                          placement to which the  bones are
                                          subject.  In these cases reduction is
                                          always easy ; indeed, occasionally it
                                          is effected by the unaided efforts of
                                          the  patient or by a bystander.  It
                                          may be accomplished by flexing the
                                          thigh up  to the abdomen, then ex-
tending the leg, and, at the same  time, by a movement of rotation, replacing the
bones in proper  position.
   The  dislocation backwards may be complete or incomplete.   When complete,
the posterior ligament of the joint is torn, the muscles of the ham are stretched,
the limb is shortened to the extent of  an inch and a half or two inches, and is
semiflexed; the  head  of the  tibia can be felt in the ham, and  there is a deep
transverse depression in front of the joint immediately below the patella.
   The dislocation of  the tibia forwards is of more frequent occurrence than
the last accident.   In it, the lower end of the femur is felt projecting into the
ham, compressing the vessels to  such  an extent occasionally as to  anest the
circulation through the lower extremity, lacerating the ligaments and stretching
 
dislocations of the knee.
261
the muscles in this situation.   The  tibia is felt  to project  forwards, its head
forming a considerable prominence on the anterior part of the knee, with a deep
depression immediately above  it and the patella, which is rendered  more evi-
dent by the extensors of the  thigh  being relaxed; the leg is usually rotated
somewhat inwards  or outwards, and there is shortening to the extent of about
two inches.
   These antero-posterior dislocations are very commonly incomplete.   When
this is the case, they present the same symptoms, but to a less marked degree,
that characterize the complete  displacements.
   In the treatment  of these dislocations, extension should be made from  the
ankle, whilst  the thigh is fixed in a semiflexed position; when the leg has been
drawn down sufficiently, proper manipulation will bring the bones into accurate
position; splints must then be applied, means taken to subdue local  inflamma-
tion, and the  joint kept perfectly at rest for two  or three weeks, at the  end of
which time passive motion may be commenced.
   The subluxation of the knee is an accident of more frequent occurrence than
any of those  that have just  been described.   It  usually occurs by the  patient,
whilst walking, striking his toe against or tripping upon^a stone, when he is sud-
denly seized with  acute and sickening pain in the  knee, often so severe as to
cause him to  fall to the ground.   Before doing so,  however, he is conscious of
having strained or otherwise injured the joint.  On examination, it will be found
semi-flexed, the  patient being unable to extend  the limb properly, and every
effort being attended by severe pain.  In the course of a very short time, the
joint becomes swollen, being distended by synovial secretion, and symptoms of
subacute synovitis  are speedily superadded to the  original injury.
   This accident, originally described by Hey, and since investigated  by Sir A.
 Cooper and others, is owing to the semilunar  fibro-cartilage slipping away from
 under the internal condyle, either before or behind  it, so as to bring  its surface
 and that of  the tibia into  direct  apposition.  The  severe pain  that is always
 experienced,  is owing  in all  probability to the  nipping of  the  loose  folds of
 synovial membrane that lie within  the joint, and that  go by the name of the
 mucous and alar ligaments, and also to the great  stretching of  the ligaments by
 the partial displacement of the bones.  The  reduction may be effected by flexing
 the joint forcibly, and then rapidly extending it at  the same time that  a move-
 ment of rotation is communicated to the leg.  The  evidence of complete reduc-
 tion consists  in the power of extending the articulation being regained by the
 patient.  The synovitis  that  usually follows  upon this injury requires to be
 treated by local antiphlogistics and rest.  After it has been subdued, the patient
 should wear a laced  knee-cap, as the joint will be weakened, and liable to a re-
 currence of the same injury.
   Dislocations  of  the knee-joint are  more liable to serious  complications than
 those of any other articulation.   Not only are the ligaments  torn,  and  the
 muscles injured, but stretching, and perhaps laceration, of the popliteal vessels,
 followed by gangrene of the limb, may occur; or the joint may fall into a state
 of suppurative and destructive inflammation, as the result of the injury.
   Compound dislocation of the knee-joint  constitutes one of  the  most serious
 injuries to which the limbs are liable; the external wound being usually large,
 ragged, and accompanied by the protrusion of the  condyles  of the femur, with
 much  laceration of the soft structures in the vicinity of the joint.   These are
 cases that certainly, as a general rale, call imperatively for amputation;  indeed,
 Sir A. Cooper  looks upon  this  injury as especially demanding removal of the
 limb.   Cases, however, have occurred in which the limb, even under these cir-
 cumstances,  has been saved.   Hence, if the patient is young, and if the vessels
 of the ham do not appear to have been seriously injured, the wound  in the soft
 parts at the  same time not  being very extensive, or  much bruised, an  attempt
 may, with propriety, be made to save the joint.   In a case of compound dislo- 
262
SPECIAL  DISLOCATIONS.
cation of the knee forwards in a boy, the late Mr. A. White sawed off the pro-
jecting end of the femur, which protruded  through the ham, and bringing the
wound together, succeeded in saving the limb.
   The head of the fibula has occasionally, though very rarely, been displaced by
the application of direct violence  to it.  Boyer and Sanson have each recorded
a case of this kind.
   Dislocations of the Ankle occur in consequence of displacement of the
astragalus from the  bones of  the  leg, whilst it continues to preserve its normal
connexion  with the rest of the foot.   These  dislocations  are almost invariably
connected  with  fracture of  the lower end of the  fibula, or of the inner mal-
leolus.  In fact, in looking at the arched cavity into which the astragalus is re-
ceived, it is evident  that this bone can scarcely be displaced laterally without
fracture of one side of this arch.   In considering these dislocations we must, in
accordance  with  the general  nomenclature of similar accidents,  in which the
distal part  is always said to be displaced from the proximal, look  upon the foot
as being dislocated from the leg,  and not consider the tibia as being  displaced
upon the  foot.   The direction of the dislocation must consequently be deter-
mined by the position into which the articular surface of the astragalus happens
to be thrown.  It is necessary to  explain this, inasmuch as a good deal of am-
biguity occurs in surgical writings from the same accident being described diffe-
rently, according to the view taken of the part displaced.   Thus, Sir A. Cooper,
speaking of the tibia as being dislocated at the ankle, whilst Boyer and others,
regarding  the foot as the part displaced, have  described the same injury in di-
rectly opposite terms.
   Dislocations of the Foot may take place in four directions,  viz., laterally,
on either side, backwards, and forwards.   In all cases, the injury appears to be
occasioned either by the foot being twisted under the  patient in jumping or run-
ning ; or else by its being suddenly arrested by coming in contact with the ground
whilst the body is carried forwards.
   The  dislocation  inwards  is  of most frequent occurrence.   In it  the inner
                                          malleolus   projects forcibly  against
                                          the skin;  there is a depression above
                                          the outer  ankle  corresponding to  a
                                          fracture of the fibula, and the sole of
                                          the foot is turned  upwards and out-
                                          wards ;  the inner side touching the
                                          ground, whilst  the  outer edge is
                                          turned up (Fig. 115).
                                            In the dislocation outwards, which
                                          is a rare accident, and, according to
                                          Sir A. Cooper, a much more danger-
                                          ous one than that just  described, the
                                          fibula is not fractured,  but  the lower
                                          end of the tibia is splintered off, in
                                          an oblique manner, from within out-
wards.   The outer edge of the sole rests against  the  ground, and  the inner side
is turned up.
   The reduction of these lateral displacements is readily effected by simple trac-
tion into proper position;  leg-splints with  lateral foot-pieces  must then be put
on, or Dupuytren's  splint  may be applied  on the same side as the dislocation,
opposite to that on which the eversion of the foot takes place.
   In the dislocation of the foot backwards, the deltoid ligament is raptured, the
fibula broken in the usual  situation, and the tibia  thrown forwards on the na-
vicular and internal  cuneiform bones; the foot is  consequently shortened, and
the heel rendered more projecting.  The dislocation forwards, in which the foot
is lengthened, and the tibia thrown upon the upper and posterior  surface of the
 
DISLOCATIONS of  the  astragalus.
263
os calcis, behind the astragalus, is an accident of such rare occurrence as seldom
to have been witnessed, although described.   In the treatment of these antero-
posterior displacements  of the ankle, traction of the foot in a  proper direction,
the leg being fixed  and flexed  upon the thigh, will readily be attended by re-
placement of the bones, the application of lateral  splints being afterwards suffi-
cient to keep the parts in proper position.
   Compound dislocations of the ankle-joint are serious, but by no means unfre-
quent accidents, the displacement occurring in the same direction and from the
same causes as the simple forms of injury.
  The treatment of these cases must depend to a considerable extent upon the
amount of laceration of the soft parts, and the condition of the  bones  forming
the arch  of the joint.   If the wound  in the soft  parts be not considerable  in
extent, clean cut, and with little injury to the bones, the limb should be  placed
on a M'lntyre's splint;  and the lips of the wound, being  well cleaned, brought
together  by strapping, or covered by lint soaked in collodion; evaporating lotions
may then be applied, the constitutional condition of the patient  carefully at-
tended to, and the case treated much in the same way as a compound fracture.  In
many instances this plan will suffice, and the  patient will recover with  a useful
limb, the joint being only partially anchylosed.
   If, however, the bones be projecting and  comminuted, and  the  wound more
extensively lacerated,  the  question of amputation  will necessarily arise.  In
many cases  the operation may  be  dispensed  with by  adopting the treatment
recommended  by  Mr. Hey, of sawing off the malleoli, removing  splinters  of
bone, cleaning the wound, bringing together its edges  by  simple dressing, and
supporting the limb at the same time upon a M'lntyre's splint.   If the joint be
still more seriously injured,  the posterior tibial artery  torn, or the  foot greatly
contused, or if  the patient's constitution be shattered and  irritable, primary am-
putation should be had recourse to.   I  believe, however, that the disinclination
on the part of surgeons to amputate in these cases, owing  to  the strong expres-
sion of opinion by Sir A. Cooper in favor of the attempt  to save the limb, has
in many^ases been carried to such  an  extent as to endanger the patient's life.
 Secondary amputation may  be  rendered necessary, in consequence of gangrene,
 erysipelas, or extensive  suppuration.
   Dislocations of the Astragalus.—The astragalus is occasionally displaced
from its  connexion with the bones of the leg above, and with those of the tarsus
below, being  thrown either forwards  or backwards, the displacement  forwards
happening far more frequently than that in the opposite direction.   In  the dis-
location  forvjards, the  head of the bone may be thrown either  outwards  or
inwards, but I do not think there is any evidence to show that complete lateral
dislocation of this  bone can occur irrespective of displacement forwards; the
so-called lateral dislocations being displacements of the bone  forwards, with
twists to one or other side.   In the luxation  backwards there is no rotation of
the bone, which is thrown directly behind the tibia, in the space between it and
the tendo Achillis.
   These dislocations invariably happen from falls upon,  or twists of the foot;
more particularly when it is in a state of extension  upon  the leg.   When the
foot is in this position, the lower end of the tibia either breaks off on the appli-
cation  of sufficient violence, or the head of the astragalus is  forced out of the
cavity of the scaphoid, and  its bed on the os calcis, the particular  kind of dis-
placement that occurs depending upon  the direction in which the force is acting
and in which the foot is twisted.
   The dislocation of the astragalus forwards with twist of the bone inwards, is
said to be of most  common occurrence, although I have more frequently wit-
nessed that form of accident in which the bone is thrown  somewhat outwards as
well as forwards.  In either case the displaced bone  forms a distinct tumor upon
the instep, in the outline of which the form of the astragalus can  be distinctly 
264
special  dislocations.
made out.  Over this, the skin  is so tightly drawn as often to  appear to be on
the point of bursting.   When the bone is thrown somewhat inwards the foot is
turned outwards,  and the  internal  malleolus  projects distinctly.   When  the
astragalus is thrown outwards, displacement of the foot in  an inward direction,
with great projection of the lower end of the fibula,  takes place.  In some cases,
fracture of the neck of the  astragalus is  conjoined  with these  dislocations, and
not uncommonly the  luxation  is compound  from  the very first, or speedily
becomes so if left unreduced,  in consequence of the  sloughing of the skin which
covers the anterior surface of the bones, the exposed portion of which  under-
goes necrosis, and perhaps eventually exfoliation.
  The dislocation backwards into the hollow, under the tendo Achillis is of rare
occurrence.  Phillips, however, mentions  two instances in which he met with it.
In these cases  the bone formed a distinct  prominence behind the ankle, and
could be felt under the tendo Achillis.
  In many cases the dislocation of the astragalus is  not altogether complete,  the
under surface of the tibia not  coming into direct contact with the upper surface
of the os calcis; a portion of  the  astragalus still  intervening between these
articulations.
  The reduction of the dislocation forwards, whether attended by lateral dis-
placement or not, varies greatly in the facility of its execution; in some instances
being effected with the greatest  possible ease, in others being attended by almost
insurmountable difficulties.  This difference in the facility of reduction depends,
I think, on whether the dislocation is complete or not.   When  the  astragalus is
not completely thrown from under the arch formed by the bones of  the leg, a
portion of it being still entangled between their articular  surfaces and that of
the calcaneum, it may usually be readily reduced by relaxing the  muscles of the
calf, and pushing the bone back into its proper position.   But  when  the astra-
galus is completely dislocated, the upper surface of the calcaneum  is  drawn up
under the arch of  the  malleoli by all the strength of the muscles  that pass from
the leg to be inserted into the foot.   Under these circumstances, in order that
reduction take place, it is necessary  first of all to separate the articular surfaces
to such an extent as to admit of the astragalus being pushed back into its socket;
this is almost impossible, owing to the great perpendicular thickness of this bone,
to the extent to which it is consequently necessary  to draw down the foot, and
to the little purchase that can be obtained on it.  In such cases  as  these, the
re luction has been greatly facilitated by the division of the tendo Achillis, by
wl dch simple operation the whole strain of the muscles of the calf is taken off.
  If  reduction is still  impracticable, the bone must  be left in its new situation.
If this be in the direction forwards, the skin will usually slough, and then a por-
tion of the exposed osseous surface, which will  probably necrose, may be excised,
or the whole of  the astragalus dissected  out by freely exposing it and severing
its ligamentous attachments; the patient  recovering with  a somewhat stiffened
                      Fig. ii6.                    but still a useful joint. This
                                                plan appears to be  safer than
                                                excising the  bone in the first
                                                instance so soon  as the dislo-
                                                cation has been found to be
                                                irreducible.
                                                  In luxation backicards, the
                                                bone has not  hitherto been
                                                reduced, although it is by no
                                                means improbable  that divi-
                                                sion of  the tendo Achillis
                                                may in future enable the sur-
                                                geon to do this.
  In compound dislocation of the astragalus (Fig. 116), the rule of practice must
 
dislocations of  the  foot.
265
depend upon the extent of injury.  If the integuments  have merely been rent
in consequence of the tension to which they have been subjected by the outward
pressure of the displaced bone, an attempt  must be made to reduce  the  dis-
location, and if this be effected, to close  the wound by the first intention.   If
the bone be comminuted as well as  dislocated, the proper practice will be to
remove the loosened fragments, and to dress  the wound in the simplest manner,
allowing it to  heal by granulation.  If the bone be irreducible, it is a question
whether it should be left or dissected out.  If it be left, the wound in the integu-
ments will certainly extend by a sloughing  process, the bone will inflame  and
become  carious or necrosed, exfoliating in fragments, and the  patient will only
recover after a prolonged, tedious, and dangerous course of treatment.  Under
these circumstances, therefore, it appears  to  me that the simpler and safer plan
both to limb and life consists in enlarging  the wound in proper directions so as to
dissect out the irreducible astragalus, and then bringing the articulating surfaces
in contact, dressing the parts  lightly, and trusting to  the formation  of a new
joint between the tibia and the os calcis.   So, also, if a simple dislocation of the
astragalus become compound in consequence  of the sloughing of the superjacent
tense integuments, the exposed and necrosing bone should be removed in part or
in whole, according to the circumstances of the case.  If, together with the dis-
location of the astrakgus, the foot be extensively crashed, amputation may be
required either at the ankle-joint or at some convenient part of the leg.
   Dislocation of the other tarsal bones is of extremely  rare occurrence.  Most
of them, however, have been  found  to have been luxated at times.   Thus, for
instance, the calcaneum has been dislocated laterally from its connexions with
the cuboid in consequence of falls from a  height, the sufferer alighting upon  his
heel.  Chelius mentions a case in which this bone was dislocated by the effort of
drawing off a tight boot.  The reduction  may be readily  effected by relaxing  the
muscles, and pressing the bone back into  its  proper position.
   The scaphoid and cuboid bones have been found to be dislocated upwards in
consequence of a person jumping from a  height and alighting upon the ball of
the  foot.  In  these  instances the limb is  shortened and curiously distorted,  the
toes pointing downwards, the arch of the instep being increased so as to resemble
closely enough the deformity of club-foot.  Reduction may be  effected by draw-
ing and pressing the parts into position.
   The great cuneiform bone  has occasionally  been found to be dislocated.   Sir
A. Cooper mentions an instance of this kind.  If reduction be not effected by
pressing the bone into its position no great evil appears to result to the patient,
the motions of  the limb not being seriously interfered with.
   Dislocation of the metatarsal bones, though excessively rare, from the manner
in which  they are locked in between the bones of the tarsus, and retained by
short and strong ligaments, yet occasionally occurs;  instances being recorded by
Dupuytren and Smith.   Liston also mentions a case of luxation of the metatarsal
bone of the great  toe from direct violence.   Luxations of the phalanges of  the
toes but rarely happen, and present nothing special in nature or treatment.
   Besides these instances of dislocations, properly so called, it  occasionally  hap-
pens that accidents are met with that may in strictness be referred to this head,
though  differing  somewhat  from  the usual  characters  of luxations.   Thus, for
instance, the sutures of the skidl are occasionally  separated in  consequence of
blows on the head.   So also the  articulations between the vertebras may suffer
displacement.   These injuries, however important, from the effects produced upon
the  contained organs,  will be considered  in the next chapters when treating of
injuries of the  head and spine.
   It occasionally happens, that in consequence of severe blows upon, or compres-
sion of, the pelvis, the symphysis of the pubes, or the sacro-iliac  articulation, is
displaced;  here the nature of the injury is indicated by the deformity that results,
and the same treatment is required as in fractured pelvis. 
266
injuries of the  head.
  The lower angle of the scapula is occasionally the seat of a remarkable kind of
displacement, in consequence of which it projects at a considerable angle from
the trunk, civing a winged appearance to the back.   The cause of this peculiar
displacement is somewhat obscure; by some it is considered to be dependent upon
the bone slipping away from under the posterior edge of the ktissimus dorsi
muscle; by others again, and apparently with more reason, it is considered to be
owino- to paralysis of the serratus  magnus.   Whether this  be dependent upon
some°morbid condition of the muscle itself,  as Dr. Jacobs supposes, or be owing
to a paralysed state of the long thoracic nerve, as Nekton thinks, can scarcely be
determined.
                  INJURIES  OF  REGIONS.


                         CHAPTER XVIII.


                      INJURIES OF  THE HEAD.


  The consideration of injuries of the head is one of the most important studies
that can engage the surgeon's attention.   The importance attached to it is not so
much due to the special considerations connected with the mere injury of the
scalp  and cranium; but rather to the effects that are produced as the result of
the implication of the brain and its membranes, in many cases  directly, and in
others indirectly, owing to the close connexion that subsists between the actions
that take place in the external and internal structures of the head.   In conse-
quence of this tendency to cerebral complication it is of the first moment in prac-
tice to study these injuries as  a whole, and with special regard  to those affections
of the encephalon  produced by them; and, from which the injury of the scalp
and the fracture of the cranium derive the greater part of their importance.  It
is therefore necessary in the first instance to be acquainted with the nature and
treatment of the principal forms of cerebral affection that supervene upon  these
accidents, before we proceed to study the special nature and peculiar modifications
of treatment required by the conditions that occasion them.

                        CEREBRAL  DISTURBANCE.

  There are two principal states of functional disturbance arising from injury to
which the brain is subject, viz., concussion and compression; either of these may
be followed by, or be complicated with,  inflammatory actions of various  kinds
that derive much of their peculiar characteristics from the condition with which
they are associated, and from  the injury by  which they are occasioned.
   Concussion  or stunning appears to be  a shock  communicated to the nervous
system from the application of such external violence as  will produce commotion
of the substance  of  the brain, or interfere with the  circulation through it; in
consequence of which its functions  become temporarily  suspended, usually in a
slight and transitory degree, but occasionally to such an extent that the patient
does not rally for many hours  from the depressed state into which he is thrown,
and perhaps sinks without recovery.   In  those cases in which  death immediately
results from the continuance and severity  of the concussion,  either no  lesion
at all may be found  in the  cerebral substance, or it may have been rendered
so  soft and semi-diffluent by the shock to which it has  been  subjected, as to be 
concussion.
267
evidently incompatible  with life, even though no distinct rupture of its substance
appears to have taken place.  In other cases, again,  more serious injury, such as
rupture of it, may have occurred.
  In  the  slighter cases  of concussion—that degree  indeed which invariably
accompanies any severe injury of the head—the surface becomes cold and pale;
the sufferer  is motionless and insensible, or only answers when spoken  to in a
loud voice, relapsing again into speedy insensibility, or rather semi-consciousness;
the pulse is feeble, the pupils contracted, and the sphincters usually relaxed; the
limbs are flaccid, and muscular power is lost.  After continuing in this condition,
which is  the first  stage of concussion, for a  few minutes or hours, according to
the severity  of the  shock, the second  stage comes  on, the circulation gradually
re-establishing itself, the pulse becoming fuller, and the surface warmer.   About
this time the  patient very commonly vomits; the straining  accompanying this
effort appears to be of  service in stimulating the heart's action,  and driving the
blood with more vigor to the paralysed brain, thus tending to restore  its functions;
and we  accordingly find that,  after vomiting has occurred, the sufferer quickly
rallies.  In the more severe cases, the symptoms that have just been described
are so strongly marked that the patient appears to be moribund; there is complete
prostration of all  nervous and physical power; the surface being cold and death-
like,  the  eyes  glassy,  the  pupils either contracted or widely dilated, the pulse
scarcely perceptible and intermittent. In this state  the patient may lie for hours,
recovery being slow, and the concussion merging into some other, and perhaps
more serious affection of the nervous centres, or, indeed, in some cases speedily
terminating  in death, apparently by failure of the heart's action.
   The terminations of concussion  are various.   We have  already seen  that in
some cases this affection may speedily give way to complete recovery, although
slight headache, some  degree of giddiness, confusion of thought, and inaptitude
for mental occupation, may last for a few days before the mental powers are com-
pletely re-established.  In other  cases again the concussion may rapidly terminate
in the patient's death, but between these conditions there are  several interme-
diate states.   Thus the recovery may be complete, but a permanently  irritable
state  of brain may be left, the patient, though capable of the ordinary duties of
life, becoming  readily excited by slight  excesses in diet or in the  use of stimu-
lants, or  by  mental -emotion, though not of an inordinate intensity.  These indi-
viduals, suffering from a preternaturally irritable brain, frequently  die suddenly,
in the course of a few months or a year or two after the receipt of  the injury.
   In other  cases the recovery continues to be incomplete,  although the patient
may.be  enabled  to  follow his  usual occupation,   and to mix  in  the ordinary
business  of  life ;  but yet his state is a precarious one, the brain being liable to
the occurrence of inflammatory disease on the slightest exciting cause.   In such
cases as these there is  frequently a certain degree of impairment of mental power,
the memory failing either generally or in certain important points, as with refer-
ence  to  dates, persons, places, or language.   The speech is  perhaps indistinct
and stuttering.   Amaurosis of one or both eyes, with perhaps squinting or para-
lysis  of the  eyelid, may be left.  The hearing may be impaired, or noises of
various kinds set  up in  the  ears.   There may be diminution  or  loss of virile
power, especially as Hennen observed, in those cases  in which the injury has
been inflicted upon the back of the head; and Holberton has noticed that when
the medulla oblongata  has been injured, the pulse may continue preternaturally
slow—an observation  that I have had  several opportunities of confirming in
injuries both of the medulla, the pons, and the crura-cerebri.
   In other cases again, the symptoms of concussion may gradually terminate in
those of  compression,  and not unfrequently  the reaction  that comes on, passing
beyond the  bounds that are necessary for the  re-establishment of the  healthy
functions of the brain, terminates in an inflammatory condition of this organ. 
268
INJURIES  OF  THE  HEAD.
   Compression of the brain  is a  common condition in  injuries of the head,
arising as it does from a great variety of causes;—from the pressure of a portion
of bone, of blood extravasated, or pus formed within the  cranium, or from a
foreign body lodged there.  In whatever way occasioned, however, the symptoms,
although presenting some differences, are tolerably constant.  The patient lies in
a state of coma, stupor, or lethargy, being paralysed more or less  completely,
heavy, insensible, and  drowsy, not answering  when spoken to, or only when
addressed in a loud voice and shaken perhaps  at the same time.   The breathing
is carried on slowly and deeply, with a stertorous or snoring noise, and  usually a
peculiar blowing with the lips  : one or both pupils are dilated; the pulse is full,
often slow; the faeces passing involuntarily, and the urine not uncommonly being
retained; the skin may be cool,  but in many cases, on the contrary,  it is rather
hot and  perhaps  perspiring;—not  unfrequently  this state  of stupor alternates
with paroxysms of delirium, or of local convulsive action.
  This  state of coma may become  complicated by the occurrence of symptoms
of inflammation ;  and unless the cause that produces the compression be removed,
it usually terminates speedily in death, the patient gradually sinking into more
complete unconsciousness, and dying in an apoplectic condition.  In other,  but
much rarer cases, the coma may continue almost an indefinite  time,  for many
weeks or even months, until the compressing cause is removed, when the patient
may recover consciousness, and the symptoms suddenly disappear.
  The diagnosis between concussion and coma has been sufficiently indicated in
the preceding description of these  two  conditions not to require special mention
here. But, in many cases, it must be remembered that one state merges into the
other, so that the symptoms are not so distinctly marked as has been indicated,
and they are more especially obscured when associated with  inflammatory action.
  There is another condition of the brain, which, although differing completely
from concussion and compression, not unfrequently  complicates these  states, or
may supervene  independently  of either,  upon severe injury of  the  head.   For
want of a better  term, this may be called irritation of the brain, and appears
often to be connected with laceration of the cerebral substance.  In it the*patient
lies in a state of semi-consciousness, unobservant of what is going on around him,
unless spoken  to or roused.   He  does not,  however, lie  quietly,  but  moans,
tosses himself about, and  not  unfrequently twists  and curls himself  forwards,
with his back bent, and the knees drawn up towards the chest.  When spoken
to,  he answers in  a peevish and irritable manner, if at all; frequently frowning
and distorting his countenance, and being evidently pained at any attempt at
fixing his attention.   He is occasionally convulsed, and, at other times, is seized
with fits of violent delirium, shouting and screaming.  The pulse is usually slow
and feeble, the skin cool, and  the face pale.   This condition most generally ter-
minates speedily  in convulsions, coma, and death.
   Inflammation  of the brain  and its  membranes from injury (traumatic ence-
phalitis'), is an affection of great frequency and corresponding importance.  It is
a condition that is specially apt to supervene in all injuries  of the head; though
the liability to it necessarily increases  with the severity of the accident.  This
form of inflammation of the brain and its membranes may set in with great in-
tensity in some cases, the symptoms of phrenitis  being strongly marked; in other *
instances, again,  it gradually  creeps on in a slow and insidious manner, not at-
tracting attention until it has given rise to some severe and ulterior consequences,
as effusion or suppuration, when its symptoms become so mixed  up with those of
compression and  of irritation, as to make the exact diagnosis of the patient's  con-
dition far from easy.  The period at which inflammatory symptoms  of the brain
may manifest themselves, after an  injury of the head, varies greatly.   In some
instances they set in  almost  immediately on the patient  recovering from the
effects of the concussion; the reaction from this state gradually assuming an in- 
TRAUMATIC  ENCEPHALITIS.
269
flammatory character.   In other  cases it is not until after the  lapse of several
days that inflammation declares itself; and, again, it sometimes happens that the
inflammatory affection does not supervene for weeks or months; but then, occur-
ring perhaps under the influence of comparatively trivial causes, may destroy the
patient.
  After death, in cases of traumatic encephalitis, we usually find both the brain
and its membranes affected.   The arachnoid is, however, the structure  that ap-
pears principally to suffer in these cases, being thickened, so as to become milky
and semi-opaque.   Adherent lymph of a greenish-yellow color, and opaque puru-
lent appearance, is seen covering one or both  hemispheres of the brain, being
deposited in largest quantity  at the seat of injury, and not unfrequently extend-
ing across and  into its  fissures, occupying  especially  the depressions about its
base.  The vascularity of the brain and its membranes is  greatly increased, the
arachnoid being reddened in patches, and the vessels of the pia mater becoming
turgid  and very numerous, forming a vascular network over the surface of the
brain.   The sinuses also are distended with  blood, the cerebral  substance ex-
hibits an increase in the quantity of red points, so as often  to present a some-
what rosy hue; and the ventricles are filled with reddish  semi-turbid serum, a
large quantity  of which  is effused about the base of the brain.  In some of the
more advanced cases, inflammatory softening of the  cerebral  substance may
occur.
  In considering the symptoms  of traumatic encephalitis it is useless to endeavor
to make a distinction between the inflammation of the brain and that of its mem-
branes ; the two structures being always more or less implicated at the same time.
The most practical division of this disease following injury, is into the acute and
the chronic, or subacute encephalitis.
  The  acute encephalitis usually comes on  within eight-and-forty hours of the
infliction of the injury.   The patient complains of severe, constant, and increas-
ing pain in his head;  the scalp is hot, the carotids beat forcibly, the pupils are
contracted,  the  eyes intolerant of light, and the ears of noise; the pulse is full,
vibrating,  and  bounding; and  wakefulness, with  delirium usually of a violent.
character, speedily comes on.  All the symptoms of severe constitutional pyrexia
set in at the same time.
  By active and proper treatment this condition may gradually subside until the
health is re-established, but more commonly the  symptoms of inflammation merge
into those of compression; the delirium becoming replaced partly or in whole by
a state  of stupor, from which  the patient is roused with difficulty, the pupils  gra-
dually dilating, the  breathing becoming heavy and stertorous, the pulse  some-
times continuing with  its former rapidity, at others becoming slow and oppressed.
The skin is hot but clammy, the patient  falls into a heavy, dull, unconscious
state, which alternates with convulsive twitchings or jerkings, and occasional de-
lirous outbreaks.  As  death approaches the sphincters become relaxed, the pulse
more feeble, the surface cooler, and the coma more intense and continuous, until
the  patient  sinks from exhaustion and compression conjoined.  In cases such as
these, pus may be found upon the surface, or within the substance of the brain,
in one case  being diffused, in the other collected into a more or less distinctly.
circumscribed abscess.   In other cases again, the symptoms of compression ap-
pear to be induced  by a thick  layer of lymph lying upon the  surface of  the
brain, or by a quantity of serous fluid being poured out into the ventricles  and,
about the base.
  The  chronic or subacute encephalitis is the  most  interesting and  important
variety  of inflammation  following injuries  of the  head.  It may come on a  few
days after the infliction of the injury, or not until months have elapsed.   It may
arise from accidents that simply implicate  the skull, as  well as from those that
extend  their direct effects to the brain and its membranes.   The patient in many 
270
INJURIES OF  THE  HEAD.
cases has apparently recovered entirely from the accident, though in others it will
be found that some one symptom indicative  of the brooding mischief still con-
tinues, such as headache, or impairment of sight, or of hearing.   Occasionally,
the coming  mischief is foreshadowed by an  unusual degree  of irritability of
temper, by loss of  mental  vigor, or some  other functional  disturbance of the
brain.   In cases such as these the subacute encephalitis may suddenly come on,
ushered  in  perhaps by an  aggravation of the persistent  symptom,  or  by the
occurrence of an epileptic  fit.  In  other  cases again, the symptoms set In sud-
denly without any warning, but usually with  much intensity, and speedily prove
fatal.
   The symptoms of the subacute encephalitis, when it has fairly set in, consist
of those of inflammation, irritation, and  compression of  the brain conjoined; in
some cases one, in other instances  another, of the  conditions appearing to pre-
dominate.   The irritation and inflammation proceed from the increased vascular
action; the compression from the  effusion of serous fluid, of pus, or of lymph,
exercising undue pressure upon the brain.   The symptoms  consist  of pain in
the head with heat of the scalp,  and either dilatation or contraction of the pupils,
occasionally one being dilated and the other  contracted.   Squinting, intolerance
of light,  delirium,  moaning, or screaming,  unconsciousness, with  convulsive
twitchings of the  limbs and face, commonly occur with  the  ordinary sympto-
matic fever; and lastly, symptoms of coma, rapidly terminating in the patient's
death.
   In the subacute encephalitis the same appearances are  very generally found
after death, as in  the more acute  form  of the  affection, but it commonly hap-
pens  that it is  the arachnoid  membrane  that  is principally affected.   So
constantly is this the case, that  some surgeons have proposed,  and not alto-
gether  with injustice, to apply the term  arachnitis, to  this  form of traumatic
encephalitis, looking upon  the inflammation  of  the arachnoid as the principal
lesion.
   The  formation of pus within the  cranium is a point of much interest in
these cases, and an endeavor has  been made to lay down  rales by which the
occurrence of suppuration  could  be accurately determined.   Thus it has  been
said,  that if, during the continuance  of encephalitis, a  fit of shivering comes
on, followed by the gradual supervention of  coma, which  slowly becomes more
and more  complete whilst  the constitutional symptoms  of inflammation do not
subside; and if, at the same time, a puffy swelling forms upon the scalp, and
the wound, if any, becomes  pale and ceases  to secrete, the  pericranium sepa-
rating from the bone, an abscess will have  formed under the skull; and further,
that in all probability its seat will correspond to these changes in the scalp and
pericranium.
   In many cases, doubtless, these signs have afforded proof of the existence of
pus within the cranium.   It but seldom happens, however, that the signs attend-
ing the formation of pus within the cranium occur in the distinct order and with
the degree of precision above stated.   In  the great majority of eases the  sur-
geon can only suspect the   presence  of pus  by the symptoms  of inflammation
terminating in coma.  But he cannot say with certainty  that pus has formed, for
the coma may arise from the pressure of other effusions;  but if the puffy swell-
ing of the scalp or suppuration of the pericranium  occur, then he may feel him-
self justified in giving a more positive opinion as to its existence in some situa-
tion within the cranial cavity.
   In traumatic encephalitis, secondary mischief often  occurs in some of the tho-
racic or abdominal viscera, the lungs  and liver being especially liable to be thus
 implicated.  In the lungs more  particularly, it  not unfrequently happens  that
congestion runs into some low form of pneumonia, and thus terminates the patient's
 existence.  In the liver it  has long been observed that abscesses are apt to form 
TRAUMATIC  ENCEPHALITIS.
271
as a consequence of injuries of the head.  These usually occur as one of the more
remote consequences of the injury, but yet there have been instances of an acute
kind.  Thus, Hennen has seen an abscess form in the liver of a temperate woman
thirty-six  hours after  the receipt  of a blow upon the head.   This  connexion
between abscess of the liver and injury of the head is not very easily  explained.
The most probable supposition is, that the hepatic abscess is a metastatic deposit of
pus consequent upon inflammation of the veins  of the diploe and of the cerebral
sinuses.
  The treatment of these various cerebral injuries, and their concomitant affec-
tions, is one of the most important and difficult  subjects that can arrest the sur-
geon's attention; the difficulty depending in a great measure on the various con-
ditions that have just been described not occurring in practice with that amount
of distinctness and individuality by which their characters can alone be conveyed
in description, but being associated together in such a way that  the exact state
of the patient cannot be so readily made out.    There are  few cases,  indeed, in
which practical tact and a nice discrimination and  analysis of symptoms are more
required than in those now under consideration.  It would, however,  be useless
to attempt to describe the shades and modifications of treatment required in the
management of the different groupings of these various forms of traumatic cere-
bral disturbance.   We must therefore content ourselves with describing the treat-
ment of each state broadly and separately, and leave  the consideration  of the
varieties that so commonly present themselves in practice  to the individual tact
of the surgeon.
   In the treatment of concussion, the first great indication is to re-establish the
depressed energies of the circulation and of the nervous system.  In effecting
this we  must, however,  be   careful not  to over-stimulate the patient.   The
safest practice is that  which is applicable to the treatment of shock  generally :
to wrap the patient up  warmly in  blankets, to put hot bottlesj around him, to
employ frictions to the  surface, and when   sufficiently covered  to allow him to
swallow a sufficient quantity of  warm  tea.   Stimulants of all  kinds  should be
avoided, as  their after-effects  may  be injurious;  unless  the  depression  of the
nervous energy is so great that reaction cannot be brought about without their
agency.
   When reaction has come on, steps should be taken to prevent the  occurrence
of inflammatory mischief.  With this view, if  the concussion have been slight,
it may be quite sufficient to purge the patient well, and to keep him quiet on  a
regulated diet for a few days,  directing him carefully to avoid all alcoholic stimu-
lants and  mental  exertion for some  time.   If  the  concussion  have been more
severe, and if the symptoms of reaction have  been  accompanied  by indications
of continuous cerebral disturbance, or been  followed by giddiness, headache, or
confusion of thought, the safer plan will be to adopt immediate steps for the pre-
vention of mischief.  The patient should be bled generally or locally by leeches
and cupping, freely purged, kept on a  low  diet, and above all, remain quiet in
bed for some days.
   Should impairment of the mental faculties or senses be left, the more prudent
plan will be to have recourse to  mild antiphlogistic  treatment.  Leeching, cup-
ping, blistering, the introduction of a seton in the  nape  of the neck, purging,
and more  especially a mild mercurial course, with strict avoidance of all  mental
and  bodily stimulation, is the plan of treatment that requires to be pursued.
These cases  must, however, be carefully watched, and kept under  proper super-
vision for some length of time, as serious symptoms are apt suddenly to declare
 themselves.
   When  acute inflammation  of the brain or  its membranes has come on, at
whatever  period after the injury, active treatment  should be at  once  adopted.
The head must be shaved and an ice-bladder kept constantly applied.   Bleeding 
272
INJURIES OF  THE  HEAD.
from the  arm, repeated as  often as the  pulse  rises, as well as  by cupping or
leeches, must be had recourse to; the bowels should be freely opened, and rigid
abstinence must be enjoined, the  patient at the  same time being  confined to a
darkened  room, and removed from  all causes of excitement.  Calomel should
then be administered, so as  speedily to affect the  mouth.   As  the disease  as-
sumes a chronic form, the same general plan  of treatment, modified according to
the intensity of the inflammatory affection, must be persevered in, the patient being
kept for a length  of time after the subsidence of all the symptoms in a state of
complete quietude.
   The subacute encephalitis which occasionally follows injuries of the head, even
at a remote period from their infliction, is a  most dangerous and unmanageable
affection,  being very apt to terminate in loss or impairment of sense, in diminu-
tion of intellectual power, or in local paralysis.   Much  of  the difficulty in the
treatment of these cases appears to arise from the fact that the inflammation is
often  of a low or erysipeloid  character,  consequently not  admitting of active
depletory  measures.
   In  these cases  the  best results are  obtained by the proper administration of
mercury and the employment of counter-irritants.  The best mode of administer-
ing the mercury is to  give calomel in small and repeated doses, half a  grain or
a grain every four or six hours until the gums are affected, and to keep them so
by diminishing but not leaving off the  mineral.   The  repeated  application of
blisters over the shaved scalp is perhaps the most useful form of counter-irritant,
to which,  in more chronic cases, a seton in the neck may be added.   So long as
any symptoms of inflammatory action continue, this plan of treatment must  be
steadily kept up.
   The irritation  of the brain, that occasionally occurs as the result of injury, is
best treated by a  moderate antiphlogistic plan, conjoined in  some cases, and in
others followed, by the administration of opiates.  This is the only consequence
of injury of the  head  in which opiates  can advantageously be  given.  They
should never be administered if there be any heat of head and fulness of pulse,
having a  great tendency to excite cerebral inflammation.   But in that peculiar
train  of symptoms that occasionally follows  injuries of  the  head, and which I
have described as irritation of the brain, and in which there is a total absence
of all  inflammatory action, I have  occasionally found  a  full dose  of laudanum
quiet the  delirium and, by inducing sleep, restore  the patient.   This, however,
requires great care.
   When  symptoms of compression occur as the result  of inflammation in the
cranium,  the treatment becomes surrounded by difficulties.  If, notwithstanding
antiphlogistic  measures have been  pushed to their full extent, rigors occur and
coma supervenes, conjoined with a certain amount  of continuous  inflammatory
action, the question always arises as to whether trephining should be had  re-
course to, on  the supposition of matter  having formed.   In these cases two
great difficulties present themselves:  the first has reference to the existence of
pus within the cranium, and the second to its situation.
   The question as to the actual  existence of pus within the cranium, and the
dependence of the  symptoms of coma upon the compression  exercised by the
purulent deposit,  is always a difficult one to determine.   There are, as has already
been stated, no absolute and unequivocal symptoms indicative of the formation
of pus within the cranium, the same symptoms that accompany  its formation
being  often closely simulated by the effusion of serum, or  of puriform lymph,
on the brain or its membranes.  But although there may not  be  any symptom
that is absolutely and unequivocally indicative of  the formation of pus in this
situation, it not unfrequently happens that the surgeon is enabled by the assem-
blage of general  symptoms and local  signs, to indicate  its  existence with con-
siderable  accuracy.   In  these cases, however, it is  usually impossible  to deter- 
            TREATMENT  OF  CEREBRAL DISTURBANCE.         273

mine the exact seat of the purulent deposit with sufficient precision to admit of
its evacuation  by the trephine;—whether the pus be between the cranium and
the dura mater, between the layers of the arachnoid, underneath this membrane,
between the cerebral convolutions, or deeply seated in the substance of the brain;
whether it be situated under the  seat of injury, and be there circumscribed, or
whether it be so extensively diffused as not to be capable of complete evacuation.
That these difficulties are real, must be obvious to every practical surgeon, and
illustrative of them I may mention the  two following cases, out of many that I
have witnessed.
   A man was  admitted into University  College Hospital with  an  extensive
lacerated wound of the scalp, denuding the pericranium.   He  continued free
from all cerebral  disturbance until the tenth day after the accident, when he
complained of  headache, had quick pulse, and a hot skin.   At  this time it was
observed that the denuded pericranium had separated from the skull.  He was
treated by  active antiphlogistic  means, the symptoms subsiding, and went on
favorably until the thirty-fourth day, when  he suddenly became delirious and
unconscious, though easily roused when spoken to loudly, and  then answering
rationally;  his pulse fell to  48.   He  died  on the thirty-ninth day,  comatose.
On examination after death, the pericranium was found detached  at the seat of
injury;  under  this the  dura mater was thick, yellow, and opaque, but no pus
was observable.  On separating the  hemispheres, however, a large abscess was
found situated deeply in the anterior lobe on the injured side,  and protruding
into the median fissure.   It contained about one ounce of pus.  In such  a case
as this,  trephining would evidently have been useless; for although it was pro-
bable that there was pus within the cranium, yet its seat could not have been
diagnosed, and the abscess could never have been reached.
   Another case that was admitted into the Hospital was that of a man who had
received a large lacerated wound on the left side of the scalp in  consequence of
a fall.  There was no injury to the bone, and the  patient went on perfectly well
until the seventy-seventh day, the wound cicatrizing.   He  was then suddenly
seized with hemiplegia of the right side,  from  which he recovered partially
by being bled;  some twitching of the muscles, however,  continuing.  On the
ninety-ninth day after the accident he became comatose, and was trephined by
Mr. S. Cooper, but without  relief, dying with symptoms of compression  of the
brain on the third day after the operation.   On examination, thick yellow lymph
was found,  covering the whole of the upper surface of both  hemispheres lying
between the arachnoid and pia mater, and extending into  the sulci between the
convolutions.   There was an abscess in the substance of the brain on the surface
of the right hemisphere on the opposite side of the seat of injury.   Here, though
the symptoms were well marked,  and the  diagnosis  as to the existence of pus
correct, trephining was also useless, as the pus could not be evacuated.  These
cases serve  to indicate the difficulties that surround any operation with the view
of evacuating matter from within the cranium.
   When, however, the symptoms of inflammation have been interrupted by an
attack of rigors followed by compression, with detachment of the pericranium,
or a puffy swelling of the scalp, there can, I think, be little doubt that the sur-
geon, though bearing in mind the extreme uncertainty of the  case, might  in
some instances be justified in trephining at the seat of local change or  of injury,
in the hope of finding pus deposited beneath the cranium, and thus giving the
patient his only chance of life.  And should it not be met with there, and the
dura mater  appear bulging, an  incision  might  even be made  through this
membrane,  in the hope of thus facilitating its escape.  Should this attempt fail,
there are few surgeons who would  have the hardihood to follow the example of
Dupuytren, who plunged a bistoury into the substance  of the brain, and thus
luckily relieved the patient of an abscess in this situation.
                                    18 
274
INJURIES OF  THE HEAD.
                      INJURIES OF  THE  SCALP.

   Contusions of the Scalp from blows are of common  occurrence, and present
some peculiarities that deserve attention.  However severe the contusion may
be, it seldom happens that the scalp sloughs.  This is evidently owing to  the
great  vascularity and consequent active vitality of the  integuments of the head.
In many cases a contusion in this situation is followed by considerable extravasa-
tion of blood,  raising up the  scalp into a soft semi-fluctuating tumor.   It
occasionally happens, especially in blows  on the heads of children, that this
extravasation gives rise to the supposition that fracture exists, owing to the edge
of the contusion feeling hard, whilst the centre is soft, apparently from the de-
pression of the subjacent bone.  In  some  cases, indeed, this deceptive feeling
will occur without any extravasation of blood  under  the scalp, the depressed
centre being due  to the compression of  the  scalp by  the blow that has been
inflicted upon it.   This I have seen occasionally in children in whom the scalp
is soft and somewhat spongy.
   The treatment of contusion  of the scalp is very  simple.   The continuous
application  of  evaporating lotions being  usually sufficient for the removal of all
effusions.   Under no circumstances should a puncture be  made or the blood let
out in any way.   Contusions of  the scalp in giris and  young women have been
known tb be followed by severe neuralgic pains in the part struck.  This affec-
tion is extremely  rebellious to treatment, but in two cases which  I have seen,
after  lasting for a considerable  length of time, gradually disappeared;  in such
cases  as  these, incisions down to the bone  are  said  to  have sometimes been
beneficial.
   It occasionally happens that  bloody  tumors of the scalp form in newly-born
children, either from contusion of the  head in consequence of the  pressure to
which it is subjected in its passage; or else by the bruising of obstetric instru-
ments.   These tumors, which are often of large size and fluctuating, are termed
cephalsematomata.   They may  occur  in  two situations, either between the apo-
neurotic  structures of the scalp and the  pericranium, or between this membrane
and the skull itself.
   The sub-aponeurotic cephalsematoma is  by far the  most  common variety of
the affection. It usually forms a large,  soft, fluctuating tumor,  situated upon one
of the parietal eminences,  and having  a somewhat  indurated  circumference.
These tumors may usually be made to subside in a few days by the use of discu-
tient  lotions.
   The sub-pericranial cephalsematoma  is  an injury of  extremely rare  occur-
rence.   But  Zeller, Valleix,  and others have  determined  its  presence.  It
appears  as a fluctuating tumor, without discoloration of  the  scalp, but with a
hard  elevated circle around it,  and a soft  depressed centre, almost communica-
ting the  sensation of a hole in the cranium.  Pressure, however, gives rise to no
cerebral  symptoms, and enables the surgeon to feel the  osseous lamina at the
bottom of the depression.   These tumors are usually of small size, seldom larger
than  a walnut, and it not uncommonly happens  that  they are multiple.   It is
worthy of note, however, that each tumor is always confined to a separate bone,
never passing beyond the sutures, where  the  adhesions are the strongest between
the pericranium and the subjacent osseous structure.  This affection is  said to
be most frequently met with in children born in first confinements, and is more
common in boys than in girls; according to Bouchard in the proportion of thirty-
four to nine.
   The pathology of this affection has been studied  by Valleix.   This surgeon
found that the pericranium  was separated from the bone  by an extravasation of
blood, and that both bone and pericranium  were covered with plastic matter, 
INJURIES  OF  THE  SCALP.
275
but otherwise healthy.  He also found  that the hard  circle surrounding  the
depression was formed by a deposit of osseous and plastic matter which bounded
the extravasation.  This deposit was effected in such a way that on a transverse
section being made, the inner wall was  found  nearly perpendicular, whilst  the
outer  sloped  down upon  the  cranium,  thus giving a  cratiform  appearance to
the margin of the  tumor.   The treatment of this affection must  be conducted
on precisely the same  principles  as  that  of the other forms of scalp extravasa-
tion.
   Wounds of the Scalp are of very common occurrence, and are  more serious
than corresponding injuries elsewhere, especially so  when  occurring in persons
about the middle period of life and of unhealthy or broken constitutions.  It is
not only that these injuries are more likely to be followed by erysipelas than
those of other parts of the body, but it is also to the great tendency to the pro-
pagation of inflammatory mischief inwards to the encephalon, and to  the com-
plication of cerebral mischief so often accompanying comparatively  slight injuries
of the scalp, that these accidents  owe much  of their  serious and often fatal
character.   But  though there be this danger to  life in  scalp injuries, there is
comparatively  little risk to the  scalp itself;  the abundant  supply of blood it
receives from closely subjacent arteries, and its consequent  great  vitality, is  the
reason why sloughing  so seldom occurs,  even though the part be  much bruised
and seriously lacerated.
   The treatment of wounds of the scalp necessarily  varies somewhat  according
to the nature of the injury.   If this be a simple cut it will  be sufficient, after
shaving the parts around and cleansing  its  interior,  to bring  it together with a
strip or two of adhesive plaster,  and to dress it as lightly as possible.    In these,
as in all other cases of injury of the head,  especial  attention  should be paid to
the state of the brain, for  however  slight  the  external  wound may  be, serious
cerebral mischief may have been occasioned;  or, at all events, the same blow
that has caused the cut in the scalp may  have  given  rise to such functional
derangement of the brain as may eventually lead to the  worst  forms of traumatic
encephalitis.
   It more frequently happens that the scalp is braised  and lacerated as well as
wounded,  and very commonly that a large flap of integument  is stripped off the
cranium, and is  thrown down over the face or ear,  so as to denude the bones.
In these cases, advantage is taken of the  great vitality of the scalp.    However
extensively contused or lacerated this may be; however much it may be begrimed
with dirt;  it is a golden rale in surgery not to  cut any portion of it away, but
after shaving the head and ligaturing any bleeding vessels, to wash and clean it
thoroughly, and replace it  in its  proper position.  Here  it must be retained by
the support of a few strips of plaster, or by the application of a suture  or two at
the points  of greatest traction.   Sutures, however, should  be dispensed with as
much as possible in the treatment of scalp wounds;  they give rise to a consider-
able degree of irritation and certainly favor the occurrence  of erysipelas.   If
the edges  do  not come properly together a piece  of  water-dressing  must be
applied, but the head  must be kept cool, and as little bandaging  and plastering
had recourse to as possible.  The patient should be freely purged  and  kept per-
fectly at rest on rather a low diet, any cerebral symptoms that occur being treated
in accordance with the principles laid down in discussing traumatic affections of
the brain.   In this way union will very probably take place through the greater
portion of the injured surface;  should it not do so, however, or should any  part
slough, granulations   spring up  and reparative  action   occurs with  surprising
rapidity.   If matter form beneath the aponeurosis of the occipito-frontalis mus-
cle, bagging must be prevented by early counter-openings, and by the employ-
ment  of compression  in proper directions.  The pus  has a special   tendency
to gravitate into  the  upper eyelid whenever  suppuration occurs beneath  the 
276
INJURIES  OF  THE  HEAD.
 frontal portion of the muscle, and here the counter-opening may be conveniently
 made.
   When the skull is extensively denuded in consequence of the scalp with the
 subjacent pericranium being stripped off,  we  must not necessarily expect that
 necrosis and exfoliation of the exposed bone will occur.  In cases  such as these
 the flap must  be laid down on the denuded osseous surface,  to which it may
 possibly contract adhesion.  Should it not do so, however, the exposed portions
 of  the cranium may inflame, plastic matter may be thrown out,  and thus granu-
 lations springing up, a covering be formed to the bone.

                          INJURIES  OF THE SKULL.
   Fractures and other injuries of the bones of the skull possess great interest
 not so much from the lesion of the bone itself,  as from its frequent complication
 with injury of the brain and its membranes.   This cerebral complication may
 either be produced by direct injury occasioned by the fragments of the fractured
 bone compressing  or wounding the brain,  or it may be the result of the same
 violence that occasions the fracture concussing or lacerating the  brain.
   Fractures of the skull are invariably the result of external  violence.   This
 may act directly in breaking and splintering the part struck, the fissures  often
 extending to a considerable distance and detaching large portions of the cranium;
 or,  the violence may act in an indirect manner,  producing the  fracture  either
 without being applied immediately to the cranium, or else at an opposite part of
 the skull to that which is struck.   Thus the base of the skull may be fractured
by the shock communicated to it when a person, falling from a height, strikes
the ground heavily with his feet.   The other variety of indirect fracture, that in
which the solution of continuity occurs at a point of the cranium opposite to that
 which has been struck, is the fracture by " contre-coup."
  This kind of fracture has been described by some surgeons as of frequent
 occurrence, whilst it has been denied by others.   There can however be no doubt
that it does occur, though less commonly perhaps than is  generally supposed.
Every hospital  surgeon must occasionally have seen unequivocal  instances of it.
 For its  occurrence to take place several  conditions are necessary.    The  skull
 must be  struck over a large surface, as when a person falls with his  head against
 the  ground.    But if the blow alight on  a thin  portion  of it, this will be
directly fractured.  If however a dense and strong part of the bone  be struck, as
the parietal eminence, or the lower part of the  os frontis,  the shock transmitted
through  the cranium generally will cause the thinnest and most brittle portions
of the skull, though distant, to give way in preference  to the stronger part on
which the blow has immediately fallen.   These fractures by contre-coup are most
common at the base of  the skull, and  are commonly much radiated.   They are
never depressed.
  An ordinary, simple, or undepressed fracture of the skull consists in a fissure,
sometimes single, at other times starred, extending often to a considerable distance
through  the bones, radiating sometimes across the skull, and at others  completely
detaching the upper from the lower,  or the anterior from the  posterior segment
of the cranium.  In some cases the fracture extends into one of the sutures, and
in other instances, which, however, are very rare, the sutures are separated with-
 out any fracture.
  These injuries usually occur from direct violence, but are also  the only forma
 of fracture that happen  by contre-coup.   A simple  fracture, such as this, gives
 rise to no signs by which  its diagnosis can be effected.   If, however, the scalp
 covering the injured bone has been wounded, its existence may be ascertained by
 running  the finger-nail,  or the end of a probe,  over the exposed surface of the
 bone, or by seeing  a fissure into which the  blood sinks.  In these  simple unde-
 pressed ^ fractures  no special  treatment is required to  the fracture  itself, the
surgeon's whole attention being directed to the concomitant injury that may have 
INJURIES  OF  THE  SKULL.
277
been inflicted on the brain or scalp.   Active precautionary measures should be
adopted without  delay, with the view of guarding against the occurrence of in-
flammation of the brain and  its  membranes, even though no  symptoms have as
yet declared themselves.  So soon as the patient has recovered from the concus-
sion, his head should be shaved, the ice-bladder applied,  and  blood freely taken
away from the arm; the bowels  should be well opened, and the room kept cool
and quiet.  The employment of free and repeated bleeding, is, however, of more
service than any other means, and should never be omitted.
   The most serious, and  indeed a very commonly fatal form of simple fracture
of the skull, is  that which  extends through the base of the cranium.   These
injuries usually  occur by falls from a height or blows upon the vertex or side of
the head,  producing a fracture which extends from the  point struck across the
base of the skull, often running through the petrous portion of the temporal bone
or into the foramen ovale.   They may also  occur as the result of contre-coup, or
by a person falling from a height on his head, and having the base of the skull
broken in by the weight of the body projected against it.  The great danger in
these  cases is the concomitant injury to the brain, either  by its direct laceration,
or by the extravasation of  blood upon it.   Though  most usually fatal,  these
injuries are not invariably so.  Not only does it occasionally happen that patients
with all those signs of fracture of the base of the skull, which will  immediately
be described, are seen  to make a  complete recovery, but in the  different museums,
specimens illustrative of recovery after this accident  may be met with. Thus, at
the College of Surgeons, there is the skull of a person who lived two years after
a fracture at its  base.
   The occurrence  of  fracture of the  base of the skull  is  very commonly sus-
pected when symptoms indicative of serious  injury to  the brain speedily follow
a severe blow upon the head, owing  to the  greater liability to injury of those
parts  of the nervous centre that are most important to  life, in these than  in any
other fractures of the skull; the same violence that occasions the fracture injuring
the contiguous portions of brain, or lacerating some of the large venous sinuses
about the base  of the  skull,  giving rise to  abundant  extravasation  of  blood.
These symptoms  are  necessarily in  the highest degree equivocal,  and much
anxiety has been evinced by surgeons to discover some special signs by which the
occurence of this particular fracture may be determined.
   There  are two signs, the occurrence of which leads  to strong presumptive
evidence  in favor of the existence of this  kind of, fracture.   These  are, the
escape of blood  and of a serous  fluid from the ears, and  occasionally from other
parts in connexion with the  base of the skull.
   The occurrence of  bleeding from the ears after an injury of the head cannot
by itself be considered a sign of much  importance,  as it may arise from any
violence by which the tympanum is ruptured without the skull being necessarily
fractured.  If, however, the hemorrhage be  considerable and  continuous, and
more especially  if it  be associated with other symptoms indicative  of serious
mischief within  the head, and if it have been occasioned  by a degree of violence
sufficient  to fracture the skull, we may look upon its occurrence as a strong pre-
sumption that the petrous portion of the temporal bone has been fractured, and
perhaps one of the venous sinuses in its neighborhood torn.
   Bleeding from the nose may of  course  arise from any injury applied to this
organ  without the skull being implicated;  but yet in  some cases of fracture of
the skull the hemorrhage proceeds from the  interior of  the cranium, the blood
escaping through the fissure in the roof of the nasal fossae.  In a patient of mine
who died five weeks after an injury of the head, accompanied by much bleeding
from the nose, a fracture by contre-coup was found extending across one orbital
plate of the frontal bone and separating its  articulation with  the  ethmoid.  In
this case the nature of the injury was suspected from  the fact of the nose itself 
278
INJURIES  OF  THE  HEAD.
having been  uninjured by the blow, although the  hemorrhage from it was very
considerable and continuous.
   The discharge of a thin watery fluid from the interior of the cranium is of
rare occurrence, but when it happens  may be considered as  pathognomonic of
fracture of the base of the skull.  Indeed it is  the most certain  sign  of this
injury that we possess.  This discharge  usually takes place through  the ear;
but it may occur from the nose, of which I have seen one instance, and  Robert
mentions  another.   Still more  rarely it takes place from a wound in the scalp
communicating with  the fracture, percolating through this, and  so being poured
out externally.  The only case of this kind with which I am acquainted is one
which was communicated to me by one  of the pupils of the College, as  occurring
at the Penrhyn Infirmary a few years ago.  In this case a boy received a wound
on the back of the head, with depressed and comminuted  fracture of the skull.
On the nineteenth  day after the receipt of the injury a large quantity of serous
fluid began  to discharge through  the  wound, and continued to do so profusely
until his death from coma four days later.
   There would consequently appear to  be three situations: the ear,  the nose,
and a wound on the head, from which this discharge has been observed.  It is
an exceedingly valuable though most serious sign; and Robert, who has investi-
gated this  phenomenon with  much closeness, states, that the cases in which it
occurs always terminate fatally.   This, however, is an  error;  for  at  least one
case has occurred at  the University  College Hospital, in  which the patient
recovered, although a large quantity of fluid was discharged  from the ear.  It is
usually associated with symptoms indicative of serious injury to the base  of the
brain, but to this there are also exceptions, for I have seen it occur in cases of
injury of the head,  unaccompanied by any severe cerebral  symptoms.  Most
generally it occurs in young people.   Robert says that it does  so invariably, but
in one of the cases that  I  have witnessed the patient was fifty-eight years  of
age.
   The quantity  of fluid that is thus discharged is always very considerable, the
pillow usually becoming soaked by it,  and thus first attracting attention to it.
It is often necessary to keep a piece of  sponge or a pledget of  lint against the
ear, in order to prevent the fluid wetting the patient, as it trickles out, and if a
cup be so placed as  to  collect it, an ounce  or  two  will speedily accumulate.
Laugier states that he has seen a tumblerful discharged  in  a short time, and as
much as twenty  ounces have been known to be poured out in three days.  The
flow is usually continuous for several days, and then ceases.   It is remarkable
that the hearing does not always appear to be destroyed in the  ear from  which
the discharge takes place.
   The nature and  the source of this discharge have been  particularly investi-
gated by Laugier, Chassaignac,  Robert, and Guthrie.  Its physical and chemical
characters are those of a perfectly clear, limpid, and watery fluid, containing a
considerable  quantity of  the  chloride of sodium, with a little albumen in solu-
tion.  It is not  coagulable by heat or nitric acid.
   The source of this discharge has not as yet been investigated with all  the atten-
tion that its  importance requires.   Laugier believed it to  be the serum of the
blood filtering through a crack in the petrous portion of the temporal bone, and so
out through the ruptured tympanum.   This explanation, however, is evidently
not correct,  for  not only is blood  extravasated in  the living body incapable  of
this  species  of  rapid and complete nitration, but the  chemical composition of
the fluid,  which differs altogether from that of the serum of the blood, in con-
taining a mere trace of albumen and double the quantity of  chloride of sodium,
is incompatible with this supposition.   By others it has been  supposed that the
fluid was  furnished  by the internal  ear, being a  continuous  discharge of the
liquor cotunnii, but its large quantity, and, above all, the fact  of its occasionally 
DEPRESSED FRACTURES OF THE  SKULL.           279
escaping  through the nose, establishes the fallacy of this explanation.   Again,
it has  been supposed, but without  sufficient evidence, that  the  cavity of the
arachnoid furnished this secretion.  I think with Robert that there can be little
doubt that this  discharge consists of the cerebro-spinal  fluid, for not only does
it resemble in appearance  and chemical composition this  liquid, but  there  is
no other source within the cranium that can yield with equal rapidity so  large
a quantity of fluid;  experiment having shown  that the  cerebro-spinal liquid  is
rapidly reproduced after its evacuation.   In order that this be discharged it is
necessary that the membranes of the brain be ruptured  opposite  the outlet by
which  it is poured forth.    This  has actually been ascertained to be the case  in
carefully conducted  dissections of injuries of the head in which this symptom
has occurred.   When it is discharged through the ear it is not improbable,  as
Berard has remarked, that  the laceration extends through  the cul-de-sac of the
arachnoid, which is prolonged around the auditory nerve in  the internal auditory
canal.  When it is poured out through the nose, it has probably been by the
fracture extending through the sphenoidal sinuses.
   The treatment of fracture of the base of the skull must be conducted  on those
general principles that guide us in the management of simple  fractures;  no
special means  can be had recourse  to, and in the great majority of cases a fatal
termination speedily ensues.
   It occasionally though very rarely happens that in consequence of a blow a
portion of the  cranium is  depressed without  being fractured,  and,  even  with-
out any serious symptoms  occurring.  Thus Green mentions a case in which
the bowl of a desert-spoon might be laid in the hollow produced in the skull  by
a blow, and no  symptoms resulted.  These depressions without  fracture can,
however, only occur in children, whose crania are soft and  yielding.   In adults
they cannot happen without the occurrence of  partial  or  incomplete fracture.
It must be borne in mind, however, that the apparent depression produced by an
extravasation under the scalp may simulate this  injury very closely, and a very
experienced surgeon may sometimes  under these circumstances  be deceived,
and be induced to cut down upon  a  suspected  fracture when in reality none
exists.
   Depressed fractures of the skull may either be simple, without wound of the
scalp,  compound, or comminuted.  In  the majority of cases, whether the frac-
ture be  simple  or  compound, there is  comminution of the injured portion  of
bone; the fragments being perhaps driven into the brain.
   Depressed fractures of the skull  present many varieties; sometimes, though
very rarely, the external  table alone is  depressed.  This is especially the case
over the frontal sinuses, where it may be broken  in, as I have seen happen from
the kick of a horse, without the inner  table being splintered, or any bad conse-
quences ensuing.   Much  more commonly, however, the inner table is driven in
with  comparatively little  injury to  the  outer  one; it has, indeed, been  stated
 that a portion of the inner table may be depressed without  there being any frac-
ture of the external one;  this, however,  can  scarcely occur, though it may
happen with but a  very trifling fissure of the outer table.
   In all ordinary depressed fractures, the internal table is splintered to a greater
extent than the external  one.  This is especially the case  when the fracture is
the  result of gunshot  injury, or when it has  been occasioned by  blows with
a pointed weapon, as the end of  a pick, or a large nail, or  the sharp angle of a
brick.  In these fractures, which constitute the  dangerous  variety termed punc-
tured, the outer table may be merely perforated or fissured, whilst the inner one
is extensively splintered.   This  splintering of the inner lamina of the skull to
a greater extent than the  outer one, has attracted much attention,  being of con-
siderable practical moment, and is usually said to  be owing  to its being more
brittle than the external table.   This, however, I do not consider to  be the only 
280
INJURIES OF THE HEAD.
cause.  I should rather attribute it to the direction of the fracturing force from
without inwards, causing a certain  loss of  momentum in passing through the
outer table;  and that thus the inner table is splintered  more widely than the
outer one, for the same reason that the aperture of exit made by a bullet is larger
than that of  entry.   If this  be the true explanation, the  reverse ought to hold
                                 good if the force be applied in the  opposite
                                 direction.   It is very seldom that we have an
                                 opportunity of examining such  a case;  but a
                                 few years ago, a man was brought to the hos-
                                 pital  who had  committed  suicide  by  dis-
                                 charging a pistol into his mouth, and upwards
                                 through the  brain.   The  bullet had  perfo-
                                 rated the palate, and passed out at the  upper
                                 part of the cranium, near the vertex (Fig. 117).
                                 On examining  the state of  the bones,  it was
                                 found that  the outer table of the skull was
                                 splintered to a  considerably greater extent
than the inner one, showing  clearly  the  influence of the  direction of the frac-
turing force.   I have since found by experiment on the dead body, that this is
most generally the  case when the blow is struck  from the inside of the skull
outwards.
   It occasionally happens as  the result  of sabre or hatchet cuts on  the  head,
that a kind of longitudinal punctured fracture occurs, in  which the outer table
is merely notched, whilst  the inner one is splintered along the whole line  of
blow.   In other cases, again, a portion of the cranium is completely sliced  off,
hanging down in a flap of the scalp,  and exposing the brain or its membranes.
   The symptoms of a depressed fracture of the skull are of  two kinds:  those
that are dependent upon the  injury to the bone, and those  that result from the
concomitant compression or laceration of the brain.
   When the  scalp is not wounded, the depression  may sometimes be felt; but
very commonly it is masked by extravasation of blood about it, and the surgeon
is only led to suspect its existence  by the continuance of symptoms of compres-
sion from the time of the injury.  In all cases  of doubt  when these  symptoms
exist, an incision should be made through  the scalp at the seat of injury, and
the state of the skull examined. When there is  a wound in the scalp communi-
cating with the fracture, the surgeon detects at once the existence  of depression
and comminution by examining the  bone with his finger through the wound.
Although symptoms of compression almost invariably exist from the first in cases
of depressed  fracture, yet  it  occasionally happens  that no cerebral disturbance
comes  on for some  days, even  though the  injury done be very extensive.   A
man, twenty-four years  of age, was  admitted  into University College Hospital,
under. Mr. Morton.   He had  been struck on the  forehead with the sharp edge
of a quoit.    The frontal bone was  extensively comminuted,  twelve  fragments
being removed, and the dura mater being exposed to a considerable extent;  yet
no bad symptoms occurred until the ninth day, when inflammation of the brain
and its membranes set in, and he speedily died.
   In other cases again, more  especially in children and young persons, in whom
the bones are soft and yielding, depression with fracture may exist to a conside-
rable extent,  and no symptom whatever of compression be produced at any time
or at any subsequent period—the patient living  with a portion of his skull per-
manently beaten in.
   The great  danger in these cases of depressed and comminuted fracture arises,
however, not  only from the compression of the brain, but from the rapidity with
which inflammation is set up in consequence of the sharp fragments wounding
and irritating the membranes and brain.  This is more  especially the case in
 
 TREATMENT OF  DEPRESSED AND PUNCTURED  FRACTURE.   281

those injuries in which the inner table is extensively splintered, as in the diffe-
rent forms  of punctured fracture.   In  these cases  there  may be no  signs of
compression, but inflammation speedily sets in, and certainly proves fatal  if the
causes  of irritation, the sharp spiculas, be allowed to remain in contact with the
dura mater.  This membrane becomes sloughy and  coated with a thick deposit
of plastic matter, whilst  the  usual  evidences of encephalitis  are  found in the
other membranes and the brain.
   The treatment of a depressed  and comminuted fracture of the skull varies ac-
cording to the nature of  the  accident, and the existence or not of symptoms of
compression.
   If there be no wound in the scalp, but the occurrence of symptoms of compres-
sion and the existence of some irregularity of the cranium at the seat of  injury
lead the surgeon to suspect  a depressed fracture, he  should make  a  crucial or
T-shaped incision down upon the .part in order to examine the bone, and if this
be found depressed to elevate or  remove it.
   If the scalp be already wounded all that need  be done to ascertain the nature
of the fracture, is to pass the finger into  the wound and thus examine the bone.
If any fragments be found lying loose they should be  picked  out, as  their pre-
sence can only excite injurious irritation; any bone that is driven below its level
must be raised, and, if completely detached,  removed.
   In order to raise  these depressed portions of bone, it is  in many cases only
necessary to introduce the point of an  elevator underneath the fragment, and
using the-instrument as a lever elevate it into position.  If there be not an aper-
ture sufficiently large for the introduction of the elevator one must be made by
sawing out an angle of the bone at a convenient spot by means of a Hey's saw.
In this way sufficient space may  usually be gained without the necessity of apply-
ing  the trephine.   If, however, the inner table be splintered to a  considerable
extent, or, if there be no convenient angle  that can be removed, the trephine
must be applied in such a way  that at least half its circle is situated upon the
edge that overhangs the depressed bone; the surgeon sawing out by means of
this  instrument a portion of the  undepressed cranium in order that he may more
conveniently get at the fragment.  After a half circle of bone  has been removed
in this way, the depressed splinters may be taken out; a Hey's saw still  being
occasionally required before the whole can be removed.  The flaps of scalp should
then be laid  down, a  suture or two applied, and water-dressing  put over the
wound.   Rigorous antiphlogistic treatment must then be adopted with the view
of preventing or removing the inflammatory symptoms which set in.
   In all cases that partake of the nature of a punctured fracture, those in  which
there is but slight injury of the  external table, but considerable splintering and
depression of the inner one, the  trephine must be applied on different principles
to those that guide us in its use  in ordinary  depressed fractures.  In  the  punc-
tured fracture it is applied not to remove symptoms of compression,  which, in all
probability, may not exist; but with the view of preventing inflammation, which
would to a certainty be set up if  the splinters of the inner table were allowed to
continue irritating the membranes and brain.   Hence it is a rule in surgery in all
cases of punctured fracture, to apply the trephine at once, so as to prevent those
injurious after-consequences, which must otherwise necessarily*result.   In these
cases a trephine with  a large crown should  be  used,  and the circle of injured
bone itself must be  sawn out.
  Should, however,  the use of the  trephine  have  been delayed in these  cases
until inflammatory action have been set up, the instrument may still be applied
with  advantage.   Some years ago, a boy was admitted into University College
Hospital, on the sixteenth day after having been struck on the side of the head
by a  large nail, which projected from a door that fell upon him.  No  symptoms
of any  kind had occurred until  the eleventh day after  the accident, when he 
282
INJURIES OF  THE HEAD.
became dull  and lost his appetite;  on the sixteenth day, that of his  admission,
he had suddenly become drowsy and delirious, but answered rationally when
spoken to, and complained of pain in the head.    The pupils were  dilated, the
skin hot, and the pulse  quick.   On examination a small round aperture  from
which some fetid pus exuded was discovered on the right parietal eminence.   On
introducing a probe, which the hole just admitted, some rough  bone could be
felt.   Mr. S. Cooper immediately trephined  the boy, removing a circle of  bone
including  the small aperture.   The inner table corresponding to  this was found
splintered to  some  extent and the dura mater was seen to be  thickened and
inflamed, but the patient recovered without a bad symptom.
  In those rare cases in which there is a depressed fracture, without symptoms
of compression or even a wound  of the  scalp, the line of practice is somewhat
unsettled, as to whether the depressed portion of bone should be left where it is,
or an attempt made to  elevate it.   Sir  A. Cooper, Abernethy, and Dupuytren
advise that, if it  give rise to no symptoms of compression, it is better not to inter-
fere with it;  and there are several cases on record of patients who have recovered
in whom this course was adopted, the depression continuing permanent.  I think,
however, that this  expectant practice should not be followed too implicitly, but
that we must be guided by  the circumstances of the particular case.  If the
depression be pretty uniform, of inconsiderable depth, and occupy some extent of
cranium, it is better doubtless to follow the practice of these great surgeons, and
to wait for symptoms of compression manifesting themselves before we interfere.
If, however, the depression be sharp, and comparatively small in  extent, we may
reasonably  suspect the existence of considerable splintering of the  inner table;
and here I think that the safer plan would be, even in the absence of all symp-
toms of compression, to trephine, for the same reason that we do so in punctured
fracture—the prevention of inflammatory irritation.
  A man was admitted  under Mr. Liston for a long, depressed fracture on the
side of the head, received by the blow of a  brickbat; though no sign of  com-
pression existed, yet symptoms of cerebral inflammation were speedily  set up,
and Mr. Liston  trephined him on  the fourth day after the accident; the  man,
who was perfectly conscious, walking into the operating theatre.   A considerable
splintering of the inner table was found,  the fragments of which were removed.
The  dura mater having  been punctured by one of the spiculaj of bone, diffuse
suppuration of the membranes of the brain set in, and the patient died in a few
days.   In this case, however, the necessity for early trephining was clearly  indi-
cated, notwithstanding the absence of any symptom of compression.
  When a depressed fracture of the skull is complicated with a fracture or other
injury of the spinal column, it is sometimes difficult to  determine how  much of
the symptoms may be due to one  accident and what proportion to the other.  In
such a case as this, however, we should, I think, treat  the depressed fracture
irrespective of the vertebral injury, thus  giving the patient a chance of recovery,
of prolongation of life, or, at least,  of return of consciousness before  death.  A
man was admitted  under my care  into the hospital with depressed fracture of
the left parietal  bone, and injury of the cervical  spine, the precise nature of
which could not be accurately determined.  He was in a state of complete  coma
and paralysis.  I trephined the skull and  elevated the depressed portion of bone,
he recovered his consciousness to a great  degree, but died in a few days, appa-
rently  from the  injury to the spine.   On examination after death we found a
fracture of the fifth cervical vertebra.

              WOUNDS OF THE  BRAIN AND ITS MEMBRANES.
  Wounds of the brain and its membranes are frequent in injuries of the  head,
and constitute one of the most important complications of these accidents.   The
extent  of injury  inflicted  upon the cerebral substance has wide limits, from slight 
WOUNDS OF  THE  BRAIN.
283
laceration without  exposure to  denudation  of the brain, disintegration,  and
escape of large portions of jts pulp.
  Injury to the brain may be occasioned in various ways.   The simplest form is
that perhaps which is not unfrequently met with in undepressed fracture of the
skull, and sometimes happens without fracture, from simple concussion or com-
motion of the head, laceration of  the cerebral substance occurring  either  under
the seat of injury, or more frequently at a distant or  opposite point, by a kind
of contre-coup.   This laceration  of the  brain by contre-coup is by no means  of
unfrequent occurrence.    I  have  seen many striking  instances of it, and have
found it  to be one of the  commonest causes of death in simple fractures of the
skull.  In a case recently under  my  care, of a  man who had been thrown off a
cab upon his head, striking and  fracturing the  skull  on the  posterior part  of
the left side, there was found extensive laceration and, indeed, disintegration  of
a great part of the right anterior  lobe of the brain, almost  immediately  opposite
to the seat of fracture.
   The brain and its  membranes are often lacerated by the sharp spiculse of a
depressed fracture which may penetrate  to a considerable depth in  its substance.
And, lastly,  the injury may be  occasioned by foreign bodies, such as bullets tra-
versing  or  lodging  in  the head, or by stabs and punctures through the thinner
portions  of the skull, especially the orbital plate of the frontal  bone.   In this
way pieces  of stick, tobacco-pipe, the point of  a knife, or a  scissor-blade, may
 puncture the anterior part of the brain.
   The symptoms of wound or  laceration  of the brain  vary greatly according  to
the age of the  patient, the seat  of injury, and other  conditions, which cannot
very readily  be  determined.  If  the injury implicate  those portions of the ner-
vous centre at the base of the brain, the integrity of which is necessary for the
proper maintenance  of the respiratory  act, immediate death must necessarily
ensue.   If, however, portions of this organ  that are  less  vital, as the  anterior
lobes and upper part of the hemispheres,  are injured,  but very slight  symptoms
may occur;  and in some cases, indeed, there is  no positive indication by which
 this injury of  the cerebral substance can be determined, except by its exposure
 and escape  through  the  external wound.  Hence it is that  even the worst in-
juries of the head are rarely immediately fatal, the patient being  seldom killed
outright, unless the medulla  oblongata be wounded.   Children, especially, have
been known to bear  extensive  injuries of the brain, and even the loss  of a con-
siderable quantity of cerebral matter, without any very serious  effects either im-
mediate  or remote.   And it is by no means of uncommon occurrence to  see them
 live for several days with an extent of  injury to the  brain that would rapidly
 have proved fatal to  an adult.
   Foreign bodies even of large size and considerable  weight have been lodged
 for a considerable time within  the cranium, in contact with  the brain, without
occasioning death.   Thus Hennen states that he has  seen five cases  in which
bullets were lodged within the  cranium,  that did not prove  immediately fatal.
Dr.  Cunningham relates the case of a boy who lived  for twenty-four days with
the breech of a pistol, weighing nine drachms, lying on the tentorium, and resting
against the  occipital bone.   And Dr. O'Calkghan has recorded the remarkable
case of an officer who lived for about seven years with the  breech of a fowling-
piece,  weighing  three ounces, lodged in  the  forehead; the right hemisphere  of
the brain  resting on the flat  part, from which it was only separated  by false
membrane.*
  •[Perhaps the most remarkable case on record of severe injury of the head, not terminating fatally is the
one reported by Professor Bige.low, of Harvard University (see American Journal of the Medical Sciences
for July, 1860), in which by the premature  explosion of a blast, a tamping-iron, three feet seven inches in
length, one and a quarter inches in diameter,  and weighing thirteen and a quarter pounds, traversed the skull.
"The wound thus received was oblique, traversing the cranium in a straight, line from the angle of the
lower jaw  on one side to the centre of the frontal bone above, near the sagittal suture, where  the missile
emerged; and the iron thus forcibly thrown  into the air was picked up at a distance of some rods from the
patient smeared with brains and blood.  From this extraordinary lesion, the patient has quite recovered
in his faculties of body and mind, with the loss only of the sight of the injured eye."—Ed.] 
284
INJURIES OF  THE HEAD.
  From the great  variety of effects produced by these  injuries, it must be evi-
dent that there can be no one set of symptoms indicative of wound of the brain,
provided there be no external wound through which the condition of the cere-
bral substance can be ascertained.  In those cases in which  this does  not exist,
we  can at most only suspect laceration, if we find that the ordinary symptoms of
compression or concussion are associated with signs that do  not usually occur in
those conditions when uncomplicated;  such as the contraction of one pupil, the
dilatation of the other, and perhaps an alternation of these states with twitchings
of the limbs,  hemiplegia of one  side, or paralysis of an  arm, and  of  the oppo-
site leg, with  perhaps involuntary spasmodic movements of the  other members.
These irregular  symptoms, when  accompanied by much coldness of the surface,
slowness of pulse, and depression  of vital power, may generally be  looked upon
as indicative of cerebral laceration.
  Wounds of  the brain and its membranes may prove fatal, either at once by
the injury of the respiratory tract; in the course of a few hours by the continu-
ance of shock, and by the extravasation of blood within the cranium;  at a later
period, by the  occurrence of encephalitis and its consequences; or more remotely
still, by the supervention of paralysis and other ulterior effects of injury of the
nervous system.
  In the treatment of injuries  of the brain little can be  done after the system
has rallied from the shock, beyond attention  to strict antiphlogistic treatment,
though  this need not be  of a very active  kind.   In  these cases, indeed, as
much should  be left to nature  as possible, the  surgeon merely removing all
sources of  irritation and excitement from his patient, and applying simple local
dressings.
  If  any foreign body be lodged within  the cranium, it must of course be re-
moved if possible.   This may be  done if it  be situated near the external wound,
or fixed in the bones, but if it have penetrated deeply into the substance of the
brain, and  have  got beyond the limits of the external wound, it would be per-
haps more dangerous to trephine the skull on the chance of reaching it,  or in any
other way to go  in search of it,  than to leave it where it is.
  Fungus or Hernia Cerebri.—In those cases  in which a laceration of the
brain and dura mater communicates with  a fracture of the skull, it is occasionally
found, more particularly in children, that a bloody fungous-looking  mass of cere-
bral matter protrudes from the wound.  This tumor increases pretty rapidly, pulsates
synchronously with the brain, and may shortly attain the size of a hen's egg, or
even become larger.  It is composed of softened and disintegrated cerebral mat-
ter, infiltrated with lymph and blood.   This softening of the  brain,  with  red
discoloration of its substance, extends for some little distance under the  base of
the tumor.  The mental condition of the patient laboring under this affection is
in many cases  not much disturbed at  first, there being merely  some degree of
cerebral irritation.   Speedily, however, stupor comes on, and  death eventually
occurs from coma.
  The treatment of this complication of fractures of the skull is usually extremely
unsatisfactory.   If the tumor be shaved off as usually recommended it commonly
sprouts again,  until the patient is destroyed by irritation and  coma conjoined.
In  some fortunate cases, however, the removal, of the  tumor  is  not followed
by  its reproduction.   All that can be done is to slice off the growth on  a  level
with the brain;  to apply a pledget of wet lint, and a compress and bandage over
the part, thus  allowing it to granulate and the wound to cicatrize.
  Extravasation of Blood  within  the Skull commonly occurs in all in-
juries _of the head accompanied  by laceration of the brain, and in many of those
in which the skull is fractured  without that organ being injured.   Indeed when
we  reflect on  the  great vascularity of  the  parts  within the  cranium,  the  large
sinuses, the numerous arteries, that ramify both within the bones and at the base 
EXTRAVASATION of  blood.
285
of the brain, and the close  vascular network extended  over the surface of this
organ, we can easily understand that  extravasation of blood is one of the most
frequent complications of these injuries, and a common cause of death when they
terminate fatally at an early period after their occurrence.
   Extravasation of blood within the cranium may occur either from the fracture
tearing across one of the meningeal arteries distributed on the inside of the skull,
or by a fragment of bone wounding a sinus, or the vascular  network  on the sur-
face of the brain, or it may proceed from laceration of this organ breaking  down
its capillary structure.   In  other cases  again, as in gunshot  wounds, the hemor-
rhage may occur as a  consequence of the wound of the vessels by the bullet or
other foreign body.
   The extravasation may .occur in four  situations.  Between the  dura mater and
the skull, where it is most commonly met with;—within the  cavity of the arach-
noid ;—upon the surface of the brain;—or, within  its substance  and its ventri-
cles. ^  It is usually most considerable when poured out upon the dura mater, or,
within the cavity of the arachnoid at the base  of the brain.  It is  in  smallest
quantity immediately on the surface of that organ, or within its  substance.  It
is, however, seldom found in the latter situation as  the result of  violence, with-
out being also met with more superficially.  The quantity effused in any one case
seldom exceeds four ounces.
   Extravasation of blood is one of the most frequent causes  of death in injuries
of the head,  by inducing  pressure of the brain  and  coma.  If in moderate
quantity there is every reason to believe that it is  not always fatal,  but that it
may undergo absorption and other changes  similar to those that take place in
apoplectic clots.
   The symptoms of extravasation are often by no means  very clear; being those
of compression associated in the  early stages of the case with symptoms indica-
tive of laceration of the brain, and, at  a later period, with those of encephalitis.
Putting  out  of  consideration,  however,  these  complications, the more  special
symptoms of compression from extravasated blood may occur in  two ways.  In
the first variety the patient is concussed or stunned as usual, after the receipt of
a blow on the head; from  this he quickly rallies, and then symptoms of  com-
pression set in, and gradually increase  in intensity.   He  becomes drowsy and
dull, with a slow and laboring pulse, dilated and sluggish pupils,  and  a tendency
to slow respiration.  As the compression increases,  complete stupor at length
comes on, with  stertor  in  breathing, and there is  either general paralysis, or
hemiplegia of the side opposite to the seat of injury.
   When the  symptoms  run this regular  course it is probable that the extravasa-
tion results from injury of one of the meningeal arteries, or large venous sinuses;
that the extravasation is confined to  the membranes of the brain,  and that there
is  no laceration of the substance of this  organ.   This may  be termed the me-
ningeal extravasation;  and most commonly occurs from  rupture of the middle
meningeal artery, which, from its situation in a deep canal in the parietal bone,
is  peculiarly apt  to be torn in injuries of the side of the skull.
   More commonly,  however, it happens that the patient never recovers his con-
sciousness after having been stunned, the symptoms of concussion speedily pass-
ing into those of compression.   In these  cases the paralysis is commonly asso-
ciated with twitchings of the  limbs or convulsive  movements of the body ge-
nerally ; there is  sometimes contraction,  at others dilatation of the pupils, and it
occasionally happens that squinting is observed.   It is especially when there are
convulsions, that the pupils are observed to be in different conditions;  and I have
most frequently noticed the pupil dilated on the side that is most  convulsed. In
these cases the extravasation is probably connected with, and  dependent on, lace-
ration or disorganization of a portion of the brain, and may consequently be
termed the cerebral extravasation. 
286
INJURIES  OF  THE  HEAD.
  The diagnosis of these two forms of extravasation from one another is impor-
tant, as it is only in the meningeal that any operative procedure can be success-
fully undertaken, and it may usually readily be effected by attention to the symp-
toms just detailed.
  The diagnosis of the compression from extravasation and that from depressed
bone or inflammatory effusions within  the cranium is easily made.   In the case
of the  depressed fracture we have symptoms of compression continuing uninter-
ruptedly from the  very first, and proper examination of the cranium will always
lead to the detection  of the injured bone.   When  inflammatory  effusions,
whether of pus, lymph, or serum, exercise undue pressure upon the brain,  we
find that the signs of compression have been preceded  by symptoms of cerebral
inflammation, and  that they are accompanied by a good' deal of pyrexia, by quick
pulse and hot skin; the character of the scalp wound likewise, and the separa-
tion of the dura mater when pus is effused, enable us to  distinguish this condi-
tion from those cases in which the pressure is the result of extravasated blood.
  From apoplexy the  diagnosis  is not  always easily made,  more particularly
when there is  no evidence that the head has been injured.  A man was brought
to University College  Hospital in a state of profound coma, in which condition
he had been found lying in the street.  There was no  evidence of injury about
the head, beyond  a bruise, which had  probably been received when he fell. The
case, which was supposed to be one of apoplexy, and treated accordingly, proved
fatal in a few hours.  On examination after death the skull was found fractured
but not depressed. On the opposite side to the bruise  and fracture a coagulum
weighing nearly four  ounces and  compressing the brain, lay between  the dura
mater and  bone.  In such a case as this, it is evident that the history can alone
afford a clue to  its true nature.
   From the insensibility of drunkenness the coma resulting from injuries of the
head may usually  be distinguished, by the absence of local mischief, by the smell
of the breath, and by the face of the drunkard being flushed and turgid instead
of pale, as  in a person who is suffering from the effects of a severe injury.
   The treatment of extravasation of blood may be  conducted on two principles,
either by means of general and  local antiphlogistic  measures, having  for their
object the  arrest of further hemorrhage,  the  promotion  of absorption, and the
subdual of inflammatory action; or else by the application of the trephine, with
the view of allowing the escape of the effused blood.
   Although ihe operation of trephining in  cases of extravasation  was  formerly
much in vogue, it is comparatively seldom had recourse to by  modern surgeons,
and is only practicable  in meningeal extravasation.  It  is very true  that if it
could  be ascertained  without doubt  that the extravasation is not only of  the
meningeal character, but that it is so situated that the blood may be  removed
through the trephine aperture, and that there were no other serious injury to  the
brain or skull, the operation might be performed.   And doubtless the case occa-
 sionally happens  in which, from the situation of the blow, and  perhaps of a
capillary fissure over  the course of the middle  meningeal artery, the gradual
supervention of signs of compression, and the occurrence of hemiplegia on  the
side opposite to that which has been struck, the surgeon is warranted in making
an aperture at  the seat of injury,  in order to remove the blood that  has been
poured out, and to arrest  its further effusion.  But  the  instances in which this
assemblage of characters could exist,  with sufficient precision to justify  an opera-
tion,  are excessively  rare.  Out of some  hundred  cases  of serious  and fatal
injury of the head that have been admitted into University College Hospital
 during the last  fifteen years, in none, I believe, has it  been found  necessary to
have recourses trephining for the removal of extravasated blood.  The most
 serious objection to the application of the trephine in cases of extravasation does
 not, however, consist  so  much in determining  the existence of  effused blood 
operation  of  trephining.
287
within  the cranium, or that the extravasation  is of the meningeal form, but
rather in diagnosing that it is so seated between the dura mater and the skull as
to admit of removal;  not  being effused  at the base, or  so  widely coagulated
over the surface of the brain as to be unable to escape  through the aperture
that may be made.  The likelihood of the co-existence  of fracture  of the base
of the skull and of laceration of the brain, giving  rise  to the cerebral form of
extravasation, must also be taken into account.   For these various reasons,  sur-
geons, now very properly content themselves, in the  great majority of cases of
extravasation, with the employment of antiphlogistic treatment, on the principles
already  stated.  With this  view the head should be  shaved, the  ice-bladder
applied, the patient bled, purged,  and kept at  perfect rest.   If, however, the
signs are urgent, and pretty clearly indicate the meningeal form of extravasation,
and more especially if there be  hemiplegia on the side opposed to that on which
the blow has been received, with an injury in the course  of the middle menin-
geal artery, the trephine may be  applied  at the seat of  injury and the  blood
removed.  It must be borne in mind that, however clear the signs, the extrava-
sation may not be met with where  the surgeon expects to  find it.   Under these
circumstances it is better not to prosecute the search by making fresh trephine
apertures.  In no case would a  prudent surgeon trephine over the course of the
middle meningeal artery, in the absence of local  symptoms, on  the chance of
finding  the blood there, as  has been recommended  by some of the older sur-
geons.
   Operation of Trephining.—Before  concluding  the  subject of injuries of
the head, it is necessary to say a few words on the operation of trephining, which,
though  far less  commonly  employed in the  present day than heretofore, is one of
sufficient frequency in practice, as well as of great importance from the serious
nature of the cases that usually require it.
   The trephine may be applied  to  the cranium for two  purposes:  either with
the view of preventing inflammation and its consequences, or for  the  purpose
of removing some cause of compression.  The  only  case in  which preventive
trephining is practised by modern surgeons is that for the punctured fracture of
the skull; in all other instances in which it is called for, the object of its  appli-
cation is the removal of a cause of compression or of irritation of the brain, such
as a depressed portion of bone,  foreign bodies either fixed in  the  skull or lying
 close under it, and pus or  blood extravasated within the cranium.
   The operation of trephining  is by no means a favorable one in its results.  Of
45 cases reported by Dr. Lenter, as occurring at the New York Hospital, in
 which,  however, there is no distinction made between the application of the tre-
 phine proper and of  various instruments,  such as the elevator, Hey's saw,  &c,
 belonging to  a  trephining case, only 11, or about  one-fourth, recovered.  Of 6
 cases in which the trephine proper was used at University College  Hospital, by
 Mr. Cooper, Mr. Liston, and myself, only one patient recovered;  one other died
 of injury  of the spine unconnected with the operation, and the remaining 4 died
 of inflammation of the brain or  its membranes.
   The Parisian surgeons have not  been more successful.   Nekton says, that all
the cases of injury of the head, in which the trephine has been  used in the
 Parisian hospitals during the last fifteen years, and they are 16 in number, have
terminated fatally.
   The  trephine should have a well-tempered crown, serrated half-way up its
 exterior, the teeth should  be short and broad, and not  too fine;  the centre pin
must not project more than about the eighth of an inch, and  care must be taken
that the screw which  fixes it is  in good  working order.   The other instruments
required are a  Hey's saw, an elevator that will  not readily snap, and a pair of
strong dissecting forceps.
   The operation itself should  be  conducted in the following way:—The head 
288
INJURIES OF THE SPINE.
having been shaved, dnd the portion of the skull to which the trephine is to be
applied having been freely exposed by means of a crucial or  T-shaped incision,
or by  the enlargement of any wound that  may exist, the  trephine  with  the
centre  pin protruded and  well  screwed down,  is to be firmly applied until its
teeth touch the skull;  it is then worked with rather a sharp and quick move-
ment, the pressure being  exercised as the hand is carried from left  to right.
The  centre pin must be withdrawn so soon as a good groove is formed by  the
crown, lest it injure the dura mater.   In  this way the outer table of the skull is
quickly divided, and the diploe cut into; the detritus which now rises by  the
crown of the trephine is soft and bloody, instead of being dry, as it  is whilst
the outer table is being sawn.   As  the instrument approaches  the dura mater,
the sawing must be conducted more warily, and must every now and then be in-
terrupted, in order that the surgeon may examine with the flat end of a probe,
or with a quill, the depth that has been obtained,  care being  taken that this
is uniform throughout  the circle.  The   surgeon now makes  each turn very
lightly, and now and then tries with a slight to-and-fro movement whether the
circle of  bone is loose.   So soon as it is, he withdraws it  in the crown of the
trephine, or raises it out by means of  the elevator.   In this operation the dura
mater must not be  wounded ; if it be injured fatal  consequences will  probably
ensue.  The objects for which the trephining  has been had recourse to must now
be carried out, depressed bone removed, and pus or  blood evacuated.   The scalp
should then  be  laid down again, a few  sutures and a piece of water-dressing
being applied.
  There  are certain parts of the skull, over the venous sinuses,  for instance, and
near the base, to which no  prudent surgeon  would  apply the  instrument.   So
also, if it were ever thought necessary to trephine at the frontal sinuses, the
outer table must first be. removed with a large crown, and the inner  table sawn
out with  a smaller one.
  After  the  operation, careful attention  must be  paid  to  antiphlogistic mea-
sures of  a preventive  and curative kind, the great danger to  be apprehended
being inflammation of the brain and its membranes.  In some  cases also, there
is reason  to believe  that suppurative phlebitis of the  sinuses and veins of the
diploe  has been the cause of death.
                          CHAPTER  XIX.

                      INJURIES  OF THE SPINE.

  Injuries of the spine, like those of the head, derive their importance from
the degree to which the enclosed nervous centre is  implicated.
  The spinal cord  is subject  to concussion, compression, and  inflammation, as
the result of external violence, and  any of these conditions may occur without
injury to the osseous  and ligamentous structures investing  it,  although, in the
majority of cases, they are directly occasioned by fracture or dislocation of the
vertebrae.  It may also be partially or completely divided by cutting instruments,
gunshot wounds, or a broken vertebra.
   Concussion  of the  spine varies  greatly in severity.  In  many  cases of falls
from a height, and of blows upon  the back, the patient complains of great pain
at some part of the spine, inability to stand, and a certain degree of weakness of
the lower extremities.   In these  cases, rest for a few days in bed, and more 
INJURIES OF  THE  SPINE.
289
especially the application of dry cupping, or the  abstraction of a few ounces of
blood from over the seat of injury, will speedily remove the symptoms.
  In other instances, however, the symptoms,  slight at first, speedily become
greatly increased in severity, or may, from the commencement, assume a serious
character.   In such cases, there is some pain at the seat of injury, below which
there is more or less complete paralysis, sometimes consisting in mere debility of
the lower limbs, at others of loss of sensibility and motion.  The sphincters are
always affected, there  being more or less incontinence of flatus and faeces, and
some difficulty in emptying the bladder, amounting at last to complete retention
of urine.  These  symptoms may, after continuing for  some weeks  or months,
gradually lessen in  intensity until  mere  debility is left, which, however, is apt
to continue for a  considerable time.   In other cases, again, they continue per-
manently, or terminate in speedy death.
   In the more chronic forms of the affection, traumatic myelitis, usually of a
fatal character, is apt  to come on.   In these cases there is paralysis of the parts
below the seat of injury, associated with  pain and twitching of the muscles, the
pain in the back being much increased on pressure.
   After death in cases of concussion of the spinal cord,  every  condition is found
between slight ecchymosis, with some redness of the  membranes, through  all
the gradations of softening up to complete disorganization of its structure.   In
many cases there is extravasation of blood into the substance of the cord itself.
When this occurs,  the clot is  most commonly found in the gray substance, or  if
not actually confined to this, at all events, towards  the  centre of the  cord, and
opposite the seat of injury.  Occasionally, blood is effused  largely into the spinal
canal.  Thus Sir A. Cooper mentions a case in which this occurred as the result
of a strain, the patient dying at about the end of a twelvemonth.   When  mye-
litis has occurred, the  membranes are found  congested and sloughy, and the cord
itself in every degree  of red softening up to complete liquefaction.
   In the treatment of concussion of the spine, it is necessary to keep the patient
in the recumbent position until  the lower limbs have regained their power.  The
most convenient attitude for this purpose is upon the prone couch, which will be
described when we come to speak of diseases of the spine.  The patient should
be cupped over the seat of injury, have his water drawn off, his bowels opened
by enemata, and his strength supported by a nourishing  system of diet, which
must be continued  so  long as the paralysis  lasts.  After a time, blisters should
be  applied to the spine, and  when merely a degree of debility is  left in the
lower limbs, the raw surface so produced may advantageously be sprinkled with
strychnine, properly diluted with starch.
   Wounds of the spinal cord may occur from stabs with  pointed instruments,
from gunshot violence, or  more  frequently from  the injury inflicted upon it  by
the pressure of fractured vertebrae.  In  the latter form of injury, there is  an
association of wound and compression, giving rise essentially to the same symptoms
as if the cord were divided.
  When the spinal cord is completely divided, a certain set of symptoms occur
that are common to all cases, at whatever part of the cord the injury  has  been
inflicted, provided  it be  not so high up as to cause instant death.
  In the first  place there is complete paralysis of sense and  motion in all the
parts below the seat of injury, though the mental manifestations continue intact.
The temperature of the part becomes lowered; though, in some  cases, when the
paralysis is not quite complete, the reverse has been observed; and, after a time,
a visible diminution takes place in its nutritive activity, the circulation becoming
feeble, with a tendency to congestion at  depending points.  This lessening of
nutritive vigor is not,  however, confined to the paralysed parts, but the whole of
the system participates in it, the patient becoming speedily anaemic and cachectic.
                                    19 
290                    INJURIES OF  THE  SPINE.
The skin assumes a  dirty cadaverous hue, and the  cuticle usually exfoliates in
branny flakes.
  These general symptoms of paralysis as the result of injury,  present important
modifications according to the point at which the cord is divided.
  When the injury has been inflicted in the lower part of the dorsal region, there
will be found  to be  complete  paralysis of all the parts supplied by the nerves
given off from the sacral and  lumbar plexuses; hence there will be paralysis of
the lower extremities, of the  genital organs, and of the trunk  as high as the
seat of  injury.  There is always in these cases relaxation of  the sphincter  ani,
and hence  incontinence of flatus, and, to a great extent, of faeces.  There is at
first retention of  urine, in consequence of the paralysed state of the bladder, the
body of which is unable to expel its  contents; after a time, however, the urine
dribbles away as fast as it is poured into the over-distended organ, the neck of
which has lost its contractile sphincter-like action.   After the first  few  days, the
urine will be observed to be ammoniacal in odor, and alkaline  in reaction.  This
is probably owing to the changes that it undergoes after it has  passed into the
bladder, the mucous membrane of which becomes chronically inflamed, secreting
a viscid alkaline muco-pus which mixes  with the  urine.  In the early stages of
the accident, the penis will usually be observed to be in a state of  semi-erection.
Patients who have met with injuries of this portion of the spinal  cord> may live
for many months, and even for a year or two, but eventually  die; usually with
sloughing of the nates, or from recurrence of some intercurrent visceral inflam-
mation of a low type.
   When the  cord is divided in the upper dorsal region, about the level of the
third dorsal vertebra, we have not only the train of  symptoms that has  just been
mentioned  as characteristic of this injury lower down, but another set of symp-
toms is  superadded  to them,  owing to the respiration  being interfered with in
consequence of the  paralysis  of the  greater  portion of the expiratory muscles.
The intercostals,  and those constituting the abdominal wall, no longer acting, an
imperfect expiration is solely  effected by the elasticity of the walls of the chest,
and those expiratory movements, such as sneezing and coughing, which are of a
muscular character,  cannot be accomplished.   In these cases  it  will be noticed,
that during inspiration, which is effected almost exclusively by the diaphragm,
the ribs are depressed instead of being expanded and raised, as in their normal
condition.   In consequence of the impediment to  respiration the blood is not
properly arterialized, and a slow process of asphyxia goes on, usually running into
congestive  pneumonia, and terminating fatally in about a fortnight or three
weeks.
  When the injury is  situated in the lower cervical vertebrae, not only do all the
preceding symptoms occur,  but there will be paralysis of the  upper extremities
as well, and the inspiration being entirely diaphragmatic, the circulation speedily
becomes affected, the  countenance  assuming a suffused and purplish  look.   If
the cord have been divided immediately above the brachial plexus, the whole of
the upper extremities will be completely paralysed; but if the  injury be opposite
the sixth cervical vertebra,  it may happen that  the upper extremities  are only
partially paralysed.   This happened in two cases  of fracture of the spine in this
region  that have lately been under my care at the hospital.  In  both ^hese
instances the paralysis  existed on the ulnar but not on the radial side of the arms,
flowing to the  external  cutaneous and radial nerves arising higher from the plexus
than the ulnar, and thus just escaping injury.   It is remarkable  that in both these
cases there  was  acute, cutaneous  sensibility along the whole line of junction
between the paralysed and the sound parts.   In cases of injury of  the cord in
this situation death usually occurs by asphyxia in'the course of a week.
  When the division of the spinal cord takes place above the origin of the phre-
nic nerve, opposite to or above the third  cervical vertebra, instantaneous death 
DIVISION OF  THE  SPINAL CORD.
291
results from the paralysis of the diaphragm, as well as of the rest of the respira-
tory muscles, inducing sudden asphyxia.
  It occasionally happens  in partial division of the cord, as  in some  cases of
compression, resulting from fracture, that the symptoms are not so clearly marked
as in the instances that have just been recorded.  Thus,  for instance, the para-
lysis may not extend to all the parts below the seat of injury; it maybe attended
by severe pain in some of the semi-paralysed parts;  or, motion  may be  affected
in one limb and sensibility in another.  These deviations from what  is usual
may generally be explained by some peculiarity in the seat of the injury to the
cord, or by the extent of its division.
  Fractures of the spine commonly result  either from direct blows upon  the
back, or else by falls upon the head, in such a way that the body is violently bent
forwards.
  The signs of this  injury, though by no means unequivocal  in  many cases, are
yet sufficiently obvious in the majority of instances to admit of an easy diagnosis.
They  are of two kinds:  those presented by the injury of the bone,  and  those
dependent on injury by compression or laceration, or both, of the spinal  cord.
  The local signs are usually pain at the seat of injury, inequality of the line of
the spinous processes, with  depression of the upper portion of  the  spine, and
corresponding prominence of the lower.  There is an inability  to support  the
body in the erect position, and to move the  spine in any way; hence, when the
upper portion of the column is injured,  the  patient holds his head in a stiff and
constrained attitude, fearing to turn it to either side.
  The more general symptoms of fracture of the spine are dependent upon the
injury that the cord  has received.   If the fracture have not implicated the spinal
canal, as when only  the tip of a spinous process has been broken off,  or if it be
unattended by displacement,  although it may traverse the body and arches, no
symptoms depending upon injury of the cord need exist, and indeed occasionally
are absent.   But in  these cases even there  is usually some degree of paralysis,
owing perhaps to the concussion to which the cord has been subjected at the
moment of injury; and occasionally a sudden movement by the patient will bring
on  displacement, by which the cord  is compressed and all the parts below  the
the injured part paralysed.   A  woman was admitted into University  College
Hospital with an injury of the neck, the nature of which could not be accurately
ascertained.  She was in no ways paralysed, but kept her head in a fixed position.
A few  days after  admission, whilst making a movement in bed, by  which  she
turned  her head, she  fell back dead.   On  examination  it was  found that  the
spinous process of the fifth cervical vertebra had been broken off short, and was
impacted in such a way between the arches  of this and the fourth as to compress
the cord.  This impaction and consequent compression probably  occurred at the
time of the incautious movement, thus producing immediate death.
  When there is only partial displacement of the fracture there  may be but in-
complete paralysis of the parts below the injury; of one arm, one leg, &c.  In
these cases there is  usually great pain  experienced at the seat of fracture, and
extending from it along the line of junction between the paralysed  and sound
parts.   This is owing as I found in a case of fracture of the sixth cervical ver-
tebra under my care, to the fractured bone compressing and irritating the nerve
that issues from the vertebral notch opposite the seat of injury.
  In the majority of cases of fracture  of the  spine there is however such dis-
placement of the bone as  to compress the whole thickness of cord, and  thus to
occasion complete paralysis.  In these cases the symptoms are such as have been
detailed when speaking of injuries of the spinal cord.
  Fractures of the spine are inevitably fatal, death ensuing in the two different
ways, and at the different periods,  that have already been mentioned.
  The treatment of  these injuries is sufficiently simple.  No attempt at reduc- 
292
INJURIES  OF  THE  SPINE.
tion can of course be made.  All our efforts must be  directed to the prolonga-
tion of life.   With this view, if the fracture be in such a situation at any point
below the upper dorsal vertebra, for instance, as will hold out a prospect of the
life being prolonged for a few weeks or months,  means must be taken to prevent
the occurrence of sloughing of the nates, an accident that is of common, and
usually of fatal occurrence,  in these cases.  The patient should therefore be laid
at once on a water-bed,  cushion, or mattrass;  he  must be kept scrupulously clean,
and his urine should be drawn off twice in the day at regular hours.  If, as
usually happens after a time, the bowels become  confined, relief must be afforded
by castor oil,  or turpentine  enemata.  A nourishing  diet must be administered,
and perfect rest in one position enjoined.  In this way life may be maintained
for a considerable length of time;  and it is  probable that ossific union  of the
fracture may sometimes take place, though the patient may not recover from the
paralysis, and will die eventually from disease of the cord.
   In cases of fracture  of the spine with depression of the arches, it  has been
proposed to trephine the injured bone and elevate the fragment  that  has been
driven in upon the  cord.  This operation, though performed by Cline, Cooper,
and Bell, is, I believe,  now generally abandoned by the  best surgeons in  this
country, owing to its invariable, and, indeed,  intrinsically fatal character.
   Dislocations of the Spine.—On looking at the arrangement of the articular
surfaces of the vertebrae, the very limited motion of which they are susceptible,
and  the way in  which  they are  closely  knit together  by strong  ligaments  and
short and powerful muscles, it is obvious that dislocations of these bones must
be excessively rare.   So seldom indeed  do they occur that their existence has
been denied by many surgeons.  But yet there are a sufficient number of instances
on record to prove incontestably that these accidents may happen.  Those cases
that have been met with have usually been associated with partial fracture, but this
complication is not  necessary.   In all  the  displacement was incomplete, and
indeed a complete dislocation cannot occur.
   The dislocation of the atlas from the occipital bone has only been described
in two instances;—by  Lassus and by Paletta,    In  the  case by Lassus, death
ensued in six hours, and the right vertebral artery was found to be ruptured.  In
the other case, the patient was said to have lived for five days, but the report is
so incomplete  that little value can be attached to it.
   Dislocations of the axis  from the atlas  are of more frequent occurrence.
They may happen with or without fracture of the odontoid  process.  In  either
case the axis is carried backwards, and the spinal cord  thus compressed.  This
accident is said to have occurred by persons in play lifting a child off the ground
by its head;  the combination of rotation and  traction  in this movement being
especially dangerous, and liable to occasion the accident.  For the same reasons
it has been met with in persons  executed by hanging.   Death would probably
be instantaneous under  these  circumstances.   It has, however been stated that
in dislocations of this kind life has been saved by the surgeon placing his knees
against the patient's shoulders, and  drawing or  twisting the head into position.
This,  however, I  cannot believe possible if the displacement have been complete,
as death must be  instantaneous, the cases of supposed  dislocation and reduction
having  probably  been instances of concussion of the  cord with sprain of the
neck.
  Dislocation  of any one of the five lower cervical vertebrae may  occur.   These
injuries are usually associated with fracture, but sometimes, though rarely, they
happen  without this complication.   In these  dislocations, as  in those that have
already been  described, the displaced  bone  carries  with it the  whole of that
portion of the  vertebral  column which is above it, no single bone being dislocated
both from those above and those below it.
  These accidents most commonly happen  by forcible flexion of the neck  for- 
INJURIES OF  THE  FACE.
293
wards, though traction and rotation conjoined have occasioned them.   In a case   (
of luxation of the sixth from the seventh cervical vertebra, recorded by J. Roux,
the accident happened by a sailor plunging into the sea for the purpose of bath-
ing, coming  head foremost against a sail  which had been spread out to prevent
the attack of sharks ; he  died on the fourth day.  In a patient of mine who fell
out of a window in such  a way  that the  head was doubled  forwards  upon the
chest, and who was brought to the hospital with supposed fracture of the spine,
we  found after death, which occurred on the fifth day, that the seventh cervical
vertebra had  been dislocated  forwards from the first  dorsal, there  being a wide
gap posteriorly between the lamina of  these  bones, with  horizontal splitting  of
the intervertebral substance, detaching with it an extremely thin and small layer
of bone from  the body of the seventh.  There was no fracture about the articular
processes, which were completely separated from one another.  The symptoms
of this accident are  necessarily excessively obscure, being very liable to be con-
founded  with those  of fracture.   Beduction  has been  effected  in a  sufficient
number of cases of this  kind to justify the proceeding being adopted when the
danger is imminent.
   Dislocation of the transverse processes of the cervical vertebrae occasionally occurs.
In  these cases the patient, after a sudden movement, or a fall on the head, feels
much pain and stiffness in the neck, the head being fixed immovably, and turned
to the opposite side to that on which the displacement has occurred.   In these
cases I have  known reduction  effected by the surgeon  placing his knees against
the patient's  shoulders, drawing on the head, and then turning it into position,
the return being effected by a distinct snap.

                          INJURIES OF THE FACE.
   Cuts about  the cheeks and forehead are  of common occurrrence.    These
injuries present nothing  peculiar, except that the structures of the face partake
of the same tendency to  ready repair, as well as to the occurrence of erysipeloid
inflammation, that characterize  the scalp when injured.  In the  treatment  of
these wounds it is of much consequence to leave as little scarring as  possible.
 Hence the edges, after being well  cleaned, should be brought neatly into apposi-
tion by fine hare-lip pins  and the twisted suture, or by a few points of interrupted
suture; more particularly if they are in a transverse direction, and implicate the
lips or nose.    When in  the neighborhood of the eyelids, especial  care must  be
" taken to prevent any loss of substance, lest the contraction of the cicatrix produce
 eversion of the lid.  In those cases in which a portion of the nose or lip has been
 lost, much may be done  to repair the deformity  by properly conducted plastic
 operations, as will be described when we come  to treat of diseases of these struc-
tures.  The  bleeding,  which is often rather free in wounds of the face, in conse-
quence of .some arterial  branch having been  divided, may  often be arrested  by
passing a hare-lip pin under the vessel, and applying the twisted suture above it,
so  that it may be compressed.  If the lip is cut from within, by being struck
against the teeth, the coronary artery may be divided, the patient swallowing the
blood that flows into the mouth.   Some years ago, a man was  brought to the
hospital, drunk and much bruised about the  face.   Shortly after his admission
he vomited up a large quantity  of  blood, which was at first supposed to proceed
from some internal injury, but on examining  his mouth, it was  found  that the
blood came from the coronary artery of the lip, which was divided, together with
the mucous membrane.
   It occasionally happens as  the  result  of wounds or  abscesses  of the  cheek
that the parotid duct is  cut across, in consequence of which the wound does not
close, a trickling of saliva taking place upon the outside of the cheek, so as to
establish a salivary fistula, a source of much  disfigurement and inconvenience 
294
INJURIES  OF  THE  EARS.
to the patient; the surface  surrounding it  being puckered in and  somewhat
excoriated, and the fistula opening by a granulating aperture.
  If this condition is recent, a cure may sometimes be accomplished, by paring
the edges of the external wound, bringing them into close apposition, and apply-
ing pressure upon the part.   If it be of old standing, the probability is that the
aperture into the mouth is closed, and that something more will be required than
bringing the lips of the wound together.   To get it to close, we may adopt the
plan recommended by Desault, of passing a small seton from the mouth into the
fistula, so as to make an  artificial opening into  the mouth, and then, when the
course of the saliva has thus been established, closing  the external wound.  In
order to make the internal artificial opening permanently fistulous, some surgeons
have  advantageously employed a red-hot wire.
  Besides the  fistula of the stenonian duct,  other  fistulous  apertures may take
place in  the cheek, as  the result of injury or  disease,  allowing the escape of a
small quantity of saliva.   These openings are always difficult to heal: the edges
becoming callous, and not readily taking on  reparative action.  Closure may be
effected in some cases  by cauterization with  the nitrate of silver, or with a red-
hot wire, due attention being paid to the general health.   In other cases, again,
the electric  cautery,  as employed by my colleague, Mr.  Marshall, may prove suc-
cessful.  If, however,  the opening be free, with much indurated structure about
it, the surgeon may find it necessary to excise a portion of the edges before bring-
ing them together.
  Foreign bodies in  the nostrils, such as pebbles, beads, dried peas, &c, are occa-
sionally met with in children, having been stuffed up  in play, and becoming so
firmly fixed  as to require extraction by the surgeon.   For this purpose a pair of
urethral  or  polypus forceps  will usually be found convenient.  In some  cases,
however, a bent probe  or  an ear-scoop  will remove  the impacted  body most
easily.
   The Ears are not  unfrequently wounded in injuries of  the head and scalp;
a portion of the external ear being sometimes  torn down and hanging over the
side of the face.   In these cases, as in scalp injuries,  the part should never be
removed, but, however lacerated and contused, should be cleaned and replaced
         by means of  a few points  of suture  and strips of  plaster.   When the
 Fig. us.   cartilaginous portion of the ear is divided, nice  management is  usually
 eSa      required in effecting perfect union.
            Foreign bodies  are often pushed into the  ears  of children  in play
          with one another.   When  pointed  or angular, such as pieces of stick,
 () j       they may readily be extracted with forceps; but when  round and small,
          as pebbles or beads, they are not so  easily removed.   Here the use of
       .   this instrument is of little  service;  the bent ear-scoop may occasionally
          be got round the body and thus remove it.
            In some cases I have found an instrument, as here represented, and
          made by Coxeter, on the  model of Civiale's  urethral scoop, useful in
          getting a foreign body out of the ear.  It  can be introduced straight
          and then passed beyond it,  when, by the action of a screw in the handle,
          the  scoop is  curved forwards, and so  enables extraction to be readily
      i   effected.   In other cases  it is best  got out  by forcibly  syringing the
      13   ear with tepid  water, injected  by means  of a large brass syringe in a
          full stream, the pinna being drawn up so as  to straighten the external
          meatus.   In this way the  bead or pebble is soon washed out by the re-
  tk,      flux of the water striking against the tympanum.   Should these means
          not suffice it is better to leave  matters alone, and to allow  the foreign
 body to become loosened, than to poke instruments into the ear with the view of
 forcibly extracting it.   These attempts are ill-advised, and I have known death
 follow prolonged and unsuccessful efforts at the extraction of a pebble from the ear. 
INJURIES  OF  THE  EYES.
295
  Injuries of the Orbit if deep are always serious, on account of the proxi-
mity of the brain; thus it may happen that a pointed body, such  as a piece of
stick or a knife, thrust into the orbit, perforates its superior wall, thus producing
a fatal wound of the brain.   Occasionally  inflammation is set up in the  loose
cellulo-adipose tissue contained in this cavity, giving rise to abscess, which may
point in either eyelid;  or, to  inflammation  extending itself to the encephalon.
In other cases wounds of the orbit may be followed by loss of vision, without the
eyeball being touched, either in consequence of injury of the optic nerve, or per-
haps from the division of some of the other nerves of the orbit producing sympa-
thetic amaurosis, as occasionally happens even from ordinary wounds of the  face,
implicating some of the terminal branches of the fifth pair.
  Injuries of the Eye-ball are so commonly followed by impairment or total
loss of vision as  to constitute a most important series  of accidents;  the delicacy
of the structure of this organ  being such, that slight wound of  its more transpa-
rent parts, or displacement of the lens, is often followed by complete opacity and
loss of sight.
  Injuries of this organ may  be  divided into contusions and wounds.
  A contusion of the eyeball, without rupture or apparent injury  of any  of its
structures, may give rise to such concussion of the retina as to be followed by
temporary or permanent amaurosis.  More  frequently contusions of the eye are
accompanied  by extravasation of blood under the conjunctiva, and  much ecchy-
mosis of the eyelids.  A " black eye" is best treated by the  continuous applica-
tion of a weak arnica and spirit lotion.
   Contusion of the eye with rupture of some of the structures of the ball is a
most serious accident.   The cornea may be ruptured, the humors lost, and vision
permanently destroyed.  Most frequently the rupture is internal, the outer tunics
escaping all injury.  In this case we may have an extravasation of blood into the
eye, completely  filling the anterior chamber, hiding and  complicating deeper
mischief within the ball.  The condition, termed hsemophthalmia, is frequently
associated with separation of the  ciliary margin of the iris.   In other cases again,
there may be displacement of  the crystalline lens,  which may be driven into the
vitreous humor, be engaged in the  pupillary aperture, or fall forwards into the
anterior chamber.   As  a consequence  of such injuries the  eye usually becomes
inflamed.with intense frontal  and circumorbital pain;  disorganization of the ball,
and ultimately loss of vision ensuing.
i  The treatment of these injuries  must  always be  of an active antiphlogistic
character.  Blood should be freely taken from the arm by venesection, and from
the temple by cupping, the iris being dilated  by the application  to the eye of a
solution of the sulphate of atropine, of the strength of two grains to the ounce of
distilled water; the patient must be  kept in a darkened room, on a strictly anti-
phlogistic regimen, and should be put under the influence of calomel and opium,
as speedily as possible.  In  this way, the  inflammation  will  be subdued, the
effused blood absorbed, and perhaps vision  restored.   In some cases, however,
opaque masses and bands of lymph will be deposited in the anterior chamber and
the pupillary aperture, preventing more or less completely the entry of light.  If
the lens be displaced into  the posterior chamber it must be left there;  if in the
anterior it may be extracted through the cornea.
   Wounds of the eyeball  may be divided into those  that are merely superficial,
and do not penetrate into  its  chambers;  and those that perforate its coats.
  The non-penetrating wounds are usually inflicted by splinters of iron, or  other
metallic bodies, which become fixed in the cornea, or between one of the eye-
lids  and  the ball.  Very painful and  troublesome  injuries are sometimes  in-
flicted by scratches of  the eyeball with the  nails of children.  In the treatment
of these superficial injuries, the  first point is  necessarily to remove any foreign
body that is lodged.  If it be fixed on the cornea, as commonly happens, it may 
29G
WOUNDS  OF THE  MOUTH  AND  TONGUE.
be picked off with the point of a lancet or cataract needle; if it is a splinter of
iron that has been so lodged, it is well to bear in mind that a small brown stain
will be left after the metallic spicula has been taken off; this, however, will dis-
appear in the course of a few days.  In order to remove foreign bodies lodged
between the ball and the eyelids these must be everted so that the angle between
the palpebral and ocular conjunctiva may be properly examined.  For this pur-
pose the  lower eyelid need only be drawn down, whilst the patient is directed to
look up; but the eversion of the upper eyelid requires some skill.  It is best
effected by laying a probe  horizontally across it, immediately above the  tarsal
cartilage;  the surgeon then taking the eyelashes and ciliary margin lightly be-
tween  his  finger and thumb, draws down  the eyelid at  the same time that  he
everts it by pressing the probe firmly backwards  and downwards against the eye-
ball ;  the patient should then look down in order that the whole of the upper
part of the conjunctiva, where the foreign  body will probably be found, may be
carefully examined.
   Penetrating wounds of the  eyeball present great variety;  they are commonly
inflicted by bits  of stick, steel  pens, children's toys, and not unfrequently during
the shooting season by the explosion of faulty percussion caps, or the lodgment
of a stray  shot in the eye.   In all cases these accidents are highly dangerous to
vision, and when the foreign body lodges, it is usually permanently lost.
   The danger that ensues  usually arises  either from  the  eye being opened to
such an extent that the humors  escape, or else, that the iris becoming engaged
in a wound in the cornea, a hernial prolapse of it occurs.   The remoter conse-
quences  usually arise from inflammation taking place within  the globe, so as to
produce an opaque cicatrix of  the cornea or of the capsule of the lens; or else
there is danger  that adhesions may form, stretching across between the iris and
the lens, or between these parts and the posterior surface of the cornea;  or that
inflammation may take place in all  the structures of the ball, giving rise to dis-
organization of it.
   The treatment of these penetrating wounds is strictly antiphlogistic.  Bleed-
ing in the arm, cupping on the temples, low diet, a darkened room, and the
administration of calomel and opium, are the principal points to be attended to.
If the iris have protruded through a wound in the cornea, it should be carefully
pushed back, and a drop or two of the solution of atropine put upon the eye.
If it cannot be returned, it  may be removed with  a pair of fine curved scissors,
and at a later period any staphylomatous tumor that may form, should be touched
repeatedly  with  a pointed piece of nitrate of silver.  If there is a tendency to
the formation of adhesions,  or to the deposit of lymph within the pupil or the
anterior chamber, our principal reliance should be  upon small doses of calomel,
in  conjunction with opium.  If the lens  or its capsule have  become opaque,
traumatic cataract thus forming, extraction may be required at a later period of
the case.
   Wounds of  the Mouth are seldom met with, except as the result of gun-
shot violence.  In these cases the amount of injury done to the soft structures,
however  great, is usually only secondary to  the mischief that results to the brain,
spinal cord, jaw  and skull, and must of course be treated on the ordinary princi-
ples of gun-shot and lacerated wounds.
   Wounds of  the Tongue usually occur from  its tip or sides being caught
between  the teeth during an epileptic fit.   They have been known to be inflicted
purposely by insane patients, in  attempts to excise  this  organ.   Should the
hemorrhage be free, the application of a ligature,  or even of the actual cautery,
may be needed to an-est it.   These wounds generally assume a sloughy appearance
for a few days;  then clean  up, and granulate healthily.  It is  useless to bring
the edges together by sutures, which readily cut out.  If a large portion of the 
wounds  of  the  throat.
297
tip be  nearly  detached, it  must, however, be supported in this  way; but the
threads should be thick, and passed deeply.
  The Palate and the Pharynx are sometimes lacerated by gun-shot injuries
of the mouth;  or the wound may result by something that the patient happened
to have between his lips being driven forcibly backwards into his mouth.   Thus,
a tobacco-pipe may, by a blow on the face, be driven into the  pharynx, wound-
ing and lodging behind the arches of the palate, breaking off short; the frag-
ment that is left in giving rise to abscess, to  ulceration of the vessels,  and
perhaps fatal secondary hemorrhage.   In  a case that was under my care a short
time back, the  soft palate was nearly completely detached from the palatal bones
by a deep transverse wound, caused by the end of a spoon being forcibly driven
into the mouth.

                       INJURIES OF THE THROAT.

   Injuries of the throat are  of great frequency and  importance, implicating as
they do some of the most important organs in the body.   They may be divided
into three categories :—
   1st.  Those that do not extend into the  air or food passages.
   2d.  Those that implicate the air-passages, with or without  injury of the
oesophagus.
   3d. Those that are accompanied by injury of the spinal cord.
   All these injuries are most commonly suicidal, and may be inflicted with every
variety of cutting instrument.    Hence, though incised, they are  often jagged,
and partake  somewhat  of the  character of lacerated wounds, with great gaping
of the edges.
   In wounds of  the first category there  is very commonly free and even fatal
hemorrhage, and  this  sometimes though none of the  larger arterial or venous
trunks are divided; the blood flowing abundantly from the venous plexuses and
from the thyroid body.  If the larger arteries are touched, as the carotid and
its primary branches, the hemorrhage may be so abundant as to give  rise to
almost instantaneous death.  Another source of danger in these cases proceeds
from the admission of air into the veins of the so-called " dangerous region," of
the neck.  For this a free wound is by no means necessary, as is instanced by a
remarkable case that occurred a few years ago near London, in which the intro-
duction of a seton into the fore  part of the neck was followed by death, from
this cause.
   The large nerves, such as the vagus and phrenic, cannot, in a suicidal wound,
be divided without injury to the neighboring vessels.  The division, however, of
the respiratory nerves on one  side only,  or even of one of them, would in all
probability be  fatal in  man, by interfering with the proper performance of the
respiratory act.  In a  case with  which I am acquainted, in which the phrenic
nerve  was divided during the operation of placing a ligature on the subclavian
artery,  death resulted in a few  days from inflammatory congestion  of the lungs.
  In the treatment of wounds of the neck of this category, the principal points
to be attended to,  are, in the first place, the arrest of hemorrhage by the ligature
of all bleeding vessels, whether arterial  or  venous;  and, secondly, bringing
together the lips of the wound.   If the cut be longitudinal, this  may be done
by strips of plaster.  If transverse, by a  few points of suture and by position,
the head  being fixed, withsthe  chin almost touching  the  sternum, and retained
in this posture by tapes passing from the nightcap to a piece of bandage  fixed
round  the chest.   I have had under my care one case, in which, owing to the
projection and mobility  of the larynx, the  wound did  not unite, a large and deep
gap being left,  which required a series of  plastic operations in order to effect its
closure.
  The air-passages are  commonly wounded in suicidal attempts.   They may be 
298
INJURIES OF  THE  THROAT.
known to be opened by the air being heard and seen to bubble in and out of the
wound during respiration.  These wounds vary much in  extent, from a small
puncture with the point of a penknife to a cut extending completely across the
throat, and even notching the vertebrae.   They  are frequently complicated with
injuries of  the larger vessels  and nerves, and sometimes with wound of the
oesophagus.   Most commonly the cut is made high up in the neck, for the suicide
thinking that  it is the opening into the air-passages that destroys life, draws the
razor across that part of the throat where these are  most prominent and easily
reached; and thus, by not wounding the larger vessels, which are saved by the
projection of the larynx, frequently fails in accomplishing his object.
  There are four situations in which these wounds occur: 1st, Above the hyoid
bone; the cut extending into the  mouth and wounding the root of the tongue.
When the wound is in this situation it is usually attended with a good deal of
hemorrhage; and there  is much trouble in feeding the patient, as the power of
swallowing is completely lost.
  2dly.  The  wound may be inflicted in the thyro-hyoid space, laying  the
pharynx open, but being altogether above the larynx.   This is the most common
situation for suicidal attempts.   In many cases the incision is carried so low as
to shave off or partly to detach the epiglottis and the folds of mucous membrane
around  it.   In other cases again, the edges of the glottis or the arytenoid car-
tilages are injured, the cut extending back to the bodies of the vertebrae.  In
these cases  also,  there is great difficulty in swallowing, and great risk of the
sudden supervention of oedema glottidis, and consequent suffocation.
  3d.   When the larynx is wounded the incision is  usually transverse; but I
have seen a longitudinal cut made through the larynx, so as to split the  thyroid
and  cricoid cartilages perpendicularly.   In these cases of wounded larynx there
is much danger of the blood from the superficial parts trickling into the air-
passages and  asphyxiating the patient, and of  inflammation of the bronchi and
lungs supervening at a later period.
  4th.  Wounds of the trachea are  not so common as those of the larynx, from
which they differ but little in the attendant dangers.   The oesophagus is seldom
wounded, as it can  only be reached through the trachea by a deep  cut, which
will  probably  implicate the large vessels on one side or the other.  The spinal
cord can only be injured by gun-shot wounds of the neck, which are necessarily
fatal.
 ^ There are various  sources of danger in wounds of the neck  implicating the
air-passages.   The  hemorrhage, whether  it proceed  from  any of  the  larger
trunks, or consist of  general oozing from  a vascular surface, may either prove
directly fatal  by  the loss of blood, or indirectly so in consequence of the Wood
trickling into  the air tube, and by accumulating in its smaller divisions produc-
ing suffocation.   Another source of danger in some of these cases arises  from
the supervention  of asphyxia, either in the way that has already been mentioned,
or, in those cases in which the wound has been inflicted above the larynx, from
the occurrence of oedema of the glottis.   This condition may likewise occur in
those cases in  which the external opening is very small, and occasionally happens
suddenly when the wound has nearly closed.
  Another source of danger is the loss of the natural sensibility of the glottis,
in consequence of which it no longer contracts  on the  application of  a stimulus.
Hence food taken in by the  mouth  may pass into the larynx  and make its
appearance in the external  wound, even though  neither the pharynx nor the
oesophagus have  been wounded.  This  I have observed in many cases of cut
throat;  hence the presence of food in the wound cannot in all cases be considered
an evidence of injury to the food-passages.  This occurrence is always a bad sign,
and  is never met with in the earlier periods of  the injury; never, indeed, until
a semi-asphyxial  condition has come on, by which the  nervous sensibilities are 
WOUNDS  OF THE THROAT.
299
blunted, or until inflammation has been set up about the rima glottidis, giving
rise to so much swelling as to interfere with the natural actions, and  to deaden
the perception of the part to the contact of a foreign body.   In these cases also
it will be found that the sensibility of the air-passages generally is much lowered,
so  that mucus accumulates in the bronchi often to a dangerous extent, the patient
not feeling the  necessity for  expectoration,  and often, indeed, having  much
difficulty in emptying his chest.
   The occurrence of bronchitis and pneumonia,  either from the inflammation
extending downwards from the wound, or in consequence of the cold air entering
the lungs directly, without being warmed by passing through the nasal  cavities,
is  perhaps the  most serious complication that can happen in these injuries, and
constitutes a frequent source of death in those patients who survive the  immediate
effects of the wound.
   The depressed mental condition of the patient also is usually unfavorable to
recovery in all those instances in which the wound is suicidal, disposing him to the
occurrence of low forms of  inflammatory mischief.
   Treatment.—We have already considered the management of those  wounds of
the throat that do  not interest the mucous canals in this  region.  When these
are opened the  same general  principles  are required  as  in the former  case.
Hemorrhage must be arrested by the ligature of all the bleeding vessels, whether
arteries  or veins, so that no oozing or trickling into the wound may take place.
   In  some cases the  hemorrhage consists principally of general venous oozing
which cannot  be stopped by ligature, the patient  drawing a large quantity of
blood into the  air-passages through the wound in them.  Under these  circum-
stances, I have found  it useful to introduce a large silver tube into the aperture
in the windpipe, and to plug the wound around  it.   So soon as the bleeding has
fairly ceased, the plugs and the tube must be removed.
   The edges must next be brought together, by a few stitches introduced at the
sides, and by attention to position, the head being fixed by tapes as already de-
scribed in the former section.  I think with Liston that in  these cases the wound
should never be closely sewed up, or stitches introduced into the centre of the
cut.   If the edges  of the  integument be closely drawn together, coagula may
accumulate behind them, in the deeper parts of the wound, so as to occasion  a
risk of suffocation, and as this must eventually close by  granulation, no material
advantage can  possibly be gained by this practice.
   There is an exception,  however, to this rule of not using  stitches in the
central part of the wound in cut throats; viz., in those cases in  which the
trachea has been completely cut  across.  Here  a stitch  or two on either side of
the tube is necessary,  in  order to prevent the wide  separation of the two por-
tions that would otherwise take place, owing to  the  great mobility "of the larynx
and upper end of the windpipe.
   In order to lessen the liability to inflammation of the lungs, the patient should
be put into a room, the temperature of which  is raised  to about 80° Fah., with
a piece of lightly-folded muslin acting as a respirator kid over the wound.  So
soon as the cut surfaces begin to granulate, water-dressings may be applied, and
the edge of the wound brought into apposition  by strips of plaster, and a  com-
press, if necessary.  During the treatment, the principal  danger proceeds from
inflammatory affections of the chest;  these must accordingly be counteracted by
the temperature in which the patient  is placed, and by as  active antiphlogistic
remedies as his condition will admit of.   It must, however, be remembered that
the mental  depression, and the bodily exhaustion  from loss  of blood, that are
commonly met with in these cases,  do not allow a  very active course of  treat-
ment to  be pursued.
   The administration  of  food in these cases is always a matter requiring  much
attention.   As a general  rule, the patient should be kept on a nourishing  diet, 
300
ASPHYXIA.
with a moderate allowance  of stimulants.   If, as not uncommonly happens, the
food-passages are opened in consequence of the wound extending into the mouth,
the pharynx,  or the  oesophagus, it is of  course impossible for the  patient to
swallow, and the administration of nourishment becomes a source of considerable
difficulty.   This is best accomplished by means of an elastic gum catheter passed
through the mouth into the gullet or stomach.   This is easier than passing the
instrument through the nose, and much better than introducing it through the
wound.  In this way  a pint or more  of the strongest beef tea, ox-tail  soup, or
Liebig's " Liquor Carnis,"  which I have used on one or two occasions with ad-
vantage, mixed with  two or three eggs, and  having an ounce or two of brandy
added to it, should be injected regularly, night and morning; until the patient is
able to swallow.   In  those cases  in which the wound is above the larynx, there
is occasional danger of the supervention of oedema of the glottis; should this
occur, tracheotomy may become necessary in order to prolong the patient's life.
   As after-consequences of wounds of the throat, we occasionally find stricture of
the trachea or aerial fistula  occurring.  If the chordae vocales happen to have
been injured,  loss  of  voice may result.

                                ASPHYXIA.
   The surgical treatment of asphyxia includes the management of those cases in
which respiration has been suspended by drowning, suffocation, hanging, or the
inhalation  of  irrespirable gases.   The general  subject of suspended animation
from these various causes cannot be discussed here, but we must briefly consider
some points of practical importance in its treatment.
   In cases of drowning, life is often recoverable, although the sufferer has been
immersed in the water for a considerable time, for it must be borne in mind that
though immersed, he may very probably not have been submersed.   The period
after which life  ceases to be recoverable in cases of submersion, cannot be very
accurately estimated.   The officers of the Humane Society, who have great ex-
perience in these matters, state that most generally cases are not recoverable that
have been more than four or five minutes under water.   In these  cases, how-
ever, although submersion may not continue  for a longer period than this, the
process of asphyxia does; this condition not ceasing on  the withdrawal of the
body from the water,  but continuing until the blood in the pulmonary vessels is
aerated, either by  the spontaneous or artificial inflation of the lungs.   As several
minutes are most commonly consumed in withdrawing the body from the water
and conveying it to land, during which time no means can be taken to introduce
air into the lungs, we must regard the asphyxia as continuing during the whole
of this period;  occupying, indeed, the time that intervenes between the last in-
spiration before  complete submersion  to the first inspiration, whether artificial or
spontaneous, after the removal of the body from the water.   The latest time at
which life can be recalled,  during this period, is the measure of the duration of
life in asphyxia. If,  however, during this period, the action of the heart should_
cease entirely, I agree with Sir B. Brodie, that  the circulation can never  be re-"
stored.  But  although we  may put out of consideration  those marvellous cases
of restoration to life that are recorded  by the older writers, and which are evi-
dently unworthy of belief,  are  we to  reject as exaggerated and apocryphal cases
such as that by Mr. Smethurst, in which  recovery took place after ten minutes'
submersion; that  by  Dr. Douglas, of Havre, in which the patient was  not only
submersed, but  had actually sunk into, and was fixed in the mud at the bottom,
for from twelve to fourteen  minutes; or that by Mr. Weeks, in which  the  sub-
mersion on the testimony of the most credible witnesses, exceeded half an hour?
I think that it would be unphilosophical in the extreme to deny the facts  clearly
stated by these gentlemen.  The more  so that in  these, as in many  other in-
stances of apparent death from  drowning, life  appears to be prolonged  by the 
ASPHYXIA — DROWNING.
301
patient falling into a state of syncope at the moment of immersion.   We should
therefore employ means of resuscitation, even though the body has  been under
water a considerable time.
  The means recommended by the Humane  Society for the recovery of persons
from drowning, and employed at their Institution  in Hyde Park, appear to be
well adapted for the treatment of the less severe forms of asphyxia.  They con-
sist, after the nose and mouth have been cleared of any mucosities, in the appli-
cation of heat by means of a bath at about the temperature of 100° Fah. until
the natural  warmth is restored;  in the employment of brisk friction,  and in
passing ammonia to and fro under the nostrils.  It is evident that these  measures
can have no direct influence upon the  heart and lungs, but can only act as gene-
ral stimuli to the system,  equalizing the circulation, if it be still going  on; and,
by determining to the surface, tending to remove those congestions that  are not
so much the consequences of the asphyxia,  as of the sojourn of the body for
several minutes in  cold water; they would therefore be of especial service during
the colder  seasons of the year.  A hot bath may also, by the shock  it gives,
excite the  reflex  respiratory movements.  With  the view of doing this  with a
greater degree of certainty, cold water should be sprinkled or dashed  upon the
face at the  time that the body is immersed in the hot bath, as in this way a most
powerful exciting influence can  be communicated to the respiratory muscles; and
the first object  of treatment  in all cases of asphyxia—the re-establishment of
respiration,—would more rapidly and effectually be  accomplished; deep gaspings
ensuing, by which the air would be sucked into the remotest ramifications of the
air-cells, arterializing the  blood  that had accumulated in the pulmonary vessels,
enabling it  to find its way to the left  cavities of the heart, and  thus  to excite
that organ to increased activity.    These means then are useful in those cases of
asphyxia in which the sufferer has been  but a short time submersed,  and in
which the heart is still acting, and the  respiratory movements have either begun
of their own accord on the patient being  removed  from  the water, or  in which
they are capable of being  excited by the shock of a hot bath, aided by  the dash-
ing of cold water in the face.   At the same time, the lungs may be filled with
pure air by compressing the chest and abdomen, so as to expel the vitiated  air,
and  then  allowing them  to  recover their usual dimensions by the  natural re-
siliency of  their parietes.  A small quantity of air will, in this way, be sucked
in each time the  chest is allowed to  expand, and  thus  the re-establishment of
the natural process of respiration may be much hastened.  This simple mode of
restoring the vital actions should never be omitted, as it is not attended with the
least danger, and does not in  any way interfere with the other measures em-
ployed.   If, by these means,  we succeed in  restoring the proper action of the
respiratory movements, it will  merely be necessary to pay attention to some points
of the after-treatment  that will  presently be adverted to.  Should we however
fail in restoring respiration, we should have recourse to other and more active
measures.
  In  the more severe cases of asphyxia warmth should be applied by means of a
hot>air bath, by which  not only  the natural temperature of the body  may be re-
established, but the blood  in the capillaries of the surface be decarbonized.  The
most direct and efficient means, however, that we possess  for  the re-establish-
ment  of the circulation of these cases, is certainly artificial respiration.   In this
way the pulmonary artery  and the capillaries of the lungs can alone be  unloaded
of the blood that has stagnated  in them, and  the left side and substance of the
heart  will be directly and rapidly supplied by red blood.   The  whole  value of
artificial respiration depends, however,  upon  the way in  which  it is employed.
Inflation  from  the  mouth of an assistant into  the nostrils  or  mouth  of the
sufferer, though objectionable, as air once respired is not well  fitted for  the re-
suscitation of the  few sparks  of life that may be left in the cases in  which it is 
302
ASPHYXIA.
desirable to employ this means, yet in many instances is the readiest and indeed
the only mode by which respiration can be set up; and should therefore always
be had recourse to in the first instance, or until other and more efficient means
can be got ready.
  The bellows, if properly constructed for artificial inflation, so that the quantity
of air injected may be measured, are no  doubt  very useful;  and  if furnished
with Leroy's trachea-pipes, or what  is  better, with nostril-tubes, may be safely
employed.   About 15 cubic inches of air may be  introduced  at  each stroke of
the bellows, and  these should  be  worked ten or a dozen times in  the  minute.
The lungs should be emptied by compression of the chest before beginning to
inflate, and after each inflation by compressing the  chest and abdomen; but care
must also be taken not to employ much force, lest the air-cells be ruptured.  But
the safest,  and at the same time the most efficient mode of introducing pure air
into the lungs, is either by means of the split sheet, as recommended by Leroy
and Dalrymple (Fig. 119), or  else by  alternately compressing the chest  and
abdomen with the hand,  and then removing the  pressure  so as to  allow the
thorax to expand by the natural resiliency of its parietes, and thus,  each time it
expands, to allow a certain quantity of air to be sucked  into the bronchi.   The

                                    Fig. 119.
quantity introduced need not be large;  for by the laws of the diffusion of gases,
if fresh air be only introduced into the larger divisions of the bronchi, it will
rapidly and with certainty find its way  into  the  ultimate  ramifications of these
tubes.   This last means of inflation has the  additional  advantage of resembling
closely the natural process of respiration, which is one  of expansion from with-
out inwards, and not, as when  the mouth or bellows are  used, of pressure from
within  outwards.  In  one case the lungs are, as  it were, drawn outwards, the
air merely rushing in to fill up the vacuum  that would otherwise be  produced
within  the  thorax by  the expansion  of its parietes; in the  other  they are
forcibly pressed upon from within, and  hence there is danger of rupture of the
air-cells.
  The inflation of the  lungs with oxygen  gas is likely to  be of  great  service in
extreme cases of asphyxia.   I have found by experiment that the contractions of
the heart can be excited by inflating the lungs with this gas, when the introduc-
tion of atmospheric air fails in doing so, and there  are cases  on record in which
resuscitation was effected  by inflating the lungs with oxygen gas, when in  all 
FOREIGN BODIES IN THE AIR-PASSAGES.          303
probability it could not have been effected with any other means.   In my Essay
on Asphyxia will be found a case of resuscitation, in which oxygen was success-
fully employed  by Mr. Weekes after the asphyxia had continued three-quarters
of an hour.  Whatever means of resuscitation are adopted they should be continued
for at least three or four hours, even though no signs of life show themselves.
  The  danger of the  supervention of secondary  asphyxia after recovery has
apparently taken place, is much increased, and indeed is usually  brought about
by some effort on the part of the patient that tends  to  embarrass the partially
restored action of the heart and lungs.   Should symptoms of secondary asphyxia,
such as stupor, laborious respiration, dilatation of  the  pupils, and convulsions,
manifest  themselves, artificial respiration  should  be immediately set up,  and
be maintained until the action of the heart has been fully restored.   In these
cases I should from the very great  efficacy of electricity in the somewhat simi-
lar  condition resulting from the administration of the narcotic poisons, be  dis-
posed to recommend slight shocks to be passed through the base of the brain and
upper portion of the spinal cord, so  as to stimulate the respiratory tracts.
  Asphyxia from the respiration  of the noxious gases, such as carbonic acid, is
best treated by exposing the surface of the body to cold air, by dashing cold water
upon the face, and by setting up artificial respiration without delay if the impres-
sion of cold upon the surface does not excito these actions.  There is a peculiar
variety of this kind of asphyxia,  that  is occasionally met with among infants,
the true nature of which was pointed out to me by Mr. Wakley, who, as coroner,"
has had abundant opportunities of witnessing it, as it is  not anjmcommon cause
of accidental death amongst  the  children of the poor.   It is  that condition in
which  a child is said to have been overlaid;  the child sleeping with its mother
or nurse being found in the  morning suffocated in  the bed.  On examination no
marks  of pressure will  be found, but the right cavities of the heart and the lungs
are gorged with blood, and the surface livid, clearly indicating death by asphyxia.
That this accident is not the result of the mother overlaying her child, is not only
evident from the post-mortem appearances, but was clearly proved by a  melan-
choly case to which I was  called a few years ago, in which a mother on waking
in the  morning, found her twin infants lying dead on either side of her.   Here
it was evident from the position of  the bodies that she  could not have overlaid
both.  The true cause of death in these cases is the inhalation of, and slow suffo-
cation by, the vitiated air which accumulates under the bed-clothes, that  have
been drawn, for the sake of warmth, over the child's head.   In  such cases as
these, resuscitation by artificial respiration should always be  attempted if any
signs of life be left.
  In cases of hanging, death seldom results from pure asphyxia, but is usually
the consequence, to a certain degree at least, of apoplexy, and commonly of simul-
taneous injury of  the  spinal cord.  In these cases, bleeding from the jugular
vein may be conjoined with  artificial respiration.
  If there should be a difficulty in  setting up artificial  respiration through the
mouth  or nose,  as is  more  especially likely  to happen when the  patient has
been suffocated by breathing noxious gases, or in cases of hanging, tracheotomy
or laryngotomy should  at once be performed,  and the lungs inflated through the
opening thus made in the  neck.

                FOREIGN BODIES IN THE AIR-PASSAGES.
  Though the introduction of foreign bodies into the air-passages is  not a very
common accident, yet a great variety of substances that admit of being swallowed
have been found there: such as  nut-shells,  beans,  cherry-stones,  teeth, meat,
money,  buttons, pins,  fish-bones, bullets,  pills, pebbles, and pieces of stick.
These foreign bodies are  not introduced into the air-passages by any effort  of
deglutition, for no  substance can be swallowed through the glottis; but if a per- 
304
INJURIES OF  THE THROAT.
son, whilst swallowing or holding any substance in his  mouth, makes a sudden
inspiration, the current of air may draw it between the dilated lips of the glottis
into the larynx.
   The symptoms vary, according to the situation in which the foreign body is
lodged, its nature, and the period that has  elapsed since the occurrence of the
accident.   The foreign body may lodge in one of the ventricles of the larynx, or,
if light, it may float in the trachea, carried up and down by the movement of the
air in  expiration and inspiration.  If too heavy for this, it will fall into one or
other of the primary divisions of the trachea, and, as  Aston  Key has  observed,
will most  commonly be found in the right bronchus, this being larger, and in a
more direct line with the  trachea than the left.  If the substance be  small, it
may pass  into one of the secondary divisions of the bronchi, and if it continue to
be lodged here for a  sufficient length of time, may make a kind of cavity for
itself in the substance of the lung, where it may either  lie in an abscess, or be-
come encysted.
   The symptoms may be  divided  into  three  stages.   1st.  Those that imme-
diately follow the introduction of the substance.   2dly.  Those produced by the
irritation  of its  presence;  and 3dly. Symptoms of an  inflammatory character
coming on at a later period.
   The immediate symptoms vary somewhat, according to the size and nature of
.the body and the part of the air-tube that it  reaches.   In all cases there is a
feeling of intense suffocation, with great difficulty of breathing, and violent fits
of  spasmodic coughing, often attended by vomiting;  during which the foreign
body may be expelled.  Indeed, its partial entry and  immediate  extrusion, by
coughing, is not uncommon.   In some cases immediate death may ensue at this
period.   If it have entered the air-passages fully, there is usually violent cough-
ing with feeling of suffocation for an hour or two, accompanied by lividity of the
face, great anxiety, and sense of impending death.  There is usually pain felt
about  the  episternal  notch.  These  symptoms  then  gradually  subside, but
any movement on the part of the patient brings them on again  with  renewed
violence.   All these symptoms are most severe if the foreign body remains in
the larynx; the voice being then croupy, irregular in tone, or  lost.   If it be
lodged elsewhere, so often as it is coughed up, and strikes against the interior of the
larynx, an intense feeling of suffocation is produced; and if it happen to become
impacted  there,  sudden death may result, even though it be not of sufficient size
to block up the air-passage,  but apparently by the intense  irritation that is in-
duced.  Some years ago a boy died at the Westminster Hospital  before tracheo-
tomy could be performed, in consequence  of a flat piece of walnut-shell that had
got into the trachea being suddenly coughed up, and becoming impacted in one
of the ventricles of the larynx.   The  symptoms, during this period, are  much
less severe when the foreign body is in the trachea or bronchi.
   When the foreign body has  passed into the air-passages, and the  immediate
effects produced  by its introduction have been got over, another set of symptoms,
dependent on the  irritation produced by it, is met with;  and it is during the
occurrence  of these  that the patient is most generally brought  under the sur-
geon's observation.   These symptoms are of two kinds : general and auscultatory.
   The general symptoms  consist of  occasional  fits of  spasmodic  cough, accom-
panied by much  difficulty of breathing, a feeling of suffocation,  and an appear-
ance of urgent distress  in the  countenance.   These attacks  do not occur when
the patient is tranquil, but come on whenever the foreign body is coughed up so
as to strike the larynx, and the upper and more sensitive parts of the air-passages.
Asa general rule, the distress is less the lower the substance is lodged; the sen-
sibility of the inferior portion of the trachea and bronchi being much less acute
than that of the larynx and the upper part of the trachea.   In consequence of the
irritation,  there is usually abundant expectoration of frothy mucus. 
            FOREIGN  BODIES  IN  THE  AIR-PASSAGES.           305

  The auscultatory signs  depend necessarily upon the situation of the foreign
body.  If this be loose and floating, it may be  heard on applying the ear to the
chest, moving up  and down, and  occasionally striking against the side of the
trachea.   If it be fixed, it will necessarily give rise to a certain degree of ob-
struction to the admission  of the air beyond it, perhaps occasioning bruits during
its passage.   If it be impacted in the larynx, the voice will be hoarse and croupy,
and there will be a loud rough sound in respiration, with much spasmodic cough
and distress in breathing.   If it be impacted in one bronchus, the respiratory
murmur will be much diminished, or even absent, in the corresponding lung, and
probably  puerile in the other; whilst  percussion will  yield an equally clear and
sonorous  sound on both sides of the chest, air being contained in the lung of the
obstructed side, but not readily passing in  and out.   If one  of the subdivisions
of either  bronchus be  occupied  by the foreign  body, the entrance of air will be
prevented in  the  corresponding lobe  of that lung  though it  enter freely every
other part of the chest.   If  the foreign body be angular, or perforated, peculiar
sibilant and whistling noises maybe heard as the air passes over and though it.
   After a foreign  body has  been lodged for a day or two, symptoms of inflam-
mation of the bronchi, or  lungs, are apt to be set up;  in some cases, however,
these only occur after a considerable time has elapsed, or, perhaps, not at all,
much depending, of course, on  the shape  and character of the irritant.  If it
continue  to lodge,  it generally forms  for itself  a cavity in  the substance of the
lung, whence purulent and bloody matters are continually expectorated,  until the
patient dies in the course of a few months, or a year or two, of phthisis.   It has
occasionally happened, however, that  the substance has been coughed up after a
very long lodgment, the patient recovering.   Thus,  Tulpius relates a  case  in
which a  nut-shell was  coughed  up  after being  lodged  for seven years,  and
Heckster one in which a ducat was thus brought up after a lapse of two years and
a half, the patient, in both  instances, recovering.   In  other cases again death
may ensue, although the foreign body is coughed up;  thus, Sue relates an in-
stance in which a pigeon-bone was spit up seventeen years after its introduction,
the patient, however,  dying in little more than  a year from marasmus.
  The prognosis depends  more  upon the nature of the foreign body and its size
than on any other circumstances.    If it be rough, angular,  and hard, there is
necessarily much more risk than if it be soluble in, or capable of disintegration
by, the mucus of the air-passages.
  The danger  depends greatly upon the  length  of time that it is  allowed  to
lodge.  Of fifty-eight  cases  (four of which have fallen under my own  observa-
tion, the  remaining fifty-four being collected from various sources, and constitut-
ing all those that  I have been  able to find recorded) I find the time  that the
foreign body was allowed to remain in, and the result of the case stated in forty-
five instances, which I have  tabulated as follows:
PERIOD THAT IT REMAINED IN.	NUMBER OF CASES.	RECOVERED.	DIED.
Less than 24 hours, .... Between 24 and 48 hours, . Between 48 hours and 1 week, Between 1 week and 1 month, Between 1 month and 3 months, Between 3 months and 1 year, More than 1 year, ....	7 4 12 8 3 4 7	5 3 5 4 3 2 4	2 1 7 4 0 2 3
Total,	45	26	19
  From this it would  appear that if the patient escaped the dangers of the im-
mediate introduction, the greatest risk occurred between the second day and the
                                    20 
306
INJURIES  OF  THE  THROAT.
end of the first month, no less than eleven patients out of twenty dying during
this period, and then that the mortality diminished until the third month, from
which time it increased again.
   The cause of death also varies according to the period at which the fatal result
occurs.   During the first twenty-four, and indeed, forty-eight hours, it happens
from convulsions and sudden asphyxia.   During the first few weeks it is apt to
occur from inflammatory mischief within the chest, and after some months have
elapsed the patient will be carried off by marasmus or phthisis.
   Treatment.—This accident  is always a very serious one, and hence requires
prompt and energetic means to be used in order to save the patient; and fortu-
nately the means at our disposal, consisting of the simple operation of opening
the trachea, and thus facilitating the expulsion of the foreign body, are usually
highly successful.   I find that of fifty-six cases in which the result was noted,
thirty-three lived, and  twenty-three died; but  on analyzing  these cases more
closely, it appears  that in thirty-six no operation was performed;  the expulsion
of the foreign body being trusted to the efforts of nature.   Of these twenty died,
and sixteen lived.   In the remaining twenty cases, tabulated below, tracheotomy
was  performed; of these seventeen lived, and only three  died, showing  a re-
markable success attendant on this operation.
PERIOD THAT IT REMAINED IN.	NUMBER OF CASES.	CURED.	DIED.
Less than 24 hours, .... Between 24 and 48 hours, . Between 48 hours and 1 week, Between 1 week and 1 month, Between 1 and 3 months,	3 2 8 5 2	2 2 7 4 2	1 0 1 1 0
Total,	20	17	3
  If, therefore, a patient is  seen a few  hours, days, or weeks, after a foreign
body has been introduced into the air-passages, or indeed at any period after the
accident, tracheotomy ought  to be performed.  But it may be asked, for what
purpose is the trachea opened ?   Why should not  the foreign body  be expelled
through the same aperture by which it has entered ? The opening in the trachea
performs a double  purpose; it  not only serves as a ready and  passive outlet for
the expulsion of the foreign  body, but also as a second breathing aperture  in the
event of its escaping through the glottis.  The advantage of the opening  in the
trachea as a ready aperture of expulsion is evident, from  the  fact that of four-
teen of the  operated cases,  in  which it is  stated how  the foreign body was
expelled,  I  find  that in twelve it was ejected  through  the  artificial opening,
whilst  in two only did it pass out through the glottis.
  The reason why the foreign  body usually  passes out of the artificial  opening
in preference to escaping  by the glottis, is,  that  the sides of one aperture are
passive, whereas those of the other are highly sensitive and contractile.  Before
the operation is performed, it will be found that the  great obstacle to expulsion
is not only the sensitiveness  of the larynx, great irritation being induced when
it is touched from within, but also the contraction  of  the glottis, by  the  closure
of which not only is the expulsion of the foreign body prevented, but respiration
impeded.   Every time the foreign body is coughed up so as to touch the interior
of the larynx, intense dyspnoea will be produced,  owing to sudden and involun-
tary closure of the glottis, by which respiration is entirely  prevented  and suffoca-
tion threatened; the expulsion of the body  is consequently arrested, unless it
were by chance to take  the glottis by surprise, and pass  through  it at  once in
the same way that it has entered it, without touching its sides.  If there is a
second breathing aperture, though the larynx is equally  irritated by the foreign 
SCALDS  OF  THE  MOUTH,  ETC.
307
body, yet this dyspnoea cannot occur, respiration  being carried on uninterrupt-
edly by one opening whilst the foreign body escapes through  the other;  and
thus, under these circumstances, it may pass  through the glottis with but little
inconvenience to the patient.
  In some cases the foreign body is expelled  at once after the trachea has been
opened; in  others, not until some hours, days,  or  even weeks, have elapsed.
Thus, in Houston's case, a piece of stick was not  coughed up until ninety-seven
days after the operation;  and in Brodie's case, sixteen days elapsed before  the
half-sovereign came away.
  The  expulsion has in some instances been facilitated by inverting the patient,
shaking him, or striking him on the back.  In cases in which the foreign body
is not readily expelled, it has been  proposed to introduce forceps and extract it.
But the uncertainty and danger of such a proceeding is  so great that  few  sur-
geons would be disposed to attempt it; the introduction of the forceps producing
violent  irritating cough, during which  their points might  readily be  driven
through the bronchi, and thus  wound the lung  or contiguous important struc-
tures.   Besides this, there would be the danger of seizing the projecting angle
at the bifurcation of the bronchi instead of the foreign body, and thus injuring
the parts seriously.  If the foreign body is fixed, the safer plan would  certainly
be to leave the aperture in  the trachea unclosed, and wait for the loosening of
the body, and its ultimate expulsion, which, have  hitherto occurred in  all cases
that have been operated on.
   Antiphlogistic treatment  must be continued  during  the  whole progress of
the case.  After the escape of the foreign body the opening in the trachea must
be closed.
   Scalds of the Mouth, the Pharynx, and the Glottis, occasionally occur
from attempts to swallow boiling water; or these parts are scorched by the  inhala-
tion of flame.  The scalding of these parts chiefly  happens to  the children of
the poor, who being in the  habit of drinking cold  water from the spout of a
kettle,  inadvertently attempt to take a draught from the  same source when  the
water is boiling.   The hot liquid  is not  swallowed, but though immediately
ejected, has scalded the inside of the mouth  and pharynx, giving rise  to a con-
siderable degree of inflammation, which  extending  to the glottis, may produce
oedema  of it, and  thus  speedily destroy life by suffocation.   In three cases
which I have had an opportunity  of examining after death, there was no  sign
of inflammation below the  glottis,  though the lips of this aperture were  greatly
swollen; and  this I believe to be invariably the  case, the  inflammation  not
extending into the interior of the larynx, as  has  been pointed out  by  Dr. M.
Hall.
   The  accident always reveals itself by very  evident  signs; the interior of the
mouth  looks white and scalded,  the child complains of great pain, and  difficulty
of breathing  soon  sets in; which, unless efficiently relieved, may terminate in
speedy suffocation.
  In those  cases in which these parts have been similarly injured  by the flame
produced by  the explosion  of gas or of fire-damp being sucked into the  mouth,
the same conditions present themselves.
  In the treatment of this injury the main point  to attend to is  to subdue  the
inflammation, before it involves the  glottis to  a  dangerous extent.  With  this
view, leeches should be  freely applied to the neck, and calomel with antimony
administered.   If symptoms of urgent dyspnoea have set in, tracheotomy must
be performed without delay, and if the child be not too young, a tube introduced
into the aperture so made, and kept there until the swelling  about  the  glottis
has been subdued by a Continuance of the  antiphlogistic treatment.    In  the
majority of the cases,  however,  that have fallen under my observation, in which
this  operation  has  been performed, the issue has  been  a  fatal one, from  the 
308
INJURIES  OF  THE  03SOPHAGUS.
speedy supervention of broncho-pneumonia;  but as it affords the only chance of
life when the dyspnoea is urgent, it must be done, though its  performance in
very young children is often attended by  much  difficulty, from the  shortness of
the neck and the small size of the trachea.

                      INJURIES OF THE OESOPHAGUS.

   Wounds of the oesophagus are  only met with in cases of cut throat, in which,
as has been already stated in treating of these injuries, they occasion much diffi-
culty by interfering with deglutition.
   Foreign bodies not uncommonly become impacted  in the pharynx and, oeso-
phagus, and may produce great inconvenience by  their size or shape.  If large,
as a piece of money or a lump of meat, it may become fixed in  the  lower part
of the pharynx or the commencement of the oesophagus, which is narrowed  by
the projection of the larynx backwards, and, compressing or occluding the orifice
of the glottis, may asphyxiate the patient  at  once.   If the foreign body  get
beyond this point, it usually becomes arrested near the termination  of the oeso-
phagus.   When it is small, or pointed, like a fish-bone, pin, or bristle, it usually
becomes entangled in the folds of mucous membrane that stretch from the root
of the tongue to the epiglottis, or that  lie along  the sides of the pharynx.   In
some cases it may even perforate  these, penetrating the substance of the  larynx,
and thus producing intense local irritation.
   The symptoms occasioned by the impaction of a foreign body in the food-pas-
sages are sufficiently evident,  The sensations of the patient, who usually com-
plains of uneasiness about the top of the sternum; the difficulty that he has  in
swallowing solids, and perhaps the occurrence of an urgent  sense of suffocation,
lead to the detection of the accident.   Should any doubt exist, the surgeon may,
by introducing  his finger, explore nearly the whole of  the  pharynx, and should
examine the oesophagus by the cautious introduction of a well oiled probang.
   If  the impaction is allowed to  continue unrelieved, not only may  deglutition
and respiration be seriously interfered with, but ulceration of the  oesophagus will
take place, and abscess form either behind or between  it and the trachea.
   It may happen that the foreign body, by transfixing the coats of the  oesopha-
gus, has  seriously injured  some  neighboring parts of  importance.  Thus, in a
curious case admitted into the University College Hospital, a juggler, in attempt-
ing to swallow a blunted sword, perforated the oesophagus and wounded the peri-
cardium, death consequently resulting in the course of a few days.
   The treatment must depend upon  the  nature  of the foreign body  and  its
situation.   Should it be of large  size, blocking up the  pharynx  so as to render
respiration impracticable, it may be hooked out with  the surgeon's fingers.   Should
asphyxia have been induced, it may be necessary to perform tracheotomy at once,
and to keep up artificial respiration until the foreign body can be extracted.   If
it be small, or pointed, as a fish-bone  or pin, for instance, though it have  lodged
high up,  the surgeon will usually  experience great  difficulty in its removal, as it
gets entangled between and is  covered in by the  folds of the mucous membrane,
where from its small size it may escape detection;  and after it has been removed,
the patient will experience for some time a pricking sensation, as if  it were still
fixed.  If the impacted body have got low down into the oesophagus,  the surgeon
must deal  with  it according to  its  nature.  If smooth and  soft, as a piece  of
meat  for instance, it may be pushed down into the throat by the gentle pressure
of the probang.   If, however, it  be rough, hard, or sharp-pointed, as a piece  of
earthenware or bone, such a procedure would certainly cause perforation of the
oesophagus, and serious mischief to the parts  around; under these circumstances,
therefore, an  attempt at extraction should be made by means of long slightly
curved forceps, constructed for the purpose. 
INJURIES  OF  THE  CHEST.
309
  It occasionally happens that the foreign  body has become so firmly impacted
in the oesophagus that it cannot be extracted with any degree of force that it is
prudent to use; under these circumstances it may become necessary to open the
tube and thus remove it.  The operation of (Emphagotomy is, however, seldom
called for, but if required may be performed by making an incision about four
inches in length along the anterior border of the sterno-mastoid muscle on the
left side of the neck, the  oesophagus naturally  curving somewhat towards this
side.  The dissection must then be carried with great caution between the carotid
sheath and the trachea in a direction backwards, the  omohyoid muscle having
been  divided in order  to afford room.   Care must be taken in prosecuting this
deep dissection not to wound either of the  thyroid arteries, more especially the
inferior one, which will be endangered by carrying the incisions too low.  AVhen
the oesophagus has been  reached, an aperture  should be made in it; and this
may be  enlarged to a sufficient size, for the extraneous substance to be extracted,
by a probe-pointed bistoury.  In this way  M. Begin  has twice  performed this
operation with success, for  the  extraction  of pieces of  bone  impacted in the
oesophagus.
                          CHAPTER  XX.

                     INJURIES  OF THE CHEST.              %

  Wounds of the chest derive their principal interest and importance from the
concomitant injury of the lungs, heart, or larger blood-vessels.  AVhen the parietes
alone are wounded,  the  injury differs in nothing from similar lesions in other
parts of the body.   In these cases if the surgeon be in doubt whether the cavity
of the  chest has been penetrated or  not, it is better for him to  wait  and to be
guided in his opinion by the symptoms that manifest themselves, rather than by
probing the  wound, running the  risk of converting  it into what he dreads, a
penetrating wound of the chest.
   Wound of the lung is the most common and one of the -most serious complica
tions of injuries of the  chest.  It may occur without  any external wound,  from
the ends of a broken rib being driven inwards upon this organ;  most frequently,
however, it happens  from a  penetrating wound of the  chest, by stab or bullet.
  The  symptoms of  this injury are sufficiently well marked.   There is in the
first place,  the immediate shock to the system that usually accompanies the inflic-
tion of a severe injury,  the  patient at the same time being seized with consider-
able  difficulty of breathing, followed by much tickling and irritating cough, and
the expectoration of frothy blood, mucus, or perhaps of large quantities of  pure
blood.   If there be  an external opening, the air may pass in and out during the
act of  breathing, and emphysema, pneumothorax, or  pneumonia  will speedily
supervene.   On  auscultating  the  chest immediately  after the infliction of the
injury,  and before there is time for the  supervention of any after-consequences,
a loud  rough crepitation will be distinctly audible at  and around the  seat of
injury.
  The principal dangers attending a  wound of the lung arise from the bleeding,
both external and internal, the occurrence of emphysema, pneumothorax, pneu-
monia, and empyema.
  The hemorrhage is usually abundant and often fatal, the patient spitting up a
large quantity of florid frothy blood.  If it do not prove fatal in the early period
of the injury, this bloody expectoration generally ceases in a great measure in the 
310
INJURIES  OF  THE  CHEST.
course of forty-eight hours, giving  way to sputa of a more rusty character.  If
the external wound be very free there may also be copious bleeding from it, but
not unfrequently the blood finds its way into the pleural sac, rather than through
the external  aperture, and accumulating in it may induce death, either by  this
internal and  concealed hemorrhage, or by occasioning  suffocation.   The symp-
toms of this  internal hemorrhage are those  that generally characterize loss of
blood, such  as coldness and pallor of the surface, small weak pulse, and a  ten-
dency to collapse with increasing dyspnoea.   The more special signs consist in
an inability to lie on the uninjured side, with, in extreme cases, some bulging of
the intercostal spaces, and an ecchymosed condition of the posterior part of the
wounded side of the chest.  The most important signs, however, are  those that
are furnished by auscultation.   As the blood gravitates towards the back of the
chest, between  the posterior wall  and the diaphragm, there will be  gradually
increasing dulness  on  percussion in this situation, with absence of respiratory
murmur, the other portions of the lung however admitting air freely.
   Emphysema, or  the infiltration  of air into the cellular tissue of the body, and
pneumothorax, or the accumulation of  air in the cavity of the pleura, are  not
unfrequent complications of wounded lung, although not by any means invariably
met with.   These accidents more commonly occur when the external wound is
small and oblique, than when it is large and direct, and not unfrequently happen
in those cases in which the lung is punctured by a fractured rib, without there
being any external  wound.  In the majority of  cases, emphysema and pneumo-
thorax occur together, but either may be met with separately.  The mechanism
of traumatic  emphysema is most commonly as follows.   The pleura costalis being
wounded and the lung injured, at every inspiration a quantity of air  is sucked
into the pleural sac, either through the external wound, or,  if none exist, from
the hole in the lung, thus  giving rise  to  pneumothorax.  At every expiration,
the air that  thus accumulates in the pleural sac being compressed by the descent
of the walls of  the  chest, is pumped into the cellular tissue around  the edges
of the wound ; and if this be oblique and valvular, being unable to escape wholly
through it, finds its way at each succeeding  respiration further  into the large
cellular planes, first about the trunk  and neck, and eventually, perhaps, into
those of the body generally.   Though this is  the way in  which emphysema
usually occurs,  it maybe occasioned otherwise.   Thus, for  instance, I had lately
under my care a woman, who had extensive emphysema of the cellular tissue of
the  trunk from fractured ribs,  but  without  any pneumothorax, the lung having
been wounded at a spot where  it was attached  to the walls of the chest by old
adhesions, and  the air having passed through them into the cellular tissue of the
body, without first entering the cavity of the pleura.   Mr.  Hilton has described
a form of traumatic emphysema that arises by the rupture of an air-cell or bronchus
without any  external wound.   The air getting into the posterior mediastinum,
and finding its way along  the  nerves  and vessels  in this  situation,  passes out
through the  cervical fascia, which closes the  upper part of the thorax, and thus
reaching the neck diffuses itfelf along the sheaths of the  arteries  and nerves
along which  it finds its way into the limbs ; its appearance in which is first  indi-
cated by its extending along the course of the vessels.
   The symptoms of emphysema are very distinctly  marked.   There is a puffy
swelling, pale, and  crackling when pressed upon, at first confined to the neigh-
borhood of the wound, if  there be one externally; if not, making its appearance
opposite the fractured  ribs, and  gradually  extending over the upper part of
the trunk and  neck, to which it is  usually limited; in some cases, however,
which are happily rare, the swelling becomes more general, the  body being
blown up  to an enormous size,  the features effaced, the movement of the limbs
interfered with, respiration arrested, and suffocation consequently induced; after
death air has been found in all the tissues, even  under the serous  coverings of 
              EMPHYSEMA--PNEUMONIA — EMPYEMA.           311

the abdominal organs.  In  traumatic pneumothorax there is a diminution cr
complete absence of the  respiratory murmur on  the affected side, with, a loud
tympanitic  resonance on  percussion, puerile respiration in  the sound lung, and
considerable distress in breathing.
   Pneumonia is an invariable sequence of a wounded lung, and constitutes one
of the great secondary dangers of these injuries; the inflammation that is neces-
sary for the repair of the wound  in this organ  having frequently a tendency to
extend beyond the part injured, and not uncommonly to terminate in  abscess.
Traumatic  pneumonia resembles  in all  its  symptoms,  auscultatory as well  as
general, the idiopathic form of the disease.  There is the same crepitation, dul-
ness on percussion, and absence of respiratory murmur as hepatization  advances;
with rusty sputa, much tinged with blood in the early stages.  It differs, however,
from the idiopathic form  of the  disease, in having a less tendency to diffuse itself
throughout the lung, it being limited to the injured  side alone, and in more
frequently  terminating in abscess,  which, however,  is  often  dependent on the
lodgment of some foreign body, such  as a piece of wadding or clothing, in the
substance of the organ.
   Empyema  conies on at a later period, being usually occasioned by the irritation
of effused blood, or of some extraneous substance that has lodged in the pleura.
Its existence  may be recognised by  dulness on percussion, and absence of respi-
ratory murmur  at the lower  and posterior parts  of  the chest up  to a level that
has a gradual tendency to  ascend, and that varies according  as  the  patient  is
upright or  recumbent; until  at last the whole side of the chest being filled with
pus, there is increase of its size on measurement,  with bulging of the  intercostal
spaces, and compression of the lung against the spine.
   The prognosis in wounds of the lungs is of course extremely unfavorable, but
less so than  that of similar injuries of most of the other viscera.   Gun-shot
wounds of  the chest are  more  dangerous than stabs, owing partly to  the lacera-
tion attendant on a bullet-wound, but  chiefly perhaps on the lodgment of foreign
bodies that so  commonly occurs in these injuries.  Guthrie states,  that more
than half of  those who are  shot  through the chest, die.   After the battle of
Toulouse, of 106 such cases, nearly half died ; and of 40 cases at the Hotel Dieu,
20 died.  The great danger and principal cause of death in these  injuries  is
unquestionably the hemorrhage that ensues.  This may prove immediately fatal
if one of the  larger pulmonary vessels  is divided.   As  the bleeding is  most
abundant at, and shortly after  the  receipt of the  wound, Hennen states that if
the patient survive the third day, great hopes may be entertained of his recovery.
After this period the chief source of  danger is the occurrence of severe inflam-
mation of  the lungs and pleura, the extent and severity of which are greatly
increased in gun-shot injuries by the frequent lodgment of foreign bodies within
the chest.   Emphysema is seldom a dangerous complication, though it may
become so if very extensive and allowed to increase unchecked.
   If both lungs are wounded at the same time, the  result is almost inevitably
fatal,  either by the abundant hemorrhage suffocating or exhausting the patient;
or  else  by the  induction  of  asphyxia  in  consequence  of  air being drawn
into both the pleural sacs, and thus by compressing the lungs arresting respira-
tion.   This,  however, does  not  necessarily  result,  and there are a  sufficient
number of  cases on record of recoveries after stabs  or bullet wounds  traversing
both  sides  of the  chest, to  show that collapse of  the  lungs and consequent
asphyxia does not necessarily result from this double  injury, which indeed has
also been determined experimentally on animals by Cruveilhier.
   The  treatment of wounds of the  chest,  implicating the   lungs,  must  have
reference to the various sources of danger that have just been  indicated.
   The local treatment is of a very simple character.   If the  wound  have  been
made  by a  bullet, all foreign bodies that are within  reach  should be  extracted. 
312
INJURIES OF  THE  CHEST.
If there is any difficulty in doing this, it may be necessary to enlarge the aper-
ture and then to remove them; but the surgeon must not go too deeply or perse-
verino-ly in search of them, lest he excite more irritation than the  foreign body
would.   Light water-dressing should then be applied, no attempt being made to
close the aperture, so that the escape of any extraneous substance that may have
been left, or  of extravasated blood, may not be interfered with.
   If the wound be a clean puncture,  the edges may be brought together and
closed by means of stitches and plasters, so that the bleeding may be arrested, and
the patient enabled to breathe with more  ease.  It is seldom  that there is any
troublesome hemorrhage from wounds of the intercostal arteries; should there be
so, the surgeon must enlarge the orifice of the wound, and secure  the bleeding
vessel in the  best way he can.
   Wounds of the internal  mammary artery are of  rare occurrence, considering
its exposed situation.   They  may however occur if the chest is  penetrated in
front through the intercostal spaces, or costal  cartilages.   The  danger in these
cases is from  the hemorrhage taking place  slowly into the anterior mediastinum,
or one of the pleurae, without any external bleeding revealing the mischief that
is going on  within.  If the  wound  of the vessel  be ascertained, an attempt
should  be made,  by  enlarging the external aperture, to seize and ligature the
bleeding ends, cutting directly down  upon them through the injured intercostal
space, or the  vessel might even be followed beneath one of the costal cartilages,
if necessary,  by cutting through this.   Should much blood have  already been
extravasated, this must  be  removed through the external  wound, by the intro-
duction of a  female catheter, or  by the  application of a cupping-glass over it,
and the case  then treated like one of effusion into the chest.
   In the constitutional  treatment of  these injuries, the  first indication consists
in diminishing the quantity of  blood  circulating through the lungs, and thus
endeavoring to arrest the hemorrhage from these organs.  With this view, a free
venesection,  to the extent of from at least twenty to thirty  ounces, or even more,
must be practised.   In  this way the bleeding may be stopped at once; should it
recur, and the pulse rise, blood  must  be taken from the arm again and  again.
The most experiended surgeons are unanimous in their opinion, that at this stage
of the injury the patient's safety lies in free and repeated venesection.  The
patient must then be kept lying on the injured side, and have nothing but ice or
barley-water  allowed.
   If the patient  survive the  third day, the danger to be  apprehended  is from
inflammation within the chest.  Here also bleeding must be practised, though it
need not be done to the same extent as in  the earlier stages of the  injury.  The
inflammation must also be combated by a rigid diet, and  by the administration
of antimonials.   In fracture  of the ribs with wounded lung, the same line of
treatment requires to be adopted; but when the accident occurs in elderly people,
we may advantageously substitute calomel and opium for the antimonials.
   If extravasation of blood into the pleura is going on, its  farther effusion must,
if possible, be arrested  by  the same means that are adopted for the stoppage of
external hemorrhage.  When the bleeding has been checked in this way, the blood
must early be let out of the  pleural sac; for, if it be allowed to  remain there,
it will speedily putrefy,  giving rise to extensive formation of pus in this cavity.
In order to prevent these occurrences, the wound should be opened freely with a
probe-pointed bistoury,  on the fifth or sixth day after the injury, so that the blood
may be  discharged.  If it do not readily come away, a  cupping-glass may be
applied over  the aperture, and thus it may be withdrawn.   Should, however, the
hemorrhage  continue, notwithstanding the employment of the means indicated,
Guthrie advises that the wound  should be closed,  so that the blood  that flows
into the pleural sac may, by accumulating in this, compress the lungs, and thus
arrest the farther escape of  blood from the wounded vessels; the  patient at the 
HERNIA  OF  THE  LUNG.
313
same time should be made to  lie on the injured side, in order to increase the
pressure  exercised upon  the  wounded and  bleeding organ.   On the sixth or
eighth day the  chest should be tapped, or  the wound opened again,  in  order to
evacuate  the extravasation, and prevent its  acting as an irritant to the pleura; or
by permanently compressing and condensing the lung, rendering this useless.
  In  all  cases of purulent effusion into the  chest, Guthrie advises with  good
reason, that  tapping  should be early performed, in  order that the lung  may not
be bound down by false membranes,  and consequently being unable  to  expand,
lead to permanent flattening of the side, and  impairment of respiration.
  If any extraneous body, such as a bullet, a piece of wadding, or of clothing, have
penetrated too deeply into the  chest to be readily extracted through the  external
wound, it would not be safe to make incisions or exploratory researches, with a
view of extracting it; for, though its presence would increase the patient's danger,
yet, attempts at extraction  would not only  add to this, but in all probability be
fatal.  In many cases, bodies so lodged form an abscess around them, are loosened,
and eventually are spit up, or appear at the external wound.  In  others, again,
they remain  permanently fixed in the  chest, becoming enveloped in a cyst, and
so remaining for years, without producing irritation.  In this way Hennen states
that a bullet has been  lodged in  the chest for  upwards of twenty  years;  and
Vidal mentions a man who lived for fifteen years with the broken end of a foil in
his chest, which, after death, was found sticking in the vertebrae, and stretching
across to  one of the ribs.
   The treatment of emphysema consists of little in addition to what is called for
by the wounded lung.   In many cases, indeed, the air becomes rapidly absorbed,
without the necessity of any local  interference.   In others, again, the  pressure
of a bandage may be required.  If, however, the emphysema be so extensive as
to interfere  with respiration,  the  external wound must be freely Opened,  and
scarification made into the cellular tissue, so as to give exit to the air.

                 HERNIA OF THE LUNG, OR PNEUMOCELE.
   Hernia of the lung is an affection of extremely rare occurrence.  It consists
in the protrusion of a portion of this organ at some part of the thoracic walls so
as to form a tumor under the skin.  It  has most frequently been  met with after
an external wound, under the cicatrix of which the hernial swelling has appeared;
but it has been known to occur from fractured ribs without any wound and even
from violent straining during labor.  In these cases it is probable that the inter-
costal muscles and costal pleura having  been divided or ruptured by the efforts of
the patient,  and not having united afterwards, the lung  has, during expiration,
gradually insinuated itself  into the aperture  so formed, until at last  the hernial
tumor appeared.
   This protrusion may occur at any part of the thoracic parietes; thus  Velpeau
has observed  it in the supra-clavicular  region of a  girl; but most commonly it
occurs on one or other side of  the chest.  The tumor may attain a large size ; I
have  heard Velpeau  state that he has seen one, half as large as  the head.  It
does not appear to shorten life.
   The only case that has fallen under my observation is one that I saw in 1839,
in Velpeau's wards at La Charite ; and, as the signs of the affection were well
marked in this case I may briefly relate it, from  notes  taken at the time.  A
man twenty-nine years of age,  left-handed,  received in  a duel, a sword wound at
the inner side of, and  a little below the  left nipple; he lost a considerable quan-
tity of blood, but did  not  spit up any; and  the wound healed in about a fort-
night, shortly after which he found the tumor; for which he was admitted three
months and a half after  the  receipt of the injury.   On examination, an indu-
rated cicatrix about half an inch in length was found a little below, and to the
inner  side of the left nipple.   On  inspiring or coughing, a soft tumor about the 
314
INJURIES  OF  THE  CHEST.
size of an egg  appears  immediately underneath the cicatrix, which it raises up;
it subsides  under pressure, or when the patient ceases  to inspire or to cough;
and  its protrusion may be prevented by pressing  the finger firmly on the part
where it appears, when a depression is felt in  the intercostal muscles.   If the
fingers are slid obliquely over the tumor, it  yields a fine and distinct crepitation,
exactly resembling that produced by compressing a healthy lung, and the spongy
tissue of the organ can be distinguished.   On applying the ear  a fine crackling
and  rubbing sound  is distinctly perceived;  it is  resonant on  percussion.   The
portion of protruded lung does  not appear to re-enter the chest on inspiration,
but is firmly fixed in its new situation.  No treatment was adopted in the case,
nor does any appear admissible  in  similar ones.   The only affection with which
a  hernia of the lung can be  confounded is a circumscribed empyema which ia
making its way through the walls  of the chest.   Here, however, the dulness on
percussion, the absence of respiratory murmur, and of crackling under the fingers,
will readily  enable the surgeon to make the diagnosis.
   It occasionally happens in extensive wounds of the chest that  a portion of the
lung protrudes during efforts at expiration.   If the wound be free the protruded
lung may return on pressure,  or during inspiration.   If  left unreturned it soon
becomes  livid and gangrenous; under these circumstances it may be removed
by the knife or ligature;  but Guthrie advises  that the  protruded part should
never be separated from the pleura costalis by which it is surrounded at its base,
so that the  cavity of the thorax may not be opened;  the wound must then be
closed in the usual way.

              WOUNDS OF THE HEART AND LARGE VESSELS.
   These injuries are generally immediately fatal from the sudden loss of blood
and  the  severe shock  that  the patient  sustains.  There are  many cases on
record, however, of  persons who have walked or run some considerable distance
after  receiving a  wound  in  the heart before falling down dead.   Olivier and
Sanson have collected twenty-nine cases of penetrating wounds of the  heart that
did not prove fatal in  the first forty-eight hours after the receipt of the injury.
On analyzing these,  it would  appear that the rapidity of death depends greatly
on the direction of the wound and the part of  the  organ injured.   When  the
wound is parallel to the axis of the heart it is not so speedily fatal  as  when in a
transverse direction, and wounds of the auricle are more immediately followed
by death than those of the ventricle;  the irregular contraction  of the different
planes of muscular fibre that enter into the formation of the wall of the ven-
tricle, tending to obstruct the free passage of the blood through the wound, and
perhaps to close it entirely.   The  size of the wound, however, will necessarily
influence the result more materially than  its direction even.   Without referring
to numerous cases recorded by the older surgeons, there are a  sufficient number
of instances reported by modern writers to prove that an individual may live for
many days,  and even recover  altogether from the  effects of a wound by which
the cavities  of the heart have been penetrated, and even with  a foreign  body
lodged in them.   Thus Ferrus  relates the  case of a man who lived for twenty
days with a skewer traversing the heart from side to side.  Messrs. Davis  and
Steward found  a piece of wood, three inches long, in the right ventricle of a
boy,  who lived five weeks after the accident had happened ; and Latour records
the case of a soldier, who lived for six years after being wounded with a musket-
ball in the side, and in the right ventricle of whose heart the bullet  was found
lodged lying against the septum.
   From the inquiries of Olivier it would appear that the right ventricle is more
frequently wounded  than the  left, next the  apex or base of the heart, the  right
auricle, and least frequently the left auricle.
   The signs of an injury of the  heart that is not immediately fatal,  are not very 
INJURIES OF  THE  ABDOMEN.
315
positive.   The hemorrhage, the  direction of the  wound, the dyspnoea, the  ex-
treme anxiety, syncope, and irregularity with smallness  of the  pulse, indicate
the probable nature of the mischief.  The most important information, however,
is  to be derived from  auscultation; the occurrence of friction,  or some  other
abnormal sound, with dulness  on percussion over the region of  the heart, may
point to the seat of the injury.
   Rupture of heart from external violence is extremely rare ; indeed I am  not
acquainted with any case of the kind, except in one instance, that occurred
recently at the hospital in my  wards.   A  man  was brought in  dead, having
fallen from the top of a cart.  The right shoulder was bruised and the clavicle
broken—showing clearly that he  had pitched on  that side ; there was  no other
bruise about the body,  or evidence that the  wheels had passed over him.   On
examination, the liver was found extensively torn, in fact smashed, and the peri-
cardium was distended with blood—there being a triangular ragged aperture at
the anterior part of the auricular appendage  of the left auricle through which it
had  escaped.
   In the treatment of these cases, little can be done.  If the patient do not  die
immediately or speedily from hemorrhage,  the principal danger  to be  appre-
hended is from  pericarditis,  which, with the  extravasation into  the sac, will
speedily destroy life.
   Wounds of the aorta and vena-cava, are as fatal as  those of the heart itself.
Dr.  Heil has however recorded a case in which a patient recovered and lived for
a  twelvemonth after receiving a stab that penetrated the ascending aorta.
                         CHAPTER  XXI.

          INJURIES  OF THE ABDOMEN  AND PELVIS.

  Injuries of the abdomen  are of frequent occurrence.   They may be divided
into contusions of the abdomen, with or without rupture of internal organs; into
non-penetrating wounds,  and into penetrating wounds ; either uncomplicated or
conjoined with injury, or protrusion  of some of the organs  contained in this
cavity.
  Contusions of the  abdominal walls from blows or kicks, usually terminate
without serious inconvenience, but in  some cases are followed by peritonitis of a
very acute character,  which  may prove fatal.
  In other cases again, the abdominal muscles may be ruptured, although  the
skin may remain  unbroken.   A man  was admitted under my  care into the hos-
pital, who had received a blow from the buffer of a railway carriage upon his
abdomen; he complained of great pain  at one spot, and on  examination after
death, we found  the rectus muscle torn across without  injury either to the in-
teguments or the  peritoneum.  If the patient live, an injury of this kind is apt
to be followed by atrophy of the muscular substance, and perhaps by the occur-
rence of a ventral hernia at a later period.   Occasionally the contusion is  fol-
lowed by  abscess  in the abdominal wall, which has a tendency to extend widely
between the muscular planes.  These  abscesses should be opened early, lest they
burst into the peritoneal  cavity, and occasion fatal inflammation.
  A contusion of the abdomen is often associated with rupture of  some of the
viscera.  In military practice, these internal injuries are met with in the so-called
"wind  contusions;"  in civil practice they commonly result  from blows, kicks, 
316
INJURIES  OF  THE  ABDOMEN.
the passage of a cart-wheel over the abdomen, or the squeeze of the body be-
tween the buffers of two  railway carriages.   These " buffer  accidents" are now
of common occurrence in hospital  practice, resulting usually from the careless-
ness of railway guards and  porters, who, trying to  pass  between carriages in
motion, are caught  and squeezed between the buffers.  In these cases the most
fearful internal injuries occur often without an  external  wound.  A man was
admitted under my care into University  College Hospital, in whom the liver,
stomach, spleen, and kidneys, were  crushed  and torn; the  heart was bruised,
being ecchymosed  on its  surface, and one of the lungs lacerated, without there
being any rupture or bruise of the skin or fracture of the ribs. In this way any
of the abdominal organs may be torn or contused, the particular one injured de-
pending on the situation of the blow.  The organ that  is most frequently crushed
in this way is the liver, owing to its large size and the ready lacerability of its
structure;  the other solid organs, such as the spleen  and  kidneys, not suffering
so frequently:  the  pancreas  I  have never seen injured.   Amongst the hollow
organs, the stomach most commonly suffers, and it is especially likely to do so if
distended by a meal at the time that it is  struck.  Any portion of the intestinal
canal maybe lacerated.  I have seen the duodenum, the ileum, the jejunum, and
the large intestine  ruptured in different  cases: the mesentery likewise may be
torn, and the spermatic cord snapt across.
   The sufferer usually dies in the course of a few hours, or at the utmost at the
end of two or three days after the receipt of these injuries, from hemorrhage
into the abdominal  cavity, conjoined with shock to  the system.  It is  seldom
that life  is prolonged sufficiently  for peritonitis to be set up, though  this is  the
chief danger to be  apprehended  in those  cases that survive the more immediate
effects of the  accident.   When the solid organs are ruptured, death most com-
monly ensues from hemorrhage.  The shock in itself may prove fatal, though
there be  but little internal mischief done; thus,  I have seen a man die collapsed
eight hours after a  buffer accident, in whom no  injury was found except a small
rupture of the mesentery, attended with but very slight extravasation of blood.
It does not follow, however,  that these injuries are  necessarily fatal.  Patients
have  lived after all the signs  of rupture of the liver or the kidneys, and it is
said that when death has occurred at a later period, cicatrices have been detected
in these organs; this indeed  is  nothing more than has been met with in ordinary
penetrating wounds of the abdomen.   A patient was admitted into the hospital
for a severe blow upon the back, accompanied by symptoms of renal injury; on
his death from other causes, nine weeks after the accident,  an extravasation of
blood, with the marks of recent cicatrization, was found in the left kidney.
   Rupture of the liver is by no  means invariably speedily fatal.   It may be so
from great  extravasation  of blood, but when this is not largely poured out, the
patient may live for  some  considerable time.   A man was  admitted last year
under my  care into University College  Hospital, who had been crushed between
the  buffers of two railway carriages.   He was collapsed, and apparently mori-
bund, but rallied in a few hours.  Two days after the accident, great pain and ten-
derness in the right hypochondrium were complained of, and dulness on per-
cussion was found to extend as low as the umbilicus.   He became jaundiced, and
there were symptoms of low peritonitis.  These were followed by great swelling
of the abdomen, which became tympanitic. The peritonitis continued, and symp-
toms of  intestinal obstruction came  on; the  dulness increasing, with fluctuation
in the flanks.  He died on the sixteenth day after the accident, and on exami-
nation no less  than two hundred and forty ounces of bilious fluid, mixed with
flakes  of lymph, were  found in the abdominal cavity.  The obstruction appear-
ing to be dependent on the pressure of this effusion, and on,the matting together
of the intestines by lymph.   There was a large rent found in the thick border
of the liver, which was apparently beginning to cicatrize. 
WOUNDS  OF THE INTESTINES.
317
  The symptoms of an internal abdominal injury are often extremely equivocal.
If the liver or spleen have been lacerated, there will be all the effects of severe
shock to the  system, accompanied by those of internal hemorrhage; coldness, and
pallor of the surface, a small and feeble pulse, anxiety of countenance, and great
depression of the vital powers, with pain at the seat of injury, and perhaps  dul-
ness on percussion, from  extravasated blood;  symptoms that speedily terminate
in the death of the  patient.   If the kidneys  are injured, the patient will  com-
monly experience a frequent desire to pass water, and this will be tinged with
blood, often to a considerable extent.   The absence of blood in the urine must
not, however, be taken as an indication  that the kidney is not injured.   It may
be so disorganized  as  to  be  totally incapable  of secreting, and consequently no
bloody urine finds its way into the bladder.  A man was admitted into the hos-
pital under my care for a buffer-injury of the back;  he passed water untinged
with blood, but after death his right kidney was  found completely smashed by
the blow, with an extensive  extravasation of blood in the cellulo-adipose tissue
around it; here it was evident  that the disorganization was so sudden and  com-
plete that no bloody urine had found its way into the bladder.
   When the stomach  is ruptured, it commonly happens that  the  nature of the
accident is revealed  by bloody vomiting;  and when the intestines  have  been
torn,, by the admixture of blood with the stools, if the patient lives long enough
to  pass  any.   These  signs,  however,  do not  occur in all cases.   A man  was
admitted into  the  hospital under  my  care, whose  abdomen had been squeezed
between a cart-wheel and a lamp post; during the five hours that he  lived  after
the accident, he vomited several times, bringing  up a meal that he  had taken
immediately before.  In  the vomited matters there was no blood to be seen, but
on examination after death it was found that the liver and spleen were  not  only
ruptured, but the stomach torn almost completely across near the pylorus.
   The treatment of  the  various injuries of the  abdomen that have just  been
described is of a very simple character.  If the symptoms indicate laceration of
one of the viscera, little can be done during the state of collapse supervening on
the accident, beyond keeping the patient quiet, and employing the  means  that
have been recommended for  lessening the effects of shock upon the system.  If
the patient survive this  period we must guard against the occurrence of perito-
nitis, and limit, if possible, the extravasation of blood into the abdomen, should
there be indications of its occurrence, by the employment of treatment  that will
presently be described.
   Wounds of  the abdominal wall  that do not penetrate the peritoneal cavity, if
uncomplicated with internal  injury usually do well, and require to be treated on
ordinary  principles.   If  incised,  and  so extensive as  to require sutures, the
stitches should only be introduced through the skin, never through muscular or
tendinous  structures, the union of which could not be effected in this way; the
parts injured must also be relaxed by  careful attention to  position.
   Wounds that penetrate the cavity of the abdomen are of especial  interest, on
account of the frequency with which  they are complicated with peritonitis, and
with injury of some of the viscera.  They may, for practical purposes, be divided
into those that penetrate the peritoneal  sac,  without wounding or causing the
protrusion of any of the  contained organs, and those that are complicated with
protrusion' or wound of some of the viscera.
   Penetrating wounds of the abdomen without visceral protrusion or injury, are
somewhat difficult to distinguish  from simple wounds of the abdominal  wall,
though the escape of a small quantity of reddish serum may reveal the  nature of
the accident.   In these  cases the surgeon should be careful not to push  his
examination too far,  by probing  or  otherwise  exploring  the injury.   In the
absence of peritonitis or other signs  of mischief, he must treat it as  a simple
wound of  the  abdominal wall, and should any  complication  occur,  must  meet
that in the way that will immediately be described. 
318
INJURIES  OF  THE  ABDOMEN.
   In a penetrating wound with protrusion or injury of the viscera, the  risk is
 necessarily greatly increased;  here the chief danger is from peritonitis, induced
 either by the  wound,—by the extravasation of the intestinal contents into  the
 peritoneal cavity, or by the accumulation of blood in it.  It but seldom happens
 that  death  results from hemorrhage in these cases, though this may, of course,
 occur if any of the  larger vessels be injured.
   A portion of intestine with its mesentery, or a bit of omentum, may  protrude
 through the wound without  being in any  way injured; the  protruded mass is
 always of very large size in comparison with the aperture from which it escapes,
 the  sides of which being  overlaid by it, constrict it pretty  tightly, so as to form
 a distinct neck to the protrusion.   If left unreduced, the mass speedily loses its
 polish and bright color, becoming dull and livid from congestion; it then inflames,
 and soon becomes gangrenous from the pressure exercised upon it by the sides of
 the aperture through which it has passed.   In many cases the protruded intes-
 tine is wounded as well.   The existence of this further injury will readily be
 ascertained, by  the  escape of flatus, or of  the more fluid  contents  of  the gut.
 The characters of the  wound vary, as Travers has  pointed  out, according to its
 size.   If it be a mere  puncture in the gut, or even an incision two or three lines
 in length, an eversion  or prolapsus of the mucous membrane will  take  place, so
 as to close it to an extent sufficient to prevent the escape of its contents.  If the
 aperture be above four lines in length, this plugging of it by everted mucous
 membrane cannot take place, and  then the  contents of the  bowel are more freely
 discharged;  but, even under these circumstances, there will be a tendency to the
 protrusion of the membrane, which forms a kind of lip over the edge of the cut.
   If the intestine is wounded without being afterwards protruded from the abdo-
 men, the same  conditions necessarily occur.   In these cases, however, there is
 the additional danger of the extravasation of the  intestinal contents into  the peri-
 toneal cavity.   This extravasation of feculent matter, unquestionably one  of the
 greatest dangers that  can occur in wounds of the abdomen, inasmuch as  by  its
 irritating qualities it  gives rise  to and keeps  up the most intense  peritonitis,
 occurs less frequently than might be expected.   For this there are several reasons.
 In the first  place, we have already seen that, if the wound  in the gut be below a
 certain size, there is  a natural  tendency  to its occlusion by eversion of the
 mucous membrane into it.   Besides this, it must be borne  in mind that, though
 in ordinary  language  we  speak of the "cavity"  of the abdomen, there  is in
 reality no such thing;  there being no empty space within the peritoneal sac into
 which the extravasated matters could fall, but the whole of the visceral  contents
 of the abdomen being  so closely and equably brought into  contact by the  pres-
 sure of the  abdominal muscles and of  the diaphragm, that it  requires  some
 degree of force for the intestinal contents to overcome this uniform support, and
 to insinuate themselves between the coils of contiguous  portions of intestine.
 The influence exercised by the continuous pressure of the abdominal walls upon
 the intestinal contents,  is well shown  by the greater facility  with which these
 escape from a portion of wounded intestine that has been protruded, than from
 one that is still lying within the abdomen.   In the former case, faeces will escape
 from a much smaller aperture than in the latter instance, in consequence of the
 gut not being supported on all sides by the uniform pressure to which it is sub-
jected within the abdomen.  It is seldom, indeed, that the faeces are extravasated
from a gut that is not protruding, unless it be very full at the time of the injury,
 or the wound in it be very extensive.
  Blood is extravasated more  readily than the intestinal contents in  wounds of
 the abdomen.   This is  in a  great  measure owing to the  vis-a-tergo influence
 existing in an artery of moderate  size, such as one of the branches of the mesen-
 teric, being sufficient to overcome the equable pressure and support of the abdo-
 minal wall. 
          TREATMENT  OF  WOUNDS  OF THE ABDOMEN.         319

  These  extravasations, whether of faeces or of blood, when once formed have
little tendency to diffuse themselves, but become localized in the neighborhood
of that part from which they were originally poured out, owing to the surround-
ing pressure, in the first instance, and, at a later period, to the deposit of plastic
matter between the folds of intestine and neighboring viscera.  In this way the
diffusion  of irritating matters through the abdominal cavity being prevented, the
likelihood of the occurrence  of wide-spread  and  fatal inflammation  is  much
diminished.
  The existence of these extravasations may, in many cases, be  recognised by
dulness on percussion around the wound, by the localized swelling to which they
give rise, and, sometimes by their escape through the external aperture.
  In the  treatment of penetrating wounds of the abdomen,  we must first consider
the management of the injured parts; and, afterwards, the prevention or cure of
the consecutive peritonitis.
  If the wound have not implicated any of the abdominal  viscera, it must be
closed by relaxing the abdominal muscles by position, by introducing a few points
of suture through the  integuments, if it be extensive, and  by applying a com-
press and plaster, supported by a bandage.   The patient should then have a  full
dose of opium given him; about two grains of solid opium  or forty minims of the
liquor sedativus; which must be repeated in from six to twelve hours, so that the
effects may be kept up.  He should then be kept perfectly quiet in bed, and no
nourishment  given for a few  days, except barley-water  and ice.   The  bowels
should not be opened by aperient medicine, lest abdominal irritation be set up,
but oleaginous enemata may be administered.
   If the intestine be wounded but not protruding, we must endeavor to limit the
peritonitis that will  ensue, and also to prevent feculent  extravasation.   With
this  view the patient should be laid'on the injured side with the wound  depen-
dent, so as to allow the faeces to escape through it if disposed to do so.   If the
injury be about the umbilicus he must lie  upon his back with the knees drawn
up and bent over a pillow.  Opium must then be administered in the full doses
already indicated, and  repeated in grain doses at least every sixth hour, so that
the system be kept well under its influence.  The value of opium in these cases
is great;  it not only seems to moderate the inflammation that takes place in the
peritoneum, but is of great utility in preventing extravasation of faeces.   This it
does by arresting the peristaltic movements of the intestine, and thus, by keep-
ing it from change of position, lessening the chance of the escape of its contents.
This arrest of the  intestinal  movements also tends greatly to the closure of the
wound.  Travers has shown  experimentally, and  his  investigations have been
confirmed by  subsequent observations on the human subject, that  wounds of the
intestines are closed by lymph that is thrown  out, not  only from the contiguous
peritoneal surfaces of  the part actually injured, but from  that of neighboring
coils; so that the aperture in  the gut becomes permanently glued and attached
to the structures in its  vicinity.  In  order that this process should take place, it
is necessarily of the first importance  that the  movements  of the bowel be para-
lysed ; and it is a beautiful provision of nature that the very inflammation which
closes the wound  arrests that peristaltic  action, the continuance of which would
interfere  with its agglutination to, and closure by, the neighboring parts.  Until
the necessary degree  of inflammation to effect this is set up,  the intestinal move-
ments must therefore be arrested by opium.
  If extravasation of feculent matter have  taken place into the  cavity of the ab-
domen, an  attempt should be made  to facilitate  its  escape by  removing  the
stitches and plasters  from the external wound, and placing the patient on  the
injured side, so that this may be in the most dependent position; should the lips
of the wound have already become adherent to one another, they might even be
gently and carefully separated by the introduction of a  probe, and  in this way an
outlet afforded for the effused matters. 
320
INJURIES  OF  THE  ABDOMEN.
  When a portion of intestine or of omentum has protruded, it should  be re-
placed as speedily as possible, before strangulation has occurred to occasion gan-
grene  of the  protruded mass.   In order  to  effect reduction, the  abdominal
muscles should be relaxed by bending the  thigh upon  the abdomen, when the
surgeon may gradually push back the protrusion by steady pressure upon it; no
force must, however, be had  recourse to, or any rough handling of the exposed
and delicate parts ; but if it be found that their return cannot readily be effected,
owing to the constriction of the neck of the tumor, the  aperture through which
they have escaped must be carefully enlarged,  in a direction upwards, by means
of a probe-pointed bistoury, or a hernia-knife guided by a flap director.  The in-
cision necessary to enlarge  the opening  sufficiently to admit  of reduction, need
not exceed half an inch in length.   In replacing the protruded parts, whether
by the aid of incision, or not, care must be taken that they are fairly put back
into the cavity of the abdomen and not pushed up into the sheath of the rectus,
or into the  subserous cellular  tissue lying  before the peritoneum;  an accident
that would be  fatal by allowing the constriction of the neck of the protrusion to
continue unrelieved.  In effecting  the return the surgeon  should not push his
finger into the cavity of the abdomen,  but must  content himself with  simply re-
placing the protruded gut, or omentum,  and allowing it  to remain  in  the imme-
diate neighborhood of the wound in the abdominal wall, to which it will contract
adhesions;  and through which its contents may escape in  the  event of any
sloughing action  being set  up in it.   If the  protrusion be inflamed it  must
equally be replaced without delay; but should the  intestine  have become gan-
grenous from continued constriction and exposure, no attempt at reduction should
be made, but an incision must be carried through it, so as to allow of the escape
of faeces, and the formation of an artificial anus.   If the protruded omentum be
gangrenous it  must be excised on a level with the peritoneum, to the aperture in
which that portion lying within the abdomen will have contracted adhesions.
  If the intestine that protrudes be wounded as well, the treatment of the aper-
ture in the gut will call for special attention; and surgeons have been somewhat
divided as to the line of practice that should be pursued in  such a case.  The
question that has  been left open is as to the propriety of stitching up the wound
of the intestine.   Scarpa and  S. Cooper were opposed  to this practice, on the
ground that it does not prevent extravasation, and that the stitches produce irri-
tation by acting as  foreign bodies.  They proposed to return  the  wounded gut,
taking care, however, to leave the aperture in it to  correspond  with that in the
abdominal wall, so that an artificial anus might  be established by the cohesion of
the edges of either opening to  one another, these adhesions preventing extrava-
sation.  To this practice the great objection exists that extravasation will pro-
bably occur before there has been time for the effusion of lymph, and the agglu-
tination of the contiguous surfaces;  besides which, it is impossible to secure the
necessary correspondence between the two apertures, the  wounded gut being very
liable to alter its position after it has been replaced.  It has also been found by
experience that one of the objections urged against the employment of a suture,
that it cannot  prevent the escape of feculent matter, is  not valid.   If it be pro-
perly applied,  it may effectually do so,  as was shown by a case under my care at
the hospital, the  details  of which have been published in " The  Lancet," for
1851.  That the  stitches act as sources of irritation to any serious extent is also
doubtful.   Travers found by experiment that when a wounded gut was sewn up,
and returned into the  abdomen,  the sutures quickly became  bridged or coated
over with a thick layer of lymph, and  gradually ulcerating this way inwards, at
last dropped into  the  cavity of the intestine, being discharged per anum, and
leaving a firm cicatrix at the point to which they had been applied.   For these
various reasons, Guthrie, Travers, and other surgeons of experience, advocate the
practice of stitching up a wounded and protruding intestine, with which opinion 
TREATMENT OF WOUNDED INTESTINE.
321
I entirely agree.  Much, however, depends upon the way in which the sutures
are applied.   They should be introduced by means of a fine round needle, armed
with sewing silk, in such a way that the peritoneal surfaces on either side of the
wound alone are brought into  contact, as  adhesion takes place solely between
them, the wound in the other structures of the gut filling up by plastic deposit.
The needle should only penetrate the peritoneal and cellular coats, no muscular
tissue being taken up  in it, lest retraction of the included fibres,  by dragging
upon the stitches, might re-open the wound.   The kind of suture that should be
used is the "glover's stitch."  When the lips of the wound  have been nearly
brought into apposition in this way, it has been proposed to leave the end of the
thread hanging out of the aperture of the abdominal wall, and to withdraw it
when it becomes loose; but I think it better not to leave it, as it might induce
great irritation, acting  like a seton in  the peritoneal cavity.  It is better, there-
fore, to cut the ends short close to the knot, when the suture will eventually be-
come covered with lymph, and find its way into the inside of the gut by ulcerat-
ing through the muscular and mucous coats.
   After the aperture in it has been thus  closed, the protruded portion of the
intestine must be reduced, having previously been properly cleansed with a  little
lukewarm water.  The reduction must be  effected in the way that  has already
been described, the surgeon being especially careful not to push the wounded coil
of intestine far into the abdomen, but to leave it close to the external orifice, so
that in the event of extravasation occurring, or the stitches giving way, a ready
outlet nay be afforded.   The after-treatment must be conducted in all  respects
on the same principles  that guide us in the management of an intestine that has
been wounded without  protruding.  Care must be taken, by attention to the  posi-
tion of the patient,  and by the administration of opium, to keep  the bowel as
quiet as possible near the external opening; the urine should be drawn off twice
in the  twenty-four hours, and no purgative whatever administered lest by the
excitation of peristaltic action adhesion be disturbed  and extravasation occur.
After the lapse of three or four days an enema may be thrown up, and repeated
from time to time.   No food should be allowed for the three first  days, during
which time tea and  barley-water should be  freely taken ; after this  beef-tea and
light food that leaves no residue, may be administered.
   Traumatic peritonitis is  the great danger to be apprehended in  all these in-
juries of the abdomen, and it is by inducing this that extravasation of faeces or of
blood so frequently proves fatal.   It is true that a certain degree of inflammation
of the peritoneum is necessary for the healing of all abdominal wounds, but it must
be limited in extent and plastic  in  character.   It is the more diffuse form of
peritonitis, attended by the  exudation  of turbid  serum, and shreddy, ill-condi-
tioned lymph, that is so speedily fatal.  In these cases, we  meet with the  ordi-
nary symptoms of the idiopathic form of this affection;—uniform tenderness about
the abdomen, more particularly in  the neighbourhood of the injury, with occa-
sional stabbing pains, accompanied by tympanitic distension, vomiting, and hic-
cup, a small, quick,  hard pulse, often assuming a wiry incompressible  character,
with considerable pyrexia, and great anxiety of countenance.   In the treatment
of this disease we must be guided by  the character of  the inflammation.  If it
be of a sthenic form, and the patient young and robust, he should be bled freely
in the arm, and have leeches abundantly applied over the surface of the abdo-
men ; a pill composed of two grains of calomel and one  grain of opium may  then
be administered every sixth hour or oftener if  the patient be  not influenced by
the narcotic; and rigid abstinence from all except ice and barley-water should
be enforced.  If the peritonitis be the result of a wounded intestine, it is safer
to omit the calomel,  using  mercurials  instead to  the inside of the thighs, but
giving opium freely.   When the peritonitis occurs in  an old  or feeble subject,
our principal trust must be  in the administration of opium, and free leeching of
                                    21 
322
INJURIES OF  THE  PELVIS.
the abdomen, followed perhaps by a blister, which may be dressed with mercurial
ointment.  In these cases, however, early support will be required, with perhaps
the administration of wine or  stimulants.

                    INJURIES OF  THE  PELVIC VISCERA.
  Rupture of the bladder, from blows upon  the abdomen, or penetration of it
by bullet wounds, is not of very unfrequent occurrence, and is especially liable to
happen if this organ be distended at the time it is struck.  The effects of these
injuries vary considerably, according to  the  part that  has given way or  been
wounded.  If the laceration have occurred in those  portions of the  viscera that
are invested by peritoneum, the urine will at once  escape  into the  pelvic  and
abdominal cavities, and speedily occasion death by the intense irritation and in-
flammation set up by it.  If,  on the other hand, that portion of the organ have
been ruptured, which is uncovered by peritoneum, the urine will infiltrate into
the cellular tissue between this membrane and the abdominal  wall, and  diffusing
itself widely, produce destructive  sloughing of the  tissues  amongst which  it
spreads.   In these  cases life may be prolonged for some  days, when the patient
commonly sinks from the  combined irritative and  inflammatory  action.  Still,
however, it must be borne in mind, that  numerous cases of injury of the bladder,
more especially from gun-shot wounds, have  recovered;  and  that, although  we
must look upon  this accident  as of the gravest character, yet  that it cannot be
considered as being necessarily fatal.
  The symptoms of a ruptured  bladder  are  sufficiently evident;  the injury in
the hypogastric  region, followed by collapse, by intense burning pain in  the
abdomen and pelvis, with inability to pass  the  urine, or, if any have escaped
from the urethra, it being tinged with blood, are usually sufficient  to  point to
the nature of the accident.  If in  addition,  it is found  on introducing a cathe-
ter, that the bladder is empty, or that  but  a  small quantity of bloody urine
escapes, the surgeon may  be sure that this organ has been burst.   In  the case
of gun-shot injury,  the escape of urine, which generally takes place through the
track of  the bullet, will afford incontestable  evidence of  the  mischief  that has
been produced.
  In the treatment of these cases, the most, important indication is  the preven-
tion of further extravasation by the introduction of a full-sized elastic catheter
into the bladder, which must be left there so that the urine may dribble away
through it  as fast as  it accumulates.  If any sign  of extravasation makes  its
appearance, free and  deep incisions  should be made  into  the  part, so as to
facilitate the early escape  of the effused  fluid and the putrid sloughs.   I cannot
but consider all active antiphlogistic treatment as out of place in these injuries,
never having seen the  slightest benefit from their employment,  The  only chance
that the patient has if once extensive extravasation have occurred, is that there
may be sufficient power left in the constitution to throw out a barrier of lymph
that will limit the  diffuse and sloughing  inflammatory action  set up, and the
prospect of this would certainly not be increased by the employment of deple-
tory measures.^   There will also be  so great a call upon the powers of the system
at a later period after sloughing has fairly set in, that a supporting or  even
stimulating plan of treatment would rather be required.
   It occasionally happens that musket-balls, pieces  of clothing, &c, have been
lodged in the bladder in gun-shot wounds of that organ.   These speedily become
incrusted with urinary deposits, and giving rise to the symptoms of  stone in the
bladder, require to  be removed by lithotomy, an  operation that  has  proved very
successful  in these cas€s, evidently in consequence  of the  healthy  condition of
the urinary organs.   Mr. Dixon has collected from various  works the details
of fifteen cases, in  which balls  that had either  primarily  entered  the bladder
or  found their way into this  organ by abscess or ulceration after  being lodged 
          INJURIES  OF  THE  URETHRA AND  PERINEUM.       323

in the neighborhood, had  been extracted  by operation.  In  ten of these cases
the result was successful, in  the remaining five no record is made of the termi-
nation.
   Mr. Stanley has related a  remarkable case in which the ureter was  ruptured
by external violence, and in  which the patient recovered; a very large accumu-
lation of fluid forming  on the injured side of the abdomen, with considerable
circumscribed tumefaction and fluctuation, and which required repeated tapping.
In another case in which the pelvis of the kidney was ruptured, a similar collec-
tion of urine took place within the abdomen, requiring tapping; as much as six
pints  being removed at one sitting.  On examination after death, which occurred
on the tenth week from the  accident,  a large cyst was found behind  the  perito-
neum, communicating with the pelvis of the kidney.
   Laceration of the urethra, not uncommonly happens from  kicks on  the peri-
neum, or, in consequence of falls from a height, the patient coming astride upon
a girder or a  plank of wood, and rupturing  the urethra at the  triangular  liga-
ment.  In  these  cases  there  is  great bruising, and sometimes wound  of the
perineum, and if an attempt have been made to pass water, the patient will find
himself unable to  do so, the  effort being also accompamied by deep and burning
pain,  followed perhaps by  the  discharge of blood or a few drops  of bloody urine
from  the urethral  The consequences of  this injury are often  most disastrous.
The immediate result is usually extravasation of urine into the perineum, which,
if it be not checked by proper treatment, rapidly passes  forward through  the
scrotum up upon the abdomen, giving rise to extensive sloughing of every por-
tion of cellular tissue with which it comes in contact, and leading perhaps to the
rapid destruction  of the integuments  of these parts, and the consequent forma-
tion of extensive and deep abscess and ulceration.   If the  patient recover from
this mischief, he will very likely do so with  a fistulous opening in the perineum,
and ultimately suffer from a very  intractable form of stricture,  which in some
cases may be completely impassable in consequence of a portion of the urethra
having  been  torn across and sloughing away.
   The treatment of this injury consists in  the early introduction of a catheter
into the bladder.   If this can be done before the  patient has made an attempt
at passing his urine, much of  the immediate danger of the case  may be averted,
by the  prevention  of urinary infiltration.  The catheter,  which should be  an
elastic one, must be left in the bladder for a few days.  If any hardness, throb-
bing, or other sign of irritation occur in the perineum, free  incision should  be
made into the part, so as to  afford a ready outlet for any urine  that may  have
been  effused.  If the surgeon find  it impossible to get a catheter into the
bladder, the urethra being torn completely across,  he should  pass it as far as  it
will go, and then putting the patient  in the position for lithotomy, make a free
incision in the mesial line, upon the  point of the instrument, so as to make an
opening in the perineum communicating with the deeper portion of the urethra.
As the  urine becomes extravasated, the surgeon  must follow  its  course with free
and deep incisions, supporting the strength of the patient  at the same time, by
a due allowance of stimulus and  nourishment.  If, when  the  urethra is  com-
pletely  torn  across, the  urine finds  a difficulty  in escaping, and  relief is not
afforded by the perineal incision, the bladder becoming distended, it should  be
tapped through the rectum,  in the way that will be described when we come  to
speak of diseases  of the urinary organs.
   Foreign bodies are occasionally impacted in the vagina or rectum.  A variety
of things, such as pieces of  stick, glass bottles, gallipots, &c, have  been intro-
duced into these canals.  Their extraction is often  attended with great difficulty,
in consequence of the swelling of the mucous membrane over and around them,
and the depth to which they have  been pushed.   In order to  remove thein,
lithotomy or  necrosis forceps may be required.   In some cases, the foreign lody 
324
BURNS  AND  SCALDS.
has been found to transfix the wall of the canal  in which  it is lodged, and by
penetrating the peritoneum, has speedily occasioned the patient's death.
   Laceration  of  the Perineum.—The  perineum is occasionally ruptured
during parturition.   When the laceration is of limited extent and recent, union
may usually be effected by bringing and  keeping the thighs  together imme-
diately after its  occurrence.  Should this not  suffice, paring the edges deeply
and bringing them together with a quilled suture will usually succeed in closing
the aperture.
   When the laceration is very extensive, extending through the posterior wall
of the vagina, the perineum, the sphincter ani, and perhaps the rectum, a very
serious condition results, requiring more energetic interference.  In  these cases
it is not only necessary after  paring the edges freely and deeply to bring them
together with a quilled suture; but,  as recommended by Copeland and Bransby
Cooper, and recently successfully practised  by  Mr.  Brown, the  sphincter ani
should be freely divided so as to paralyse its action and prevent any undue drag-
ging upon the sutures.  In the after-treatment the principal points to be attended
to, as shown by Mr.  Brown in a  very interesting paper that he has published on
this subject, are to keep the bladder emptied by the frequent use of the catheter,
so as to prevent the trickling of urine into the wound interfering with its union;
the free use of opiates, in order  to prevent all action of  the bowels for at least
ten or  twelve days; and careful superintendence and attention to the cleanliness
of the parts.
                          CHAPTER  XXII.

                   EFFECTS  OF HEAT AND COLD.

                           BURNS AND SCALDS.

   A burn is the result of the application of so  great a degree of heat to the
body as to produce  either  inflammation of  the part to which it is applied, or
charring and complete disorganization of its tissue.  A  scald is occasioned by
the application of some hot fluid to the body, giving rise to the same destructive
effects that are  met with in burns, though  differing from them  in  the appear-
ances produced.
   Local effects.^—Burns and scalds vary greatly in the degree of disorganization
of tissue to which they give rise; this variation depending partly upon the inten-
sity of the heat that is applied, and partly upon its  duration.   The  sudden and
brief application  of flame to the surface produces  but very slight disorganization
of the cuticle, with some inflammation of the skin.   If the part be  exposed for
a longer time to the action of the flame,  as when a woman's clothes take fire,
the cutis itself may be disorganized, and, if the  heat  be still more intense, as
when molten metal falls  on the  body, the soft parts may  be deeply  charred, or
the whole thickness of a  limb  destroyed.   So  also, the  effects of  scalds  vary
greatly, not only according to the temperature of the liquid, but according to its
character; the more oleaginous and thicker the fluid, the more severe usually
will the scald be.
   These various  results  of the  application  of heat to  the surface  have been
arranged by Dupuytren into six different degrees  of burn.   In  the first there is
merely a scorch of the skin, slight redness with efflorescence of the  cuticle, but
no permanent injury.   In the second degree there  is not only general redness 
STAGES  OF BURNS.
325
of the part to which the heat has been applied, but vesicles form, either at once
or in the course of a few hours, and sometimes attain a very considerable magni-
tude.    In the  third  degree,  the cutis itself is destroyed,  yellowish-gray  or
brownish eschars forming, which involve the whole thickness of the skin, the
surrounding integument being more or  less reddened and vesicated, and the
part extremely painful.   If this  amount of injury is the result  of a  scald, the
eschars will be found to be  soft,  pulpy, and of an ashy-gray character.  In the
fourth degree, the whole  thickness of the skin and part of the subcutaneous
cellular tissue are destroyed, dry yellowish-black insensible eschars being formed
with considerable inflammation around them, leaving on  their separation deep
and luxuriantly granulating ulcerated surfaces.  In the fifth degree, the eschars
extend more deeply, implicating the muscles, fasciae, and  soft structures.   And
in the sixth degree, the whole  thickness of the  limb  is completely destroyed
and charred.   This is the  celebrated classification  introduced  by  Dupuytren,
and adopted by most writers on the subject as a practical exposition  of the local
effect of burns.   These various degrees are usually found associated  to a greater
or less extent; indeed,  in the more severe forms, the three or four first  degrees
are almost invariably met with.
  The primary local effect then of a burn, if superficial, is to excite inflammation
of the skin; if more extensive, to destroy the vitality of more or less of  the soft
structures, and even the bones.   When the cuticle is unbroken the inflammation
speedily subsides, with some desquamation.   When the  soft  parts are  charred
they are detached  by a process of ulceration, analogous to what happens in the
separation of sloughs, and an ulcerated  suppurating surface is  left, remarkable
for  the large size, the florid  color, the great vascularity, and the rapid  growth of
its  granulations.   The  cicatrization of such  an ulcer  as this, though  generally
proceeding with great  rapidity, has a constant tendency to be  arrested by the
exuberance of the granulations.   The cicatrix that results is usually thin, and
of a bluish-red  color, and is especially characterized  by a great disposition  to
contract, becoming, after a time,  puckered up, and much  indurated.   This pro-
cess of contraction and hardening, which begins immediately on the completion
of  cicatrization,  continues for many months, giving rise frequently to the  most
serious deformities,  and to the complete loss of motion and use in parts.   These
cicatrices  are  of a fibro-pkstic  and fatty character, and often extend  deeply
between, and mat together the. muscles,  vessels, and soft  structures of  a limb,
of the face, or neck.
  The constitutional effects resulting from burn are  of  the most serious  and im-
portant character; they are  dependent not so much upon the depth of the injury
as upon  its situation, the extent of surface implicated, and the age of the  patient.
Thus  a person may have  his foot completely  charred and  burnt off by a stream
of melted iron running  over it, with far less constitutional disturbance and danger
than if the surface of the trunk and face  be extensively scorched to the first and
second degrees.  Burns about the trunk, the head, and the face, being far more
likely to be attended by serious constitutional  mischief than similar injuries  of
the  extremities.   In children the  system generally suffers more severly from
burns than in  adults.    The  constitutional  disturbance induced by  burns  in
whatever degree, maybe divided  into three stages: that of compression and con-
gestion,—of reaction and inflammation, and,—of exhaustion and suppuration.
  The period of depression and  congestion  occupies the first forty-eight hours;
during which death may occur before inflammatory action can come on.  Imme-
diately on  the receipt of a severe burn the patient becomes cold, collapsed, and
is seized with fits of shivering, which continue for  a  considerable time  ;  he  is
evidently suffering from the shock of the injury;  the severity of the  shivering
is usually  indicative of the  extent of the constitutional disturbance induced  by
the  burn,  and is more  prolonged in those injuries that occupy a great extent of 
326
BURNS  AND  SCALDS.
surface, than in those which, being  of a more limited superficial  extent, affect
the tissues deeply.   On  the subsidence of the symptoms of depression there is
usually a period of quiescence before  reaction comes on, and during this period
the patient, especially if a child, not unfrequently dies comatose; death resulting
from  congestion of the brain and its membranes, with, perhaps, serous  effusion
into the ventricles or the arachnoid.   Besides these lesions the mucous'mem-
brane of the stomach and intestines, as  well as  the substance of the  lungs, are
usually found congested.
   The  pathological phenomena of  this period  are altogether of  a congestive
character.
   The next period, that of  reaction and inflammation extends from the second
day to the second  week.   In it irritative  fever  sets in early, with a degree of
severity proportionate to the previous  depression, and as this stage advances we
commonly find special symptoms occurring, dependent upon  inflammatory affec-
tions, more especially of the abdominal and thoracic  viscera.   Death, which is
more frequent during this stage than in the preceding one, will usually be found
to be connected with some inflammatory condition of the gastro-intestinal mucous
membrane, or of the peritoneum.   The lungs also are frequently affected, show-
ing marked evidence of pneumonia or bronchitis; but the cerebral lesions are not
so common as in the first stage ; though when they  occur they present more une-
quivocal evidence of inflammatory action.
   It  is in this state of burn  that that very remarkable and serious sequela, perfo-
rating ulcer of the duodenum, is especially apt to occur.   Mr.  Curling, who first
attracted attention to it, explained its occurrence by the highly probable suppo-
sition that Briinner's glands endeavor by  an increased action  to compensate for
the suppression of the  exhalation of the skin, consequent upon the burn; and
that the irritation thus  induced, tends to inflammation and ulceration of them.
This  ulceration may, as Mr. Curling remarks, by rapidly proceeding to perforation,
expose  the  pancreas, open  the branches of the hepatic artery, or by making a
communication with the serous cavity of the abdomen produce  peritonitis, and
thus cause death.  It usually comes on between the  first and second  weeks (about
the 10th day) after the  occurrence of the injury; seldom earlier than this.  The
only  exception  that  I  am  acquainted  with  was in the case of  a child nine
years of age,  who died, on the fourth day after  the burn, in University College
Hospital, and in whom  an  ulcer, about the  size of a shilling,  with sharp-cut
margins, was  found in the  duodenum, the intestinal  mucous membrane gene-
rally  being inflamed.  That these ulcers are not invariably fatal is  evident from
a case mentioned by Mr. Curling, in which on death occurring eight weeks after
the injury from other  causes, a recent cicatrix was  found in the duodenum.
These affections seldom  occasion any very  marked symptoms to  indicate the
nature of the mischief,  the patient  suddenly sinking.   In some  instances there
is hemorrhage, though this  is  not an unequivocal sign, as I have several times
seen it  happen  from simple inflammatory congestion of the  intestinal  mucous
membrane ; pain in the right hypochondriac  region and  perhaps vomiting may
also occur.
   The  third period, that of exhaustion and suppuration, continues  from the
second  week to the close of the case.  In it  we frequently have  symptoms of
hectic, with much constitutional irritation from the long continuance of exhaust-
ing discharges.   If death occur, it is most frequently induced by inflammation
of the lungs or pleura; affections of the abdominal organs and brain being rare
during this stage of the injury.
   The influence of extent, degree,  and  situation on the prognosis  of burns has
already been stated.  The most fatal element indeed of these  injuries  is super-
ficial extent.  The cutaneous secretion being arrested over a large surface of the
skin,  congestions of the internal organs and of the mucous  membranes  must 
TREATMENT OF  BURNS.
327
ensue as a necessary result; and hence death may happen directly from this cause,
or from the supervention of  inflammation in the already congested parts; more
particularly in the  early periods of life, when  the balance of the  circulation is
readily disturbed.  The degree of burn rather influences the prognosis unfavor-
ably so far as the part itself is concerned, than as the general system is affected.
The most fatal period  in cases of burn is the  first week  after the  accident.   I
find that  in fifty cases  of death from these accidents,  thirty-three proved  fatal
before the eighth day;  twenty-seven  of these dying before the  fourth day.  Of
the remaining seventeen cases, eight died in the second week, two in the third,
two in the fourth, four in the fifth, and one in the sixth.
   The treatment of burns must have reference to the constitutional condition, as
well as to the local  injury.   A vast variety  of plans of treatment have  been
recommended by different surgeons, which will be found detailed in Mr. Cramp-
ton's very excellent Report on this subject published by the Provincial Associa-
tion.   I shall here, however, content myself with describing the method that is
usually followed with much success at the University College Hospital.
   The constitutional treatment is of the utmost  consequence.   We have  seen
how death arises at various  periods after these accidents from different causes,
and we must  modify our treatment accordingly. The first thing to  be done after
the infliction  of a severe burn is to bring about reaction;  the patient is in a state
of extreme depression, suffering great pain, and may sink from the shock unless
properly supported.   A full dose (about thirty minims for an adult) of the liquor
opii should be given at once in some warm brandy and water; and repeated, if
necessary, in  the course of an hour or  two; to a child  the dose must be  propor-
tioned according to the age.  The burnt clothes having  been removed, the patient
should be laid  upon a blanket, and, whatever the degree of  the  burn  be well
covered with the finest wheaten flour  by means of an ordinary dredger.  The
flour should be laid on thickly but uniformly  and gradually, forming a soft and
soothing  application  to the surface.  If the  cuticle have been abraded  or vesi-
cated, the flour will form a thick crust  by admixture with the  serum discharged
from the  broken surface.  If the skin  be  charred, the discharge, which will
be speedily set up around the eschar, will cake the flour on to the  part,  forming
as it were a coating impervious to the  air.   The crusts thus formed should not
be disturbed  until they become loosened by the  influence of  the  discharges of
the part,   when they should be removed ; and the ulcerated surface that is ex-
posed, dressed with water-dressing, red wash or lead ointment, according to the
amount of irritation  existing, the  suppurating sore indeed being managed on
ordinary principles.  In some cases lint dipped in the  " Carron oil," composed
of equal  parts of linseed oil and lime water, to which  a small quantity of spirits
of turpentine might  be added, has appeared to agree better than anything else.
Whatever local application be adopted,  I hold  it to be of the utmost importance
in the early stages of the burn to change the dressings  as  seldom as possible, not
until they have been loosened, or rendered offensive by imbibition of the discharges.
Every fresh dressing causes the  patient very  severe pain, and certainly retards
materially the progress of the case.
   When  the  stage of reaction has fairly set in, the patient's secretions should be
kept free by the administration of  an occasional mild  purgative and  salines.
Should any inflammatory symptoms about the  head, chest, or abdomen manifest
themselves, it will be necessary to have recourse to antiphlogistic treatment pro-
portionate to  their severity.   I have certainly seen  patients saved under these
circumstances by the employment of bloodletting,  and  the proper  application of
leeches.   At  a later  period in the case, when  the strength has been exhausted
by the continuance and the amount of  the discharges,  good diet, quinine, and a
general tonic  plan of treatment will be required, and any symptoms of hectic that
supervene must be met in the ordinary way. 
328
EFFECTS OF  COLD.
   As  cicatrization advances, much attention should be paid to repressing  the
 exuberant granulations by the free use of the nitrate of silver, and  the position
 of the  part  must be carefully attended to, so  as  to  counteract, if possible,  the
 after-contraction that ensues.   With this view, the part must be properly fixed
 by means of bandages, splints, and other mechanical contrivances.
   Operations for the removal of the effects of contraction, consequent upon
 burns, are occasionally required, and  if judiciously planned  and executed, may
 do much to  remedy the patient's condition.   The great obstacle to the success
 of these operations, however, consists  in  the fact that the  granulations which
 spring from  the contracted cicatrix are in their turn  liable to take on  the same
 contractile action as  the original cicatrix.  After the division  of the cicatrix,
 also, it is often found that the subjacent structures have been so rigidly fixed in
 their abnormal position as not to admit of extension.   It may then be necessary
 to divide them before the part can be restored to its normal shape.
   These operations are most likely to be successful when they  are practised  for
 contractions at the flexures of the joints, as at the bend of the elbow, for instance.
 There,  all  that  need be done, is  to divide the  cicatrix down to the  subjacent
 healthy structures, and  then, by the  proper  application of splints, gradually to
 extend the limb;  if any muscles or tendons are found to offer  resistance they
 may be divided, if this can be done without inflicting too serious a wound upon
 the part, and impairing its after-utility.  Much caution, however, will here be
 necessary; for if the contraction be of old standing, the arteries and nerves will
 likewise have become shortened, and will be  incapable of stretching under any
 force that it may be  safe  to employ.   Operations that are undertaken for the
 removal of the disfigurements  that occur about the face, as  the  result of burns,
 are seldom attended  with much  success or  satisfaction to  patient or surgeon.
 Instead of simple division of the cicatrix, it has been proposed to dissect it away
 entirely in some cases, in others, to transplant portions of healthy skin upon the
 surface thus denuded; in other instances, again, to  divide it gradually by the
 pressure of a silver wire, passed through and twisted over it.  Operations such
 as these are, however, seldom called for.  Their applicability to any  particular
 case must  be determined by its nature, for in  this, as in  other departments of
 plastic  surgery,  it is difficult  to lay down very specific rules, so  much  being de-
 pendent on the  varying circumstances of the different cases, the surgeon being
 guided  by his judgment in applying the proper mode of operation to each.
   Amputation may be required if the burn have destroyed  the  whole thickness
 of a limb; the part charred should then be removed at once, at the most conve-
 nient point above  the  seat of injury; so also amputation  may be required at a
 later period, if, on  the  separation  of  the eschars, it is found that a large joint
 has been opened, and is suppurating, or if the disorganization of the limb is so
 great as to exhaust the powers of the patient in the  efforts at repair.  Great
 caution, however, should be employed in determining on the propriety of ampu-
 tating when the burn has extended, though in  a minor degree, to other parts of
 the body, lest the powers of the patient be  insufficient for the double call that
 will thus be made upon them.

                                FROST-BITE.

   When the body has been exposed to severe or long-continued cold we find, as
 in the case of burns, that local and  constitutional effects are produced.  The
local influence of cold is chiefly manifested on the extremities  of the body, as
 the nose, ears, chin, hands, and feet, where the circulation is less active than at
the more central parts.   It chiefly occurs to  an  injurious degree in  very young
 or aged persons, or in those whose constitutions have been depressed by want of
the necessaries of life. 
EFFECTS OF  COLD.
329
  In the first degree of frost-bite  that  calls for the attention  of the surgeon,
there is a feeling of stiffness, with complete numbness of the part that has been
exposed to cold; it looks pale, has  a bluish tint, and is somewhat shrunk.  In
this state the vitality of the part is not destroyed, but is merely suspended.   On
the return of circulation and the vital actions  in the  affected part, a burning
tingling pain is felt, it becomes red, and shows signs of a tendency to inflamma-
tory action.   Indeed,  this appearance of inflammation, often  accompanied by a
burning sensation, is probably the immediate consequence of extreme degrees of
cold, as is experienced on touching  solidified carbonic acid or frozen mercury.
  In the next degree of cold, the vitality of  the  part  is completely destroyed;
all sensibility and motion in it are lost, it becomes shrunken and livid; but
though  its vitality may have been  annihilated by the immediate  application of
the cold, it is not until the part has become thawed that gangrene usually mani-
fests  itself;  it then appears  to  do  so  by the  violence of the reaction induced,
the part rapidly assuming a black color, becoming dry, and separating eventually,
as all other mortified parts do, by the formation of a line of ulceration around it.
  The  constitutional effects of a  low temperature need not detain us.   It is well
known  that  after exposure to severe or  long-continued cold, a feeling of heavi-
ness and stupor comes on, which gradually creeps on to an irresistible tendency
to sleep, which, if yielded to, terminates  in coma and a speedy, though probably
painless, death.
  The  treatment of frost-bite consists in endeavoring to restore the  vitality of the
frozen parts.   In doing this  the great danger is, that reaction may run on to so
great a degree as to induce sloughing of the structures whose vitality has already
been seriously impaired.  In order  to prevent this accident occurring, the most
gradual elevation of temperature must be had recourse to for restoring the part.
The patient  should be placed in a cold  room, without a fire,  any approach to
which  would certainly lead  to  the destruction of the  frost-bitten  members.
These must  be gently rubbed with snow or cold water, and held between the
hands of the  person manipulating;  as reaction comes on, they may be enve-
loped in flannel or woollens, and a small quantity of some warm liquid or spirit
and water administered to the patient.   In this way sensibility and motion will
gradually return, often with much  burning and stinging pain,  redness,  and
vesication of the part.  If gangrene have come on, or if the reaction run into
sloughing, the sphacelated part if of small size,  may be allowed to detach itself
by the natural process  of separation ; if of greater magnitude, amputation of the
injured limb  may be required.  This  should  be done  at the  most convenient
situation for the operation so soon as the  line of separation has fully formed. 
DIVISION    THIRD.

        SURGICAL DISEASES.
                         CHAPTER  XXIII.


                               ABSCESS.

  An  abscess signifies a collection  of pus occurring  in  any of the  tissues or
internal cavities of the body.  In structure, an abscess consists of an accumula-
tion of pus situated in the midst of,  and surrounded on all sides by a layer of
fibrine deposited  in and consolidating the neighboring  tissues.   This  lymph,
which constitutes  the  wall of the abscess, varies greatly in thickness and con-
sistence, in some cases being scarcely perceptible, in others, some lines in thick-
ness and of corresponding firmness,  constituting, perhaps, the principal  part of
the mass.  This wall of " limiting fibrine" is always very vascular, in consequence
of the inflammation and congestion of the tissues that enter into its composition.
Outside it there is an infiltration of sero-plastic matter, and beyond this again we
reach the healthy tissue.
  Surgeons divide  abscesses  into various kinds according  to  the  symptoms
attending them, their duration and cause.  Thus they speak habitually of acute
and  chronic,  hot  and  cold, lymphatic,  diffuse,  metastatic, and  puerperal
abscesses.
  The acute or phlegmonous abscess may  be taken as the type of the disease.
When  it is about to form, the part  which has  been previously inflamed swells
considerably, with a throbbing pulsatile pain; the skin becomes shining, glazed,
and of a somewhat purplish-red.   If the abscess  be very  deeply seated, the
superimposed  tissues  become brawny and cedematous, without, perhaps, any
other  sign  indicating  the existence  of pus.  As  the swelling approaches the
surface  it  softens at one  part,  where fluctuation becomes perceptible, and a
bulging of  the skin  covering its  summit takes place ; this pointing of the abscess
indicates that  it is about to burst and discharge its contents, which it speedily
will through a circular aperture  formed in the skin.   The pointing is an interest
ing pathological phenomenon, and takes place in the following way: An abscess
originally formed perhaps deeply in the substance of a  limb, enlarges  by the
extension of the periphery of its wall, and by the innermost layers of this struc-
ture at the same time degenerating into  pus.   As the  wall extends, it has a
special tendency to approach towards a free surface whether that  be external or
internal, skin or mucous membrane ; all the tissues between  it and the surface
towards which it is  progressing being gradually absorbed or  melting into the
abscess.  It is in this that the pointing essentially consists, and the mode in
which it is finally accomplished would appear  to be as  follows: The pressure
that the tumor exercises from within outwards causes compression of  those ves- 
ABSCESS,  VARIETIES  OF.
331
sels that,  passing from the deeper parts, ramify between the  summit of the
abscess and the superjacent skin for its supply.  In consequence of this  pressure
upon and interference with the circulation  through these vessels, the nutrition
of the parts supplied by  them is arrested, and they become softened, disinte-
grated in structure, and less resistant to the progress of the  tumor  than those
tissues which surround it on other sides, and which have not had their  vascular
supply interfered  with or lost their normal cohesion.  The abscess then naturally
makes its way at  this, the  point of its circumference, where it meets with least
resistance to its progress.  As it approaches the  surface, the skin at first  becomes
more  or less  livid, tense, and cedematous, conditions indicating the interference
with its circulation; as the  summit of the abscess  presses upwards, the over-
lying skin loses its tension and becomes relaxed; it then sloughs at the  most
central point, from which  the cuticle has previously  peeled off, and the  outward
pressure of the pus speedily detaching the slough, the abscess discharges itself.
Though acute  abscesses, if left to themselves, usually run this course and burst
through the skin, the mucous or serous  surfaces, or even  into  the  interior of
joints, yet some collections of pus,  if very deeply seated, cannot find their way
to the surface, but extend through  the cellular  planes of the  limb in a lateral
direction, burrowing and undermining parts to a great extent;  or if  situated in
dense and unyielding structures, as in bone, are imprisoned within a case  through
which they may be unable to penetrate;  in other rare instances the abscess dis-
appears by  the pus becoming absorbed.   After an abscess has burst, the cavity
usually closes by granulations springing up  from within,  and  by the collapse of
its walls; in some cases, however, it does not completely close, but contracts into
a narrow canal, forming a sinus or fistula.
   Chronic abscesses are of very common occurrence, a piece of dead bone having
given rise to irritation in its vicinity, or a gland, or some  portion of the subcuta-
neous cellular  tissue having become indurated, tender, or subacutely inflamed,
at last slowly  and without any constitutional symptoms  or much appearance of
local disturbance  except the swelling, softens and breaks down into a somewhat
thin, flaky, curdy, puriform fluid, though in other instances the  pus  is perfectly
healthy.  These abscesses do not readily  point,  but  often extend laterally, bur-
rowing for a considerable  distance from their original seat.  In other cases they
become circumscribed by a thick and dense wall of fibrine, through which it may
be extremely difficult, and  perhaps impossible, to detect  fluctuation,  the disease
then simulating a solid tumor.  The duration of these chronic abscesses without
opening, is often  very remarkable, even  when  situated in soft  parts.   I lately
attended a gentleman, with Dr. Boott, who had a  large  chronic abscess in the
iliac fossa and groin, perfectly stationary for nearly two years.  When  situated
in denser structures, as in the substance of the breast for instance, the wall may
become so dense as to resemble a cyst, and the disease will continue in the same
state for a great length of time. In  the bones, abscesses may exist for an indefi-
nite period, unless opened by surgical operation.
  The cold, lymphatic or  congestive abscess occurs  not  unfrequently with  but
very slight precursory local symptoms,  and indeed not uncommonly without any
at all.  The patient, who has usually been  cachectic, and suffering  some  time
from general debility, after feeling slight uneasiness in the groin, iliac fossa, or
axilla, finds suddenly a large fluctuating tumor in  one or other of these situa-
tions; there is perhaps no  pain in the part, and  no discoloration of the skin,
but the fluctuation is always very distinct, the limiting  fibrine being in  small
quantity.   On opening such an abscess as this, there will usually be a copious
discharge of thin  unhealthy pus, which when examined  under the  microscope
will be found  to contain ill-developed, withered cells; in some cases the contents
appear to be a clear semi-transparent or oily-looking matter, probably sero-plastic
effusion. 
332
ABSCESS.
    Diffuse abscess forms rapidly in the cellular tissue, as the result of diffuse in-
  flammation  of it.   In these cases there is no limiting fibrine, and hence the pus
  often spreads widely, producing extensive destruction of parts before it is disco-
  vered.  A particular variety of  this form of abscess is the puerperal, occurring
  in women after  parturition, in various parts  of the body, especially in  the iliac
  fossa, the cellular planes of the thigh or in the joints, and in the adipose  tissue
  of the orbit, often destroying the globe of the eye.  To  these forms of the  dis-
  ease the metastatic abscesses are closely allied.   They commonly occur in con-
  nexion with phlebitis, are very numerous, and are met with in the substance of
  organs as well as the cellular tissue and joints.  The three last species of abscess
  are varieties of the acute form.
    Abscesses are met with in all regions of the body, but more especially in  the
                                 cellular  tissue;  particularly in  those  parts
                                 where this  tissue is  abundant, and the absor-
                                 bent glands are numerous.   They may occur ■
                                 at any period of life, from the earliest  infancy
                                 to old age.   I have opened a very large abscess
                                 in the  axilla  of  a child  about a fortnight
                                 old.  Their size varies from that of a pin's point
                                 to a tumor containing a pint or more of pus.
                                 In some cases when very large they are multi-
                                 locular, the different cysts being connected by
                                 narrow channels of communication;  in this
                                 way I have seen a large abscess extending from
                                 the  lumbar  vertebras through  the  iliac  fossa
                                 down the thigh,  the ham, and the leg, until at
                                 last it was  opened by  the side of the  tendo
                                 Achillis, forming five or six distinct cysts com-
                                 municating with one another by contracted
                                 channels  (Fig. 120).
                                   The  pressure  effects of abscess  are often
                                important.   By  compressing the nerves of a
                                part it may give  rise to very severe pain and
                                spasm at a distance  from its  seat, and in this
                                way in some neuralgic affections it has turned
                                out that the pain has been  occasioned by the
                                pressure of an abscess on the trunk of a neigh-
                                boring nerve.  When  bloodvessels come into
                                relation with an  abscess, they usually become
                                coated by a thick layer of lymph, which guards
                                them from  injury.    In some  cases, however,
                                they become obliterated by the conjoined effects
                                of the pressure and the inflammation, in which
                                they partake as well as the adjacent tissues.
                                1° other  cases, however, more particularly  in
strumous and cachectic individuals, the  bloodvessels not having been guarded
by the protecting lymph, have ulcerated  and burst into the cyst of the abscess,
occasioning sudden, dangerous, or even fatal hemorrhage.   I am not acquainted,
however, with any case in which a large artery or vein has  poured  its contents
into an abscess that had not been opened.  The  various mucous canals, more
especially the trachea and the'urethra, may injuriously be compressed by neigh-
boring abscesses; so also bones may become necrosed and joints inflamed  and de-
stroyed from  the same cause.
 ^ The diagnosis of abscess, though  usually easily made, at times requires atten-
tion.   The surgeon believes that an acute abscess is  about  to form when, after
 
TREATMENT  OF  ABSCESS.                   333
rigors and some modification of the inflammatory fever, he finds the  local  signs
characteristic of the formation of pus;  more especially a  throbbing pain in the
part, with softening of any induration that may have existed, and oedema of the
cellular tissue covering it.  His  suspicion is turned to certainty, and  he knows
that an abscess has formed, when, after the occurrence of these symptoms, fluc-
tuation can be felt, and the other signs manifest themselves.   This fluctuation
may, however, readily be confounded with the unduktory sensation that is com-
municated  by some tissues from the mere infiltration of sero-plastic  fluid into
them.   This, indeed, is a difference of degree rather than of kind, as  pus would
make its appearance in the course of a few hours, if the tumor were left to itself.
The mere occurrence of fluctuation is not  of itself sufficient  to determine  more
than that a fluid exists in the part.   The  question necessarily arises, is this fluid
pus?  In the majority of instances the history of the case, the character of the
pain, the previous existence and the continuance of symptoms of inflammation,
enable the surgeon to answer in the affirmative.   But if there be but obscure
evidence of inflammation having existed, and if the swelling be of long standing,
the fluctuation being perhaps deeply seated and indistinct, the safer plan will be
for the surgeon to introduce an exploring needle, and to see what the  true na-
ture of the fluid is; by this  simple means many embarrassing  mistakes in  diag-
nosis may be avoided.   The ^tumors  with which abscesses may be confounded,
are those soft solid growths in which there is a high degree of  elasticity, giving
rise to a species of undulation, as  in some kinds of encephaloid tumor; so also
fluid tumors  of various kinds, such  as cysts and enlarged  bursae, may be con-
founded with abscess.  In these cases the previous symptoms, the situation, and
the general appearance and feel  of the tumor, will usually enable the  surgeon to
effect a ready diagnosis;  but should any doubt  exist, the  exploring needle  or
trochar must be introduced,  when the escape or not of a  drop or two of pus will
determine the question.   The diagnosis of an abscess having pulsation commu-
nicated to it by a subjacent artery, from an aneurism, will be discussed when we
come to speak of that disease.   It may be well  to  mention  that the pains occa-
sioned by the pressure of some forms of chronic abscess upon neighboring nerves
have been mistaken for rheumatism.
   Abscesses  vary greatly in danger, according to their nature, size, situation,
&c.   The chronic form is usually attended by more risk  than the acute and the
diffuse.  The puerperal and the metastatic are especially hazardous to life,  being
generally associated  with a bad state of the  blood.  The  large size of some
abscesses is an  element of great risk, occasioning not only a very abundant dis-
charge  of pus, but  likewise great constitutional irritation  when opened.   Ab-
scesses that are situated in the neighborhood of important  organs, as about the
neck of the bladder, or in the anterior mediastinum, are necessarily much
more hazardous from the peculiarity of their situation than those which are met
with in less important  regions.  The  cause  of the abscess  also influences the
result;  if it be a piece  of dead bone that can be  removed, the discharge will
speedily cease on its being taken away, but if it be so situated that it cannot  be
got rid  of, it will, by acting as a continuous source of irritation, keep up  a dis-
charge that may eventually prove fatal.   The constitution of the patient influences
our prognosis.   Such an amount of discharge as would inevitably prove fatal in
a cachectic system, may influence a sound one but very little; so also, the wasting
effect of the  abscess is better borne about the middle than at either of the extreme
periods of life.
   The treatment of abscess presents three points requiring attention.   The first
object should be to prevent the formation of matter; the next to take steps for
its evacuation when formed; and, lastly, to endeavor to close the  cavity that
results.
   In order to prevent the formation of matter, it is nececessary to  get  rid  of 
334
ABSCESS.
any local irritant that may exist, thus  dead bone should be removed, or extra-
vasated urine let out of the cellular tissue.  After this  has  been done, the pre-
ventive treatment must consist in  the active employment of local  antiphlogistic
means, such  as leeches and cold evaporating lotions; any slight tenderness that
continues after the  inflammation has subsided must be removed, and that swell-
ing from exudation-matter, which is especially the precursor of chronic abscess,
must be got rid of by the continuous application  of some discutient lotion.  One
composed'of  iodide of potass, 5i,  spirits  of wine §i, water |vij, is  extremely
useful; in some cases absorption  may  advantageously be promoted by mercurial
ointments or  plasters.  When once pus has formed, it is a question whether it can
be absorbed again;  in general, it  certainly cannot;  more  especially  if once a
distinct cyst  has been  formed around it; but  in some cases it may undergo
absorption.   Thus, in hypopium, we occasionally observe that the pus deposited
in the anterior chamber of the eye is removed, and I think it  probable that the
same may happen when it is infiltrated into the tissues of a part, without a very
distinct wTall  surrounding  it.   The more fluid parts of chronic abscesses occasion-
ally become  absorbed, leaving  a cheesy residue  behind, which may degenerate
into cretaceous matter.
   When, notwithstanding the employment of antiphlogistic means, it is evident
that pus is about to form, the treatment  should be completely changed, and by
the aid of warmth and poultices, an endeavor should be made to hasten suppu-
ration.   When this is fully established, the abscess having become " ripe," steps
must be taken for the evacuation of the matter.    The treatment of acute and of
chronic abscesses differs essentially in  this respect.
   In the acute, abscess the matter should  be let out as soon as it is fully formed
especially in  those varieties of the disease connected with a morbid state of the
system, as in the metastatic and puerperal forms.   When  this is done, the con-
stitution at once experiences great relief, the fever and general irritation  subsid-
ing materially; the free incision by which this is accomplished not only letting
out the pus and lymph, but removing tension,  and by encouraging local bleeding
lessening the inflammatory action.  The rule of  opening an acute abscess early
is  especially  imperative when the  pus is  formed in  the sheaths of the tendons
and  under fibrous  expansions, as in  the palm  of the  hand; so, also, when it
is situated  deeply in the  cellular planes  of a limb, under the larger muscles,
where  it has a tendency  to diffuse itself  extensively.   In  those  cases  likewise
in which it is lodged in close proximity to a  joint, or under  the periosteum, it
must be let out  early; so also when it presses upon mucous canals or important
organs, as on the urethra  or trachea, or when it is  dependent  on  the infiltration
of an irritant fluid into a part, as by urinary extravasation, it must be evacuated
without delay.   The pus  should always be let out early  before the skin covering
it is  thinned, when the  abscess  is  situated in the neck,  or in any other part
where it is desirable that  there should  be  as little scarring as possible.
  In the case of chronic abscesses, the rule of surgery is not so explicit.  Here
the collection is often large, coming on without  any very evident symptoms and
giving  rise to no material  inconvenience;  but if it be opened, putrefaction of the
pus,  consequent upon the  entry of air  into the extensive cyst, will give  rise to
the most serious constitutional disturbance, setting up irritative fever, that may
rapidly prove fatal in a debilitated*frame, and  should  the  patient escape this
danger, the drain of an abundant suppuration  may speedily waste him.   Hence,
it  not uncommonly happens that a patient may carry a chronic abscess unopened
without any very serious disturbance, for  many months  or even years, but when
once opened, that he will  die in a few days.  If, however, the chronic  abscess
be so small that no  danger is to be apprehended  from the inflammation of its
cyst, or if it be situated in parts where its presence may give  rise to  dangerous
pressure, the  matter should be let out without delay. 
OPENING  OF  ABSCESS.
335
  There  are three modes by which  abscesses may be opened, xeach of which
possesses advantages in particular cases;—these are by incision, by tapping with
a trochar, and by making an aperture  into the cyst with caustic.
  Incision is the only plan  that should  be  practised  in  acute  abscesses.  For
this purpose a lancet, an abscess-bistoury (Fig. 121), or a sickle-shaped knife may
be used.  The incision  should be made either at the  point where fluctuation is
most distinct,  or at the most dependent part of the tumor, so as to prevent after-
bagging of the matter.   It should be made by holding  the bistoury or lancet

                                   Fig. 121.
short, and introducing it perpendicularly into  the softened part.   If the depth
to be reached is  considerable, a  bistoury  should be used, the blade  of  which
should be half turned round after its introduction, when  the pus wells up by its
side, the point being  felt to  move freely in  the cavity of the  abscess.   The
incision must then be  continued for a moderate extent  in the direction of the
natural folds of  skin of the part, or in the  course of the  vessels.  The pus
should be let out freely, so as to allow the walls of the abscess to collapse, but it
should not be forced out by squeezing the sac.   It may happen, after the escape
of the pus, that  the cavity of  the  abscess fills with blood by rupture of some
small vessel situated in its wall; this, however, is of little moment, the hemor-
rhage speedily ceasing on the application of pressure, of a bandage, or of cold.
After the opening has been made,  a poultice of water-dressing must be applied;
the cavity left eventually fills  up, either by the coalescence of its sides,  or by
granulating from below;  if it fill  again with  pus, a fresh incision,  termed a
" counter-opening," must be made  in the most dependent part.
  In the treatment of chronic and cold  abscess, all three plans may be employed
for opening the sac.   If it be of small size, an incision  should be made into it
at once.   If the  collection  be  considerable, we must wait  until an opening has
been rendered necessary by the tendency  to implication of the skin,  or by
injurious pressure being exercised on important parts; the pus should then be let
out by the valvular aperture recommended  by Abernethy, the object being  to
limit the entry of air into the  interior  of  the  abscess, to lessen  the  chance of
putrefaction of any pus that is left,  and of consecutive inflammation of the cyst.
The valvular opening is made by drawing the  skin covering the abscess well to
one side, then passing the bistoury directly into the sac, and allowing as  much
of the pus to escape as will  flow out  by the  collapse of the walls of the abscess;
before the matter has quite ceased to flow, and before any air  can consequently
have got into the sac, the  skin should be allowed to recover its  natural  position,
so that the aperture in it and  in the cyst may no longer directly  communicate.
A piece of plaster, or of lint soaked in collodion should be  placed upon the external
wound, which will  probably heal under this covering in  the  course of a  short
time.  When the cyst of the abscess has again filled somewhat, this process may
be repeated; and less and less pus being allowed to accumulate in  it before each
succeeding evacuation, it may gradually contract and close.
  Instead of making the valvular  opening in this way, a  chronic abscess  may
sometimes  be advantageously opened by tapping with a trochar  and  canula  of
moderate size, the instrument being introduced obliquely between the skin and
the abscess, and then made  to dip down into the sac.  After the  withdrawal  of
the  canula, the aperture may be closed as in  the former  case.  There is, how-
ever, one  disadvantage in this plan of  opening abscesses; that if  the  discharge
be curdy or shreddy, it is very apt to block up the canula, and thus to interfere
with the proper evacuation of the matter. 
336
ABSCESS.
  The potassa fusa, though a painful application, maybe advantageously used for
opening those chronic  abscesses, the skin covering which is much undermined,
congested and  discolored.  In  these  cases  I commonly employ it with  great
advantage.  It is also  useful  in  the  after-treatment, when  much solid plastic
matter is  left, by dissolving  this away, and thus preventing the formation of
sinuses.
  In  some  forms of  abscess  it will be found that  those processes  which are
necessary  for the filling up and closure of the cyst, after its contents have  been
 evacuated, do not readily take place;  and it becomes necessary to have recourse
 to other measures, in order to excite  sufficient healthy  inflammatory action, to
 occasion the deposition of that plastic  matter by which the cavity is filled.   With
 this view a seton of two or three threads may very usefully be passed across the
 cyst by means of a naevus needle, or by a long straight needle pushed up through
 the canula used for tapping (Fig. 122).  It should be left in for a few days,  by
 which time healthy inflammation will be set up.  In other cases again, after the
 cyst has been tapped, some tincture of iodine diluted with twice  or thrice its bulk
 of water should be injected, or a camel's-hair brush  dipped in the pure tincture
 be applied to the inside of the walls.   These methods of exciting inflammation
 are especially  useful when  the  cyst  is thin, and of a very  chronic character.
 When the walls are very  thick and dense, as sometimes happens in  abscesses of
 very old standing situated in the neck, an elliptical piece of the anterior portion
 of the  cyst  should be  dissected out, and  the remainder of the cavity, lightly
 dressed with lint,  be allowed  to fill  by granulation.  This plan of treatment,
 which I believe was introduced by  Mr. Syme, I have found very successful, and
 have  in this way cured abscesses in the neck of seven or eight years' standing,
 which have resisted every other  plan  employed.
  The  constitutional treatment  of abscess must  be  conducted on  the  general
 principles  laid down in  discussing the  management of suppurative inflamma-
 tion (p. 65).
                            SINUS  AND FISTULA.

  After an abscess has  been opened, its cavity may not  fill up completely, but
 contracting into a narrow suppurating track, forms a canal without disposition to
 close, and from which a small quantity of pus constantly exudes, thus  constitu-
 ting a sinus or fistula.
  The causes of this non-closure of the cyst of an abscess may be referred to the
 following heads.   1st. The presence of a foreign body, as of a piece of dead bone,
 at the bottom, may keep the track open.  2d.  The passage of irritating secretions,
 as of urine, faeces, saliva,  &c,  through the abscess will  prevent its complete
 closure; and 3d, the contraction  of neighboring muscles will occasionally prevent
 the due coalescence of  the sides of  the abscess; as when it is  in  the neighbor-
 hood of the sphincter ani, and as may occasionally happen in abscesses about the
 limbs.
  A sinus or fistula consists of a narrow channel often long and  winding, having
an external orifice that is  usually somewhat protuberant, being situated under or 
ULCERS.
337
in the midst of loose florid granulations.   The walls of this channel, which are
always  indurated, are lined by a structure resembling mucous membrane; this,
however, it is not, but simply consists of a layer of imperfectly formed granula-
tions, exuding ichorous  pus.   If the orifice be occluded, this pus  will collect
within  the sinus, and distending its walls, reconvert it into an abscess.  In struc-
ture, therefore, a sinus or fistula may be said  to  be a long, narrow, chronic
abscess, with a permanent external aperture.
  The  treatment of a sinus or fistula has reference to its cause in the first instance;
for  until the foreign body that keeps it open  and maintains the  discharge  is
removed, it  will be  useless to attempt its  closure.   After its removal, we may
endeavor to procure obliteration of the sinus by one of three methods.
  1st.  The employment of pressure, by means of a roller and graduated com-
presses, so as to cause an agglutination of  its opposite sides.  This plan is  useful
in those cases in which the sinus is recent, without much surrounding induration,
and so situated, as upon the trunk, that pressure can easily be applied.
  2d.  A more healthy inflammation  may often usefully be excited in the sinus,
by injecting it from time to time with a weak solution of the sulphate of zinc,  or
of iodine, by passing the threads of a seton through it, or stimulating it by the
occasional contact of a red-hot wire.   My colleague, Mr. Marshall, has invented
a very ingenious and useful apparatus, by means of which a platinum  wire,
introduced cold, is heated red-hot by the galvanic current.   This plan of treat
ment, which is fully detailed in a paper published in the " Medico-Chirurgical
Transactions" for 1851,  has frequently been employed with much success in the
University College Hospital  in the treatment of fistulae and sinuses to  which
other methods were not  very applicable.
  3d.  The last method consists in laying open  the sinus from end  to end, and
then dressing the wound so that it may heal from the bottom; in this way  neigh-
boring muscles that have kept it open by their  contractions, may also be set  at
rest.  The division of the sinus should be done with a probe-pointed bistoury,
introduced through the external opening either  by the aid of a director or with-
out, such assistance.  The operation should be done effectually, the sinuses being
usually followed as far as it is prudent to go, and laid completely open.
                          CHAPTER XXIV.

                                ULCERS.

  Various forms of ulcer, affecting the cutaneous surface or mucous membranes,
are familiar to the practical surgeon.  When occurring in the skin, as the result
of non-specific disease, they may be arranged under the  following  heads : the
Healthy—the Weak—the  Indolent—the Irritable—the Inflamed—the Phage-
dsenic  or  Sloughing—the  Varicose—and the Hemorrhagic.    Besides these
varieties, each of which is marked by distinct characteristics, various other forms
of ulceration depending on specific causes, as the  syphilitic, scrofulous, lupoid,
cancerous, &c, are met with, all of which will be treated under their respective
chapters.
  The  varieties presented  by ulcers are by  no means dependent on local con-
ditions  merely, though these influence them greatly, but are  in a great measure
owing to constitutional causes.   Indeed  the aspect of an ulcer, the character of
its granulations and of its discharge, are excellent indications of the state of
health and of the general condition of the patient, as well as of the local  disease
that exists.
                                    22 
338
ULCERS.
   Ulcers may be situated upon any part of the cutaneous surface as the result of
 violence ; most commonly when occurring from disease of a non-specific character
 they are seated on the leg, but when arising from some specific affection  they
 occur in particular situations, as on the penis, lips, &c.
   The healthy or purulent ulcer may be considered the type of the disease, pre-
 senting a circular or oval surface, slightly depressed, thickly studded with small
 granulations exuding  laudable  pus, and having a natural tendency to contract
 and heal.  It is the object of all our treatment to bring the other forms of ulcer
 into  this condition.   In the management of this  healthy ulcer the  treatment
 should be as simple  as possible, water-dressing and the pressure  of a bandage
 usually enabling it readily to cicatrize.
   The weak ulcer not uncommonly occurs  from emollient applications having
 been continued for too long a time to the  last variety of the disease, the granu-
 lations then becoming high and flabby,  with a semi-transparent appearance about
 them, and sometimes rising  in large, exuberant,  gelatinous, reddish-looking
 masses above the  surface of the sore.   These  high  granulations have a feeble
 vitality, and readily slough.  The treatment of this form of ulcer consists in keep-
 ing the part elevated and carefully bandaged, with an astringent dressing to the
 sore; such as a weak solution of the sulphate of  zinc, or of copper, or the " red
 wash," according to the following formula:  Sulphate of zinc grs. xvj.;  comp.
 tinct. of lavender and spirits of rosemary, of each 5xJ-> water _viij., will be
 found a  most useful application in  addition to touching the  granulations from
 from time to time with the nitrate of silver.
   The indolent ulcer is always  of a very chronic character; it is situated upon
 the  outer side of the  lower extremities, between the ankle and calf, and most
 frequently occurs in men about  the middle period in life.   It  is deep and exca-
 vated, with a flat surface, covered by irregular and badly-formed  granulations,
 exuding  a thin and sanious pus, having hard, elevated, and  callous edges,  and
 presenting generally an irregular and rugged look. The surrounding integument
 is congested and matted to the  subjacent  parts; there is usually very little sub-
 cutaneous  cellular tissue about it, the skin being firmly  fixed to the subjacent
 fascia; and it would appear as if it were  in consequence of this want of a vas-
 cular substratum  from which  to spring, that  granulations  do not  readily arise.
 There is  no pain attending this  ulcer, and its surface, which often attains a very
 large size, may usually be touched without the  patient feeling it. The principle
 of the treatment here is two-fold, to depress the edge, and to elevate the base of
 the sore.   This is effected  by pressure  and stimulation conjoined.  The treat
 ment should  be commenced  by rubbing  the surface of the ulcer  and  the sur-
 rounding congested integument with nitrate of silver; a linseed-meal poultice
 should then be applied for twenty-four hours, after which the sore should be
 properly  strapped on the plan recommended by Baynton.   The best plaster for
 this  purpose is the emplastrum saponis, to  which some of the empl.  resinse is
 added to make  it sufficiently adhesive,  this, spread  upon calico, should be cut
 into strips sixteen or eighteen inches  in length,  and about  an  inch and a
 half in width; the centre of the strip should  then be laid smoothly on the side
 of the limb opposite to the sore, and its ends being brought  forward, are to be
 crossed obliquely over it.  Strip after strip must be applied in this way until the
 limb is covered for a distance of a couple of inches above and  below the ulcer.
 If the sore  be near the ankle,  this joint  should  be included in the strapping.
 Each strip of plaster should be  applied with an equal degree of pressure, which
 may often be  considerable, and  should cover at least  one-third of the preceding
 strap; the  limb must  then be  carefully bandaged from the  toes  to the knee.
 Under this plan of treatment, the edges will subside, the surface of the sore be-
 come florid, and granulations, yielding  abundant discharge, speedily spring up.
 Much of its success will depend upon the close  attention that is paid to the case;
if the skin be irritable,  no  resin-plaster should be used, but merely the soap or 
VARIETIES OF  ULCERS.
339
lead, and the plaster should be changed at least every forty-eight hours.   If the
discharge be very abundant, small holes should be  cut  in the  strips to  allow it
to escape.  When by this plan of treatment the edges of the sore have been
brought down, and the granulations sufficiently stimulated, an  astringent lotion
with bandaging may advantageously be substituted for the plasters.  In  some of
these cases I have found benefit from the  internal administration of liquor arse-
nicalis.
   The irritable ulcer is mostly  met with in women  about the  middle period of
life,  more  especially in  those of  a nervous and bilious temperament.  It is usu-
ally  of small  size, and situated  about  the ankles, or upon the shin.  Its edges
are irregular, but not elevated, the surface grayish, covered with  a thin slough,
and  secreting unhealthy sanious pus.   Its principal characteristic is the exces-
sive  pain  accompanying it, which often,  by preventing sleep,  disturbs seriously
the'general health.   In the treatment of this ulcer we must attend to the con-
stitutional as well as the  local  condition.  The  patient should be put upon an
alterative course of medicine, aloetic purgatives and some sedative at bed-time to
procure rest.  The mode of topical medication  that I have  found to  succeed
best is to brush the surface of  the sore and the  surrounding parts from time to
time with  a strong solution of the nitrate of silver, and then to keep emollient and
sedative applications to it, such as lead and opium lotions.   The occasional ap-
plication of the nitrate of silver deadens materially the sensibility of the  sore
and  assists its granulation.
   The inflamed ulcer is  characterized by much redness, heat, and swelling of
the surrounding parts,  with a thick and offensive discharge, often streaked with
blood; it may come on from the over-stimulation of one of the other varieties.
The treatment must be locally and generally antiphlogistic.   The elevated posi-
tion, the application of leeches  around the sore,  and of cold evaporating lotions
to the surface of the limb, will speedily subdue the inflammatory action, after
which, the healing process takes place with great rapidity.
   The sloughing ulcer, when not specific, is an increased degree of the inflamed
variety, usually  occurring in a feeble or cachectic constitution,  and generally
accompanied by a good deal of  fever of the irritative type. An angry dusky red
blush forms about the sore, which becomes hot and painful; the surface  assumes
a grayish sloughy look, the edges are sharp-cut, and the ulcerative action extends
rapidly.   The treatment in these cases should consist  in improving the general
health by lessening irritation, and keeping  up tone.  The administration of opiates
with nourishing but unstimulating diet, should be trusted to at the same time that
the local action is subdued by rest and warm opiate lotions.    When the inflam-
matory condition has subsided,  tonics should be given internally, and a grain or
two  of the sulphate of copper or of zinc may be  added to the  lotion with which
the sore is dressed.   The  specific varieties of sloughing ulcer will be considered
in the chapter on hospital gangrene, &c.
   The varicose  ulcer  derives  its chief characteristic  from being complicated
with, or dependent upon,  a varicose  condition of the veins of  the leg.   In  this
affection of  the venous trunks, the  skin  gradually undergoes  degeneration, be-
coming brawny,  of a purplish-brown color, and and being traversed in all direc-
tions by enlarged and tortuous  cutaneous veins.  The ulcer forms at one  of these
congested  spots, by the breaking down of the already disorganized and softened
tissue,  forming a small irregular chasm of an unhealthy appearance, and  varying
much in character, being  sometimes inflamed, at others irritable or sloughy,  and
then becoming  indolent.   One of the most serious effects of  this ulcer is, that
by penetrating  into one  of the dilated veins  it  occasionally gives  rise  to very
abundant hemorrhage, the patient, in the course  of a few seconds, losing a pint
or two of blood.   This hemorrhage maybe readily arrested by  laying the patient
on his  back,  elevating the  limb, and compressing the bleeding  point with  a 
340
MORTIFICATION,  OR  GANGRENE.
pledget of lint and a roller.  The treatment of a varicose ulcer must have special
reference to  the  condition of the veins that occasion  it;  no local applications
having much effect,  unless the  pressure of the column of blood in the dilated
vessels be taken off  the  part.   This  may be  done by means of a well-applied
bandage, made of elastic material, or, a laced or elastic stocking applied to the
leg, so as to keep up a uniform  pressure upon the distended vessels.  In  some
cases, the length of the column  of blood may be broken by the application of a
vulcanized india-rubber band below the knee.   In many cases  the cicatrization
of the ulcer cannot be brought about in this way, or if it heal,  it will constantly
break open again; or hemorrhage may have occurred from  a ruptured vein  upon
its surface;  means must then be taken for the  permanent occlusion of the vari-
cose  vessels by their  ligature,  as will be described in the chapter  on those
affections.   As this  procedure,  however, is attended by some  danger from the
occasional induction  of phlebitis or erysipelas, it should  not be had recourse to
unless the existence  of one or other  of the conditions just mentioned urgently
calls for it.
  The hemorrhagic  ulcer is a dark  purplish-looking sore, occurring in women
suffering from  amenorrhoea, and having a special tendency, whence its name, to
ooze blood about  the menstrual  periods; it usually partakes of the character of
the irritable ulcer, and requires to be treated by constitutional means, having for
their object  the improvement of  the patient's  general health; with this view the
preparations of iron  and aloes are especially useful.
  Various forms of ulcer occur upon the mucous membrane of the throat, rectum,
and  genital  organs.   As these,  however, are  commonly of a specific character,
they will be hereafter described.   When ulcers of the mucous membrane are not
of a specific  character, they present the general appearances characteristic of the
cutaneous, healthy, inflamed  or weak varieties, and  require the topical applica-
tions suited  to these  conditions;  though generally they will bear and require the
free employment of caustics, especially of the nitrate of silver.
                          CHAPTER  XXV.

                  MORTIFICATION OR  GANGRENE.

   The local death of a part of the body, in surgical language, is termed Morti-
fication or Gangrene; when the morbid action is confined to the osseous struc-
tures or to the cartilages, it is termed Necrosis ; when limited to tie soft tissues
of a limb, Sphacelus, and  when accompanied by ulceration, it is called  Slough.
Many other varieties of gangrene are recognised by surgeons; like all other dis-
eases, it may be acute or chronic in its duration;  as the parts affected are moist
and swollen, or, dry and shrivelled, it may be divided into the moist and the dry
or mummified gangrene; so,  again, according to its  cause, it  is  spoken of as
idiopathic or traumatic, and very frequently and most correctly, perhaps, arranged
under the denominations  of constitutional and local, without reference to the
comparatively accidental circumstances of its dryness  or moisture. Besides these,
various specific forms of the disease are met with which will require special con-
sideration.
   Whatever form the gangrene may assume, there are certain local phenomena
that are common to all the varieties of it.  There is  complete loss  of sensibility
and of motion  in  the part  affected, tite temperature of which falls considerably
below that of the  body generally, giving rise to a sensation of damp and  clammy 
VARIETIES OF  GANGRENE.
341
coldness, and after a  time there is an odor of putrescence  evolved, with very
commonly an emphysematous  crackling from effusion of gas into the tissues  of
the part.  The color of the part affected is usually of a dark purplish or green-
ish black, more or less mottled with red.  This, which is unlike anything else  in
the system, shows that changes of importance have taken place in the solids and
fluids of the diseased tissues, and is usually connected with the moist and swollen
form of the disease.  In  the dry variety of gangrene, the color is often at  first
of a  pale tallowy-white, with a mottled appearance upon the surface.   The skin
soon  shrivels, becomes dry, horny, and semi-transparent, and eventually assumes
a brown wrinkled appearance;  in other cases, again, the gangrened part is brown,
dry,  and shrivelled from the very first.  The  differences in the color of the mor-
tified part, indicate corresponding differences in the cause of  the affection.   In
general terms it may be stated that  the dark  varieties of gangrene are the result
of destructive changes taking place  in the very part itself, or are of constitutional
origin,  whilst the pale form of the affection occurs  as a consequence of some
obstruction in the supply of  blood to the part, and  is a local disease only, in-
fluencing the constitution secondarily.
   The processes  adopted by nature for the arrest  of  gangrene by the formation
of a  line of demarcation, and for the detachment of the parts that have lost their
vitality by the extension of ulceration along the line of separation, have already
been fully described (pp.  71 and 72).
   The constitutional symptoms vary greatly;  when the  disease is strictly local,
affecting a part of but limited extent, and of no great importance perhaps to the
economy,  they  are not  very strongly  marked.   If, however,  the  gangrene,
although limited, implicate organs of  importance to the system, as  a knuckle  of
intestine, for example, marked symptoms declare themselves.   Whatever the pre-
cursory condition may be, the  full invasion of the gangrene, if it be of rapid oc-
currence, is always accompanied by constitutional disturbance of an asthenic type,
attended by great depression of the powers of the system, with a dull and anxious
countenance, and a feeble, quick, and easily  compressible pulse; the tongue  is
brown, and soon  becomes loaded with sordes.   When the gangrene is internal,
a sudden cessation of pain, with hiccup, vomiting, and tympanitic  distension  of
the abdomen, may be superadded  to  the symptoms, and  indicate the mischief
that has occurred.  Death usually supervenes with  low delirium, twitchings, and
coma.   When the invasion of the gangrene is more gradual, as we see in some
of the  constitutional  forms affecting the  lower extremities,  the symptoms are
usually those of irritative  fever, eventually subsiding into the asthenic form.
   The  diagnosis of gangrene is easily effected when this condition has fully de-
veloped itself, but in the early stages, before it is positively declared, it is not
always  an easy matter to determine  its existence.  The ecchymosis and  discolo-
ration of a bruise, the collapse and lividity that result from  cold, or the dark
purple  hue occasioned by long-continued congestion, may readily be confounded
with impending gangrene.  In these cases of doubt, the surgeon should not be
in too great a hurry to pronounce an  unfavorable  opinion, and still less to act
upon it, for it not uncommonly happens that parts of the body that had to all
appearance lost their vitality, may by proper  treatment regain it.
  The prognosis  of gangrene is always bad, so far as the part itself is concerned,
though it occasionally happens that when it has  not fully occurred, partial re-
covery  may unexpectedly take place.   So far as the life of the patient is at stake,
much will  depend on the  cause of the affection, and the age and strength of the
individual  in whom it occurs.  At advanced periods of life, and in a feeble state
of system, the result is always unfavorable; so also  whilst the gangrene is spread-
ing, the prognosis is bad,  as it is impossible to say  where the  morbid action may
stop; but when once the line of demarcation  has formed, indicating as this does
the possession of  a certain vigor of constitution, the principal danger is over, and 
o 10
MORTIFICATION,  OR  GANORENE.
then the result will depend on the power of the patient, and the support that can
be given during the processes of separation and of repair.
  The causes of gangrene are  very various.   They may be arranged under four
principal heads.
  1st. The intensity or specific nature of the  inflammation  of a part  may give
rise to its death by the stagnation of the blood within its vessels, or by inducing
such changes in it as are incompatible with life.
  2d.  The arrest of the circulation through  a part is a common cause of gan-
grene, and may be occasioned in one of three ways:  either by strangulation of
the part generally;  by the  obstruction  of the flow of blood through the  main
arteries leading to  it; or, by the return  of  blood through  the principal veins
coming from it being interfered with.
  3d.  Traumatic causes of various kinds give rise to different forms of gangrene,
most of which we  have already considered.   Thus  the severe contusion,  com-
pression, or laceration of a part may occasion gangrene of it (page 116);  the in-
filtration of an irritating fluid into a part; and, lastly, its exposure to intense heat
or cold will destroy the vitality of the tissues implicated.
  4th.  Specific poisons of various kinds occasion special disease,  of which gan-
grene is the  principal characteristic.   Thus Hospital  gangrene, malignant pus-
tule, noma, carbuncle, and  ergotism  are instances of specific  affections, accom-
panied by gangrenous action.
  Among  the causes, some  are constitutional, others  local,  in their action:
those form s  of gangrene are said to be constitutional which arise from intense or
specific inflammation of the part—from obstruction of the circulation  in conse-
quence of a diseased state of the heart and vessels, or from the action of various
specific poisons.  On the other hand, those varieties of gangrene are local which
arise from injuries of all kinds, whether applied to the part itself, or to the main
artery leading to it,  by its ligature or wound.
  Some of the varieties of gangrene that have just been indicated, such as those
arising from  the intensity of the inflammation, and from various traumatic causes,
have already been  discussed (pages 71 and 117); whilst those that arise from ob-
structed circulation, or that take  the form of specific diseases, are left for our
consideration here.
  Gangrene from Arrest of Circulation.—A partis often purposely strangled by
a surgeon in many operative procedures,  or its circulation may in this way be
arrested, as the result of certain diseased  conditions.  In  either case the stran-
gulation acts by stopping  more or less completely the whole  circulation of the
part.   If it  be sufficiently severe, it may kill  the tissues outright; as, for in-
stance, when a naevus or pile is tied, all flow of blood to or from the part is sud-
denly arrested, and its vitality destroyed, the tissues that have been  strangled
shrivelling and separating  by ulceration  along the line of ligature.  When the
strangulation is not so severe as this, great congestion in the part ensues, conse-
quent on the interference with the return of the  venous blood; the part  strangled
becoming dark and congested, phlyctenae  or  vesicles arising on its surface, and
effusion taking place into its tissue.  Inflammation becoming at last superadded
to the effects of the strangulation, and still more embarrassing the circulation of
the part,  sloughing takes place by the conjoined action of the strangulation and
the inflammation;  all this we see occurring in a constricted gut.
  When a part of the body is deprived of its proper supply of blood,  mortifica-
tion may ensue. This we see occasionally happen when the circulation is arrested
through the main artery of a  limb by  its ligature or wound.  Most  commonly,
when the principal trunk of an artery is obstructed,  the collateral circulation is
sufficient to maintain the vitality of the part;  but should this be interfered with
in any way, gangrene ensues from the simple  deprivation of  that blood which is
necessary to the maintenance of its  life.  Indeed,  the sudden loss of a  large 
SPONTANEOUS  AND  SENILE  GANGRENE.           343
 quantity of blood from the system generally may  occasion the death of some of
 the extreme parts of the body, in which  the circulation  is naturally most lan-
 guid.  Thus Sir B. Brodie relates the case of a surgeon, who, being bled to an
 inordinate extent, was seized  with gangrene of both feet.
   When a limb becomes gangrenous in consequence of the ligature or wound of
 its main artery, without any other injury to the vascular system, it will be found
 to become cold, to feel heavy, and to  lose its sensibility.  At the same time it
 assumes a dull  tallowy-white color, mottled with  grayish or  brownish  streaks.
 This state of things is chiefly  met with in the lower extremity; the integuments
 of the foot  die, become  semi-transparent  and horny-looking where  they are
 stretched over the tendons of the instep,  and the part thus presents a shrivelled
 appearance.   In the course of a short time the pallid color will be lost, the part
 becoming brown or blackish.  This  form of gangrene may invade the whole of
 the lower limb, but most commonly is limited to  the foot, stopping either just
 above the ankle, or if not, then  immediately below the  knee, as Guthrie  has
 observed; the arrest taking place in one or other of these two spots on account
 of the greater freedom of the collateral circulation here than in other  Fi  123
 parts of the limb.  If any of the large  venous  trunks become ob-
 structed or otherwise implicated,  so that the return of blood through
 them is  interfered  with,  at  the  same  time that  the supply by the
 arteries is arrested, the limb generally assumes a greenish-blue color,
 and rapidly runs into putrefaction.   In some of these cases it hap-
 pens that sloughs of the integument and subcutaneous cellular tissue
 form although the limb generally preserves its vitality.   The treat-
 ment of these forms  of gangrene, which  are strictly local, is de-
 scribed in the chapter (p.  170) on wounded arteries.
   Gangrene may occur from the circulation being arrested by disease
 taking place in the coats of the arteries.   This, is the variety of the
 affection that is commonly called spontaneous, and when occurring
 in old people, senile gangrene.
   This affection commonly occurs in consequence of the coats of the
 arteries becoming rigid and calcified (Fig. 123), and unable to main-
 tain  the  circulation of the limb.  It  is met with in the lower ex-
 tremities of people past the  middle  period of life, and  increases as
 age advances; a sensation of weight  in the limb occurs, with cold-
 ness, itching,  and tingling in the feet,  and with cramps  in  the
 calves  and the circulation  of  the  part  is  habitually  defective.
 This condition  commonly  exists  for  a  considerable  length  of
 time before  gangrene  comes  on.  In many  instances this  sets  in
 without  any exciting  cause;  but in  other cases  the mortification
 is immediately  set up  as the result  of  some slight inflammation
 accidentally  induced; by  the excoriation  produced,  perhaps,  by  a
 tight boot, or by a trivial wound in cutting a corn; the inflammation
 occasioned by this slight injury being sufficient to disturb the balance
 of the circulation in the already weakened part to so great an extent,
 that gangrene ensues.   This  generally makes its appearance in the
 form of a cold, purple or blackish-red spot on the side of one of the
 toes; this spot is surrounded  by  an  inflamed areola, and  is accom-
 panied by much smarting and burning pain; it spreads by gradually
 involving the inflamed areola, which continues to extend  in  propor-
 tion as the gangrene progresses.   In this way the affection gradually
 creeps up the limb, invading perhaps one toe after the other, involv-
 ing the instep and the sole of the foot, and, unless  it terminate by
the formation of the line of demarcation, or death put an end to the  grene
patient's sufferings, it may extend up the ankle or leg.  The part that is affected
 Femoral and
tibial arteries
obstructed  in
senile   gan- 
344
MORTIFICATION,  OR GANGRENE.
is always black, dry, and shrivelled, resembling closely the appearance presented
                   Fi(r l2i              by  a dried mummy;  hence it is often
                                      termed  mummification  (Fig.   124).
                                      There is usually considerable  constitu-
                                      tional  disturbance,  of an irritative or
                                      asthenic form in these  cases, and the
                                      disease is generally fatal in from a month
                                      to six weeks.   I have known the disease
                                      continue, however, with  very little con-
                                      stitutional  disturbance,  for  more than
                                      twelve  months.    In  other  instances,
                                      again, the gangrene being limited to a
                                      small extent, the patient may recover.
                                        Gangrene  may  also  occur from in-
flammation affecting the principal artery of a limb, and  perhaps occluding it
completely, without any previous disease in the vessel.  In these cases there are
the usual signs of arteritis, such as tenderness along the course  of the  vessel,
cessation  of pulsation in its  terminal branches, intense superficial pain in the
limb, followed by the rapid supervention of dark, dry gangrene  in the whole of
the extremity up to the point at which the vessel is inflamed.   This  affection, of
extremely rare occurrence, has been described as spontaneous gangrene.   In some
cases it partakes of the characters of the humid form, *>wing to the implication of
the veins.  It is, I believe, most frequently  met with in the upper extremities, at
least  all the instances that I  have seen of it have been situated there, and is, I
think most common in women, occurring even at an early period of life.   It is
of the dry variety, in consequence of the arrest of the flow of blood into the limb,
and commonly occurs in a broken constitution, being frequently fatal by the super-
vention of typhoid  symptoms before any attempt can be made by nature to sepa-
rate the mortified part; after death, in these cases, the inflamed vessel will be found
firmly plugged up by a dense coagulum, which completely arrests the circulation
through it.   But the  pathology of  the  arterial  system, in reference to  these
two forms of gangrene, will be more fully discussed in a subsequent  chapter.
   3dly. Gangrene may arise from obstruction to the return of blood through the
veins of a part, the disease occurring from the circulation being arrested by the
overloading of the capillaries with venous blood.   Gangrene is especially apt to
occur, if the arterial supply is diminished, at the same time that the return of
venous  blood is interfered with;  as when an artery and  vein are compressed, or
when the femoral vein is wounded accidentally at the time that the artery is liga-
tured.  Gangrene from this cause is always of the moist kind, attended by great
swelling from oedema,  with discoloration and rapid putrefaction of the part.
   This gangrene, from venous obstruction, is also especially apt to occur in those
cases in which the heart's action is  weakened,  or  the flow  of blood in the
aorta lessened, at the same time  that the  force of the impulse in  the arterial
system is so lowered that the heart is unable to push the blood through the loaded
vessels.   Those cases  of gangrene of the extremities that are occasionally met
with from pure  debility, as after fevers, often appear to originate in this way.
   The various forms of traumatic gangrene, whether arising from the severity of
the injury, from the inflammation following it, from the depraved condition of
the blood, from  the irritation of extravasated fluids, or from the effects of burns,
or of frostbite,  have already been considered when treating of these respective
injuries; and the more specific forms of the affection we  shall shortly describe.
   Treatment.—As gangrene proceeds from such a great variety of causes, it must
be very evident that no one plan of treatment can be applicable to this condition,
and it becomes necessary, not only to modify our therapeutic means according to
the cause of the disease, but also with special reference to the constitution of the 
   TREATMENT  OF  SPONTANEOUS AND  SENILE  GANGRENE.  345

 patient, and with regard to the stage in which we meet with the gangrene; and,
 indeed, it often requires great tact and experience to accommodate the treatment
 in this way to the varying phases of the case.  I have already  considered the
 treatment of the inflammatory (p.  72) and the traumatic and local (pp. 120 and
 170) forms of gangrene, and shall, therefore, consider merely in this place the
 general principles that guide us in the management of those varieties that  have
 been considered as the  result of constitutional causes—the spontaneous  forms;
 in these cases the constitutional management of the patient is of greater moment
 than the local treatment of the disease.
   In the constitutional treatment of  these  forms of gangrene, there are three
 principal  indications: 1st.  To remove the cause, if possible, and thus to arrest
 the gangrene.   2dly. To support the powers of the system during the process of
 the separation of the slough;  and 3dly.  To lessen the irritability of the nervous
 system.
   In the removal of the constitutional cause, we must look wholly  to the  con-
 dition of the patient's system; if this be in an inflammatory or febrile state, we
 must have recourse to the modified antiphlogistic plan described at p. 72.  But
 the opposite condition, that of debility, may equally occasion, or complicate, the
 gangrene, which may recognise an enfeebled state of  the circulation of the  part,
 or of the system generally, as its cause, and there may be every possible combina-
 tion between this and the inflammatory condition.  Under  these circumstances,
 it will be  necessary to conjoin an antiphlogistic plan of treatment with remedies
 of a tonic, or even stimulating character.  It is  this  plan of treatment that is
 commonly found to succeed best in the spontaneous  gangrenes;  here moderate
 antiphlogistics are perhaps required in the earlier stages, with a light nutritious
 diet and mild tonics as the disease advances, and in the later periods, when the
 constitutional symptoms  assume an asthenic character, stimulants should be given.
 The best stimulants to administer  in these cases are wine or porter, according to
 the patient's habits of life, and these should be given in combination with  nou-
 rishment, so as  not merely to fill up the pulse, but to produce a more permanent
 tonic influence on the system generally.   If much depression occur, the medicinal
 stimulants, more especially ether, ammonia, and camphor, are of material service.
 The only tonics that are of much value, in these cases, are the preparations of
 bark and some of the vegetable bitters, as  gentian, and cascarilk;  and  though
 the specific  virtues that were formerly  attributed to  them  can  no longer be
 accorded, yet, when they do not irritate the  stomach, they are of  unquestionable
 service in combating the asthenic symptoms and improving the digestive powers.
 In these cases,  I look upon bark or gentian, in combination with the chlorate of
 potass and ammonia, as of undoubted value.
  After the proper employment of means calculated to remove the constitutional
 cause of the gangrene, the  system  must be  supported against the  debilitating
 effects  that accompany the process  of ulceration and of suppuration necessary for
 the separation of the mortified parts.  During this period, there is less irritation
 and more debility, and stronger tonics and stimulants can be borne, but we  should
 be careful not to overstimulate the patient.   On this, point it is extremely difficult
 to lay  down any rule;  every possible variety as to the quantity and quality of
 food and stimulus being  required by different individuals.   The safest guides are
 the state of the pulse and tongue;  if they improve, the means employed  agree.
 At the same time hygienic measures should be carefully attended to; cleanliness
 and free ventilation, with the abundant use of  the  chlorides, are  of the  first
 moment, so that the patient be not poisoned by his own exhalations.
  The  third indication, that of lessening the irritability of the system that  always
 supervenes, and which is partly owing to the severity of the pain, and partly  to
 the shaken and depressed state of the nervous system, is best  carried out  by the
administration of opium; and although this drug may not act as a specific, as 
346                MORTIFICATION,  OR GANGRENE.
Pott supposed, yet in many cases, but especially in the gangrene of the toes and
feet of old people, it is undoubtedly a remedy of the greatest value.   From half
a grain to a grain of the solid opium may be administered  advantageously every
sixth, eighth, or twelfth hour, according to  the  effect it is found to produce, care
being taken at the same time that it does not confine the bowels.  The hiccup,
which is often distressing in these cases, is  best remedied by the administration
of ether and  camphor.
  The local treatment of the gangrenous part should be conducted on the prin-
ciples, described at p. 73, leaving the separation of the sloughs as much as possible
to nature, diminishing the fcetor which occurs,  by the  use of the chlorides,  pre-
venting the absorption of morbid matters by the line of separation, and dressing
this with wet lint or calamine cerate;  and lastly, endeavoring to heal the ulcer
that results on the detachment of the gangrened part.
  The treatment  of " senile gangrene," presenting, as it does, some peculiarities,
requires  a few words to be specially devoted  to it.  By some surgeons this disease
has been treated on a strictly antiphlogistic plan, on the supposition that the
obstruction of the  arteries was caused by the inflammation of their  coats; this,
however, is certainly an erroneous doctrine in a  great number of cases;  and
though inflammation may occasionally affect the calcified coats of an artery, it is
always a low form  of the disease that does not bear depletion.   Sir B. Brodiea
very justly observes, that in these cases the local precursory inflammation termi-
nates in mortification, because  the  inflamed part  cannot obtain the additional
supply of blood that it requires ; hence  if blood is abstracted from  the system,
and  the action  of the  heart weakened,  the cause of the disease will only be
aggravated.   But though depletory measures are not admissible, we must guard
against running  into the  opposite extreme, and over-stimulating patients labor-
ing under this disease.   Senile gangrene  commonly occurs in individuals be-
longing  to the wealthier classes of society, who have lived high, taken insuffi-
cient exercise, and consequently got  the  system into an irritated, plethoric, but
enfeebled state.  In this condition stimulants and the more powerful tonics are
not well borne, they heat  the  system, accelerate the  pulse, and interfere with
digestion; and, as  Sir  B.  Brodie observes, it is  of great importance in  this
disease to attend to the state of the digestive organs, in order that nutrition may
go on, and that blood of a  proper quality may be made.  In order to accomplish
this, a light, nourishing  diet,  partly animal  and  partly vegetable, should be
given, and  a  moderate quantity of wine, beer,  or brandy allowed.   The bowels
must be relieved from  time to time  by a  rhubarb draught  or simple aperient
pill.  It is better to avoid  mercury in any form in this disease, as  it depresses
the system, and  hence it should not  be  used,  even as an aperient, unless the
state of  the  liver imperatively require it.  If the  digestion become  impaired, a
stomachic,  as the  infusion of cascarilk, or the compound infusion of gentian
with a  little  ammonia, may be administered.   The administration of opium in
these cases, as recommended by Mr. Pott, has received the sanction of  almost
every practical surgeon.   Sir B. Brodie's opinion on this  point is peculiarly
valuable ;  he says,  " If I am, not greatly mistaken, the result of a particular case
will very much depend on this,—whether opium does or does not agree with the
patient."  About two grains of opium may be administered in divided doses in
the course of the twenty-four hours, the quantity being increased as the system
becomes accustomed to its effects.  If it  disturb the stomach and occasion head-
ache notwithstanding the  use of aperients, it  must, however, be discontinued,
as it will increase the irritation of the system.
  The local means to be employed in senile gangrene are of  a simple character.
It is of great importance to keep up the temperature of the limb, and to equalize
its circulation as  much as possible; this is best done by the application of cottou-
                           a Lectures on Pathology, p. 366. 
TREATMENT OF  SENILE  GANGRENE.
347
wadding  or  of carded wool,  as recommended by Mr. Vance,  in  thick layers
around the foot and leg, so as to envelope the limb completely in this material,
over which  a large  worsted stocking may be  drawn, or a  silk handkerchief
stitched.   This dressing  need not be removed more than once or twice a week
unless  there  is much discharge from  the  line  of separation, then it  must be
changed  more frequently;  the gangrened  part itself  should  be covered with a
piece of  lint soaked  in  chlorinated lotions.  When the soft parts have been
separated, and the bones of  the  foot  exposed,  these  should  be cut across by
means  of cutting-pliers or a small saw, and  the sore that results dressed in the
ordinary  way with some astringent lotion or slightly stimulating ointment.   The
Balsam of Peru, either pure  or diluted with an equal  part of yolk of egg, is a
very excellent application in  these cases.  In  the event of the patient recover-
ing, he must be careful to avoid exposure* to cold, and to keep the legs warmly
clad at all seasons of the year.           *
   The question of amputation in cases of gangrene of the limb  is of great im-
portance  to  the practical surgeon,  and is  one,  on certain points of which the
opinions  of  practitioners are still  at variance.  At  first sight it  appears ra-
tional to  cut off a limb that  is dead, disorganized, and offensive, and  this  may
be done  when  the gangrene is, strickly speaking, a local condition; as, for
instance, the result of a severe injury; any affection of the constitution in such
a  case as this being secondary  to the  local mischief,  and dependent on the
irritation set up by it, and on  the  effort made by nature to rid  the system of a
spoiled member.   But when the constitutional disease is the  primary affection,
and when the  gangrene  is consecutive  to and dependent upon this,  it would
clearly be useless to cut off the mortified part, as the same morbid action might,
and would, be set up in the stump or  elsewhere.  Hence  the broad question of
amputation  in  cases of gangrene turns upon the fact  of the mortification being
local or constitutional in its origin.
   When the gangrene is local, therefore,  we usually  amputate  at once.  This
is especially the case when the  mortification results from  severe injuries, or is
the result of the wound or ligature of  an artery.  Here  I think, for the reasons
that have been given (p. 172), that amputation should be performed as soon as
the gangrene has unequivocally manifested itself, without waiting for the line of
 demarcation.   The result of amputation for traumatic gangrene is, on the whole,
very unfavorable, the patient very  commonly sinking from a  recurrence of the
disease in the stump, or from the constitutional disturbance that had previously
set in; those cases being especially unfavorable in which  the cellular  tissue of
the limb is much infiltrated and  disorganized, the affection indeed partaking
more of  the characters of constitutional disease, with some forms of which it is
closely associated.
   There  are two exceptions  to the rule of amputating  in traumatic  and  local
gangrene before the occurrence of  the line of demarcation, viz., in the  case of
gangrene from frostbite, and in  that from severe burns; in these  injuries it is
better to wait for the line of separation  to form, and then to fashion the stump
through  it as the circumstances of the case require,
   In gangrene from constitutional causes, it is a golden rule in surgery never to
amputate until the line of separation has formed; for as it is impossible in these
cases to  say where the mortification  will stop, the  amputation  might be  done
either too high, or not high enough;  and,  under any circumstances, the morbid
action  would to a certainty be set up in the stump.   It is  not even sufficient in
such cases as these  to wait until the line of demarcation has formed before re-
moving the limb; these  spontaneous or constitutional  gangrenes having often a
tendency to remain stationary for some days, and then creeping on, may readily
overstep  the  line by which they had  at first appeared to be  arrested.   Besides
this, the  local disturbance and inflammation set up by the amputation might be 
348
GANGRENOUS  DISEASES.
too great for the lessened vitality of the system or part, and might of itself occa-
sion a recurrence of the  gangrene.   Hence in these cases  it is always well to
wait until the line of separation has ulcerated so deeply that there is no chance
of the gangrene overleaping this barrier, at the same time that means are taken,
by the administration of tonics, nourishing food, &c, to improve the patient's
strength and fitness for the operation.  So soon as this has been done in a satis-
factory manner, and all the soft parts, except the ligaments,  have been ulcerated
through, the mortified part should be separated, by cutting through the remain-
ing  osseous, ligamentous, or tendinous structures, and then means  should be
taken to fashion  the  stump that has been  so formed by nature.  In some cases
this will be  sufficiently regular to serve  every useful purpose after it has cica-
trized ;  in most  instances,  however, it will  be found that  the bones protrude
to such an extent, or that the ulceration has affected the soft parts  so irregu-
larly, that it will be  necessary, in  order to  give  the  patient a useful  limb, to
amputate through the face of the stump, or higher up;  all  this,  however, must
be left to the discretion of the surgeon; but no procedures  of this kind should
be undertaken until the  patient's strength  has been restored sufficiently to bear
the operation.
   In senile gangrene  it has  recently been proposed to  amputate the  thigh high
up.  This practice has been successfully adopted by Mr. Garlike, Mr. James of
Exeter, and others, and certainly deserves a trial in all cases in which the health
is otherwise good and the constitution tolerably sound.  It has not as yet been
adopted in a sufficient number of cases to warrant a positive opinion on its merits;
but it would appear that for it to succeed, the amputation should be done as  near
the trunk as possible, so  that there may be a better chance of meeting with a
healthy condition of the  vessels and  good  vitality in  the limb; the operation
being performed on the  principle, that this form  of gangrene is dependent on
local disease obstructing the vessels of the part, and not always on constitutional
causes.
                          CHAPTER XXVI.


                       GANGRENOUS DISEASES.

                                BED SORES.

  When a part of the  body is compressed too severely, or for too long a time,
even in a healthy constitution, it loses its vitality and a local limited slough re-
sults.   This separates, and an ulcer is left, which cicatrizes  in the usual way.
But in certain deranged states of the health, more especially when the blood is
vitiated^ and  the constitutional  powers  lowered, as  during fever, or when the
patient is old, debilitated or paralysed, the skin covering those points of the body
that are pressed upon  in the  recumbent  position, such as the  sacrum, the tro-
chanter, the elbows, shoulders, and heels, becomes congested and inflamed, as-
suming a dull reddish-brown color, and speedily becomes excoriated without any
pain being felt by the patient.  If means be not taken to relieve the part from
the injurious compression to which it is  subjected, and more especially if it be
irritated by the contact of faeces or urine, the subcutaneous cellular tissue cor-
responding to the inflamed patch will be found  to have become widely softened
and doughy, being converted with the  skin covering it, into  a tough grayish
slough, from under which a thin ichorous pus exudes.  This slough may extend
by. a process of undermining of the integuments covering it, and on its separa- 
SLOUGHING  PHAGEDENA.
349
tion extensive mischief will be disclosed, the fascia and tendons being exposed,
or the bones laid bare, and soon  becoming roughened and  carious.  In some
cases even the inferior aperture of the  spinal canal may be laid open, or death
result from a low form of arachnitis, in consequence of the irritation spreading
to the membranes of the cord.  In other cases again, the patient dies worn  out
by discharge and irritation.
  The treatment of these cases is in a great measure of a'preventive character.
When a patient is likely to  be confined to bed  for many weeks, especially by
an exhausting disease, steps should be taken by proper arrangement of the  pil-
lows and by the use of the water-bed and cushions to prevent pressure being in-
juriously exercised upon any one part.  At the same time cleanliness and dry-
ness should be carefully attended to by proper nursing, by the use of a draw-sheet,
and by furnishing the bedstead with the necessary arrangements of bed-pan, &c.
The skin on the exposed parts may be protected by the application of soap-plas-
ter spread upon wash  leather or amadou, or, what is better, may be strengthened
by being washed with spirits of wine, either pure, or having two grains of the
bichloride of mercury dissolved in each ounce.
   If the skin have become chafed, the removal of pressure is imperative, and the
sore may be dressed with the Balsam of Peru, either pure or  diluted with the
yelk of egg, spread upon lint.  In these cases also the use of the prone couch may
occasionally be advantageously substituted for that of the ordinary bed previously
employed.   When sloughs have formed, their separation must be facilitated by
the use of charcoal or chlorinated poultices,  and the ulcers that are left should
be dressed with astringent and aromatic applications;  but  no dressing that the
surgeon  can apply will cause these ulcers to heal unless the patient's general
health improve, and then they will  speedily get well under simple treatment.

                        SLOUGHING  PHAGEDENA.
   This affection, which  is also commonly known by the names of hospital,  con-
tagious, or pulpy gangrene, is a disease characterized by a rapidly destructive and
spreading ulcer, covering itself as it extends by an adherent slough; and attacking
open sores  and wounds.  It is rarely met  with in its fullest extent,  except in
military practice;  the accumulation of the wounded, and the want of the neces-
sary cleanliness and attention during an active campaign, appearing to dispose
to it.  It used formerly to desolate the civil hospitals; hut  thanks to the sani-
tary measures that are now  so generally adopted in  these institutions, it has
almost disappeared from them, though still an outbreak of it occasionally takes
place.  During the last ten years, it  has been  met with in most of the  London
hospitals, and has twice made its appearance in that of the University College.
   When sloughing phagedaena invades a wound that is previously perfectly
healthy, the surface of the sore becomes covered with gray soft points of slough,
which rapidly extend, until the whole of the ulcer is affected.  At the same time
it increases rapidly in superficial extent, and commonly in depth; the surround-
ing integument becomes cedematous, swollen, and  of a  livid red color; the edges
of the ulcer are everted, sharp-cut, and assume a circular outline, and its surface
is covered with a thick, pulpy, grayish-green, tenacious mass, which is so firmly
adherent to the sore that it cannot be wiped off from it, being merely moved or
swayed to and fro when an attempt is made to clean it.  There is usually some
dirty yellowish-green, or brownish discharge, and occasionally some bleeding; the
pain is of a severe burning, stinging, and  lancinating character, and  the foetor
from the surface is considerable.   The ravages of this  disease  when  fully deve-
loped, are very extensive.   The soft parts, such as the muscles, cellular tissues,
and  vessels, are transformed into a gray pulpy mass, and the bones are denuded.
The larger bloodvessels  resist the progress of the disease longer than any other
parts, but may at last be exposed, pulsating at the bottom of the deep and foul
chasm.  There is little risk of hemorrhage taking place however in the early 
350
GANGRENOUS  DISEASES.
stages, but when the sloughs are separating, an artery may give way, and bleed-
in°- to a dangerous or fatal extent ensue.   Hennen states that there is most dan-
ger of this happening about the eleventh day.   When the sloughs are  thrown
off, in the  form of reddish-brown or grayish-green, viscid, and pulpy masses, a
very sensitive granulating surface is  left, having a great tendency to bleed, and
to be again invaded by the sloughing action.
   Blackadder has  described  an ulcerated  form of  this affection, in which a
vesicle containing a bloody ichor forms, with a hot  stinging pain; this breaks,
leaving a circular ulceration about the size of a split pea.  The ulceration, once
formed, rapidly extends by sharp-cut edges into the surrounding integument.
   On the two occasions that I have had the opportunity of witnessing outbreaks
of this disease, in the University College Hospital,  the  surface  of the  wound
affected became rapidly covered with  a yellowish-gray pultaceous slough.   In
some cases there was  hemorrhage, but most commonly a small  quantity of fetid
discharge only was  poured out, the  edges of the sore became sharp-cut and de-
fined, and the ulceration extended farther in the skin by an  eighth or a quarter
of an inch than in the subjacent cellular tissue.  In the majority of instances
the disease was confined to the skin  and cellular tissue, exposing but not usually
invading the muscles and bones, though in some cases these were affected.  The
ulcers, which had a somewhat circular shape, were  surrounded by a dusky in-
flamed areola of some width.    When once the  morbid action was stopped, they
cleaned rapidly, throwing out large vascular, granulations.
   The constitutional  symptoms are inflammatory  in the first  instance,  with a
tendency to asthenic and irritative fever as the  disease advances. In the majority
of cases they follow the local invasion of the sore; Blackadder, Rollo, Delpech,
and Wellbank have all found this to be the case,  and in the instances at Uni-
versity College Hospital it certainly was  so.   Hennen and  Thompson,  on the
other hand, state that the constitutional symptoms precede the local ones.   This
discrepancy of observation may be explained by the difference in the cause of
the disease; if it occur from contagion the constitutional symptoms will be secon-
dary, if from causes acting on the general system they may probably be primary,
to the local affection.
   All wounds and sores are liable to be attacked  in this way, but the disease
most frequently affects those that are of recent origin; the  more chronic affec-
tions, and those that are specific, very usually escape.
   The causes are of various kinds; primarily it commonly originates from over-
crowding in hospitals, from want of cleanliness, ventilation, and change of dress-
ings ; from the accumulation, indeed, of animal exhalations arising from  the sick
and wounded, which  is a source of various forms of  low fever and of allied dis-
eases.  But  though  it commonly has  its origin in  this way,  especially in the
crowding of  military  hospitals  after a  hard-fought action, it is met with out of
hospitals.   In the  winter  of 1851  several well-marked  cases  of this affection,
three or four of which were of a very severe character, occurred amongst the out
patients at the University College Hospital.  In these cases, as in many others,
it was probable that the disease was  occasioned by some atmospheric or epidemic
influence.  At this particular season,  influenza, erysipelas,  and  phlebitis were
also  very prevalent.   This had been  observed at the time of the first occurrence
of the disease at our hospital, in 1841,  and I think it is difficult not to recognise
a similarity of cause in these different affections.  When once it has occurred it
may rapidly spread by contagion, though there is no evidence to show that it is
of an infectious character.  Hence  the necessity of  preventing its being spread
by nurses or attendants, and of destroying the  dressings used by the patients.
   In the treatment of this affection the first point to attend to  is to prevent the
extension of the disease to patients that are  not as yet affected by it.  This may
be done by separating those that have been seized with it from the healthy, by 
SLOUGHING  PHAGEDENA,
351
 ventilating the wards, washing the floors with a solution of the chlorides, whiten-
 ing the walls, and fumigating the apartment with chlorine gas.
   The extension of the sore must be stopped by the free application of fuming
 nitric acid, or of the actual cautery to its edges and surface.   I have used both
 these agents, but give the preference  to  the nitric acid if strong and freely ap-
 plied, the sides and edges being well  sponged  with  it.   The actual cautery is,
 however, very useful in those cases in which there is a tendency to hemorrhage
 from the surface of the sore; after the cauterization a strip of lint,  soaked in a
 strong solution of the watery extract of opium, should be laid around the margin
 of the ulcer,  so as  to cover the surrounding areola;  and the separation of the
 sloughs must be encouraged by the continued application of yeast or chlorinated
 poultices.  When they have separated, and the surface of the sore has  cleaned,
 it may be dressed with a lotion composed of one grain of the sulphate of copper,
 and five of the watery extract of opium to  the ounce of water.   The granulations,
 which are very luxuriant  and vascular, will be found to  skin  over  with great
 rapidity.
   Should arterial hemorrhage occur, it must be arrested  by the application of a
 ligature to the bleeding point, but if this does not  hold, as will probably be the
 case from the softened state of the tissues, the actual cautery must  be  applied,
 or, the limb at last removed in the event of all other means failing.
   In some cases it happens that though the sloughing action is checked at one
 part of  the surface, it  has a tendency to  spread at another.  When  this is the
 case it may be necessary to apply the caustic or cautery repeatedly.   In others
 again, the sloughing action cannot be  stopped,  but opens  large arteries,  and de-
 stroys the greater part of the soft tissues of a limb, and then it  may be a ques-
 tion whether  amputation should be performed during the  spread of the  disease,
 or the patient left to die of hemorrhage or  exhaustion.  Such a contingency is
 not of common occurrence, but yet it may happen, and  the  operation  be  suc-
 cessful, as appears by the following case, though there would necessarily  be great
 danger from a recurrence of  the disease in the stump.   The wife of a  butcher
 applied at the hospital, with a  slight wound of  the forearm, inflicted by a hook.
 It was dressed in the ordinary way, but in the course of a few days she returned
 with extensive sloughing phagedaena of the part; she was immediately admitted,
 and the disease was arrested by the- energetic employment  of the local treatment
 above described; not, however, until after considerable destruction of the tissues
 on the inside of the forearm had taken place.   She left the hospital before the
 wound was completely cicatrized, and returned in a few days with a fresh attack
 of the disease more extensive and severe than the first, and which could not be
 permanently stopped, either by the actual  cautery or  nitric  acid.   The radial
 artery was opened and  required ligature, and the  whole of the soft parts, from
 the wrist to the elbow, were totally disorganized, and the bones exposed.   There
 was now very severe  constitutional irritation, and  the case was evidently fast
 hastening to a fatal termination.  Under  these  circumstances I  amputated  the
 arm midway  between the  shoulder and elbow; and, notwithstanding that  the
 local disease was progressing at the time of the  operation,  and the  great consti-
 tutional disturbance that  existed, the  patient having  a pulse  of 160 to  170, at
 which it continued for more than a fortnight, she made a good recovery; to which
 the free administration of stimulants greatly contributed.
  The constitutional treatment  of this  disease must have  for its object the re-
 moval of the combined state of debility and irritation in which we find the  patient.
 The bowels should  be kept freely opened by warm aperients; as nourishing a
 diet as the patient will  take,  with a liberal supply of stimulants,  should be
 ordered,  and these may be increased by the  addition of the brandy-and-egg mix-
ture, or of ammonia in proportion  as depression comes on.  At the same time,
I have found  great service from the  administration  of ten-grain  doses of. the 
352
GANGRENOUS  DISEASES.
 chlorate of potass in decoction of bark or of senega every sixth  hour, to which
 five or ten  grains of carbonate of ammonia may be given if there be much de-
 pression, or opiates from time to time, in  sufficient quantity to  allay pain and
 procure  sleep.

               GANGRENOUS STOMATITIS, OR CANCRUM ORIS.
   A peculiar phagedaenic  ulceration closely resembling the  kstdescribed affec-
 tion is occasionally met with in the mouths of ill-fed children living in low and
 damp situations, most commonly occurring between the second and sixth or eighth
 year, but more especially about the period of the second dentition.
   The mildest form of this affection presents itself as small, deep, and foul  gray-
 ish ulcers,  situated  on the  inside of the lips or cheeks, and attended with  a red
 spongy condition of the gums  and much fcetor of the breath.   In  these cases,
 good food  and air with nourishing diet, the  administration of bark, with the
 chlorate of potass, and the  use of chlorinated lotions, with the honey of borax,
 will soon bring about a cure.
   In the  more severe form  of  the  affection, the true  cancrum oris, we find
 commonly during  convalescence from some of the eruptive diseases of childhood,
 or if mercury have  been incautiously administered during  a weak state of the
 system, that one of the cheeks becomes swollen, brawny, tense, and shining, being
 excessively hard, and  presenting a red patch in  its centre.    In consequence of
 this swelling  it is  often difficult to open the mouth; but if the surgeon can gain
 a view of its  inside, he will see a deep and excavated foul ulcer opposite to the
 centre of the  external swelling, covered with a brown, pulpy slough.   The gums
 are turgid,  dark, and ulcerated, the saliva is mixed with putrescent matters, and
 as the ulceration in the mouth extends, the swelling sloughs and  a large, dark,
 circular  gangrenous cavity forms  in the cheek, opening through into the mouth;
 during all this time the child suffers little, but as the disease advances, commonly
 becomes drowsy, and at last dies  comatose.  When fully developed, this affection
 is most fatal.   Rilliet and Barthez state that not more than one in twenty cases
 recovers.
   The treatment of cancrum  oris is that of hospital  gangrene;  the sloughing
 mass should be deeply cauterized with nitric acid, but not with the actual cautery
 lest the  cheek be destroyed, the mouth syringed with the  dilute  chlorides, and
 the system  supported with beef-tea, wine, and ammonia, in doses proportioned to
 the age of the child.

                                   BOILS.
   A boil is a hard, circumscribed tumor of a violet or purplish-red color, flat
 tened though  somewhat conical, suppurating slowly and imperfectly, and always
 attended by a small conical central slough of cellular tissue, and  of the under
 surface of the true skin.   The tension and hardness accompanying this affection
 render it extremely painful and annoying to the patient.   It is most commonly
 seated in the thick skin of the back, the neck, or the nates.
   Boils most frequently make their appearance in young people, but are common
 enough at  all ages and are usually seen  in very plethoric  or in very enfeebled
 constitutions,  often  following some  of the more  severe  febrile diseases,  and
 attending convalescence from them.   In other cases, the system appears to have
 fallen into a cachectic state,  often without any evident cause, and this terminates
 by a critical eruption of boils.   A sudden change  in the habits of life, as from
 sedentary to active pursuits, a course of sea-bathing, &c, will also occasion them.
 They are commonly met with in the spring of  the year, but may  occur at all
 seasons, and are occasionally epidemic, as has been the case during the last two
years in London. _ When once they occur, they are often extremely tedious,  crop
after crop continuing to be evolved. 
CARBUNCLE.
353
  In the treatment of boils, the constitutional condition of the patient, on which
the disease is  dependent, requires to be  carefully attended  to.   As they most
commonly occur in a cachectic and broken state of the system, the preparations
of iron will be found to act beneficially.  This mineral may very advantageously
be administered in combination with ammonia and chlorate of potass, after which
the patient may be put upon a course of sarsaparilla or bark with the mineral
acids.  During this plan of treatment, it is necessary to keep the bowels free by
the occasional administration of an aloetic purgative.  If the boils occur in young
people who are otherwise tolerably healthy, or in plethoric individuals, this tonic
plan of treatment will not succeed; but saline aperients and the  liquor potassae,
in doses of from twenty to thirty minims twice  a day, will speedily remove the
affection.  In some cases yeast may be advantageously administered.
  The local  treatment of this disease is of a simple  character :  when  they are
forming, the most useful  dressing is a warm spirit lotion  kept applied with lint
and oiled silk; as suppuration comes on, a linseed meal poultice, either simple or
made with port wine, may be advantageously applied.  Most commonly the boils
may be  allowed to break, when  they discharge  a thick  pus, together with the
central core,  thus leaving a small cavity in and under the skin, which, however,
soon fills lip.  The surgeon may in some cases find  it necessary to  open them
with a crucial incision if  they are large, and  do not appear disposed to break of
themselves.

                               CARBUNCLE.

  A carbuncle consists essentially of a circumscribed and limited inflammation
of the subcutaneous cellular tissue, rapidly running into suppuration and slough.
Indeed, the formation of pulpy grayish or ash-colored sloughs, whether resulting
from the specific nature of the  inflammation, or from the strangulation of the
parts by the  accumulation of serum and blood is characteristic of the disease.
  A carbuncle  begins  as a  flat, painful,  hard, but somewhat doughy,  circum-
scribed swelling of the integuments  and subjacent  cellular tissue.   It is of a
dusky red hue, slightly elevated, but never loosing its flattened  circular shape;
as it increases in size, the skin  covering  it assumes a purple or  brownish-red
tint, becomes undermined, and  gives way at  several  points, forming openings
through which ash-gray or  straw-colored sloughs appear; and from which  an
unhealthy purulent discharge scantily issues.   The size of these swellings varies
from one to six inches in diameter; most  commonly they are about a  couple of
inches across.   Carbuncles are generally met  with on the posterior part of the
trunk or neck, being  rarely seen anteriorly, or on  the extremities.  I have,
however, had to treat a very large carbuncle situated  on the abdomen, and have
met with  them on  the shin, forearm, forehead, and often on  the face.  The
constitutional disturbance  attending this disease is always of the asthenic type,
the complexion is peculiarly sallow or  yellow, the  pulse feeble,  and tongue
loaded;  and  if the tumor be large, or is seated on the head, a fatal termination
may take place, the patient sinking into a state of low fever.
  This affection, with many points of resemblance, yet differs from boils in its
greater size, the dusky red of the inflamed integument, its broad flat character,
and the large quantity of  contained slough in proportion to  the small amount
of purulent discharge.   Unlike  boils, carbuncle is very rare  in  young  people,
and never occurs in plethoric individuals.  Indeed, it is always occasioned by,
and is by itself indicative of a broken state of the constitution, being usually met
with in individuals of a debilitated and irritable habit of body who have passed
the  middle period of life.
  The treatment of  carbuncle consists in  supporting  the constitutional powers
by the use of the preparations of bark in combination with  ammonia,  dietetic
stimulants, and  such nourishment as  the patient will take,  care  being b'ad at
                                    23 
354
ERYSIPELAS.
the same time to clear out the bowels well, as the intestinal canal in these cases
will often be found to be offensively loaded.   The local treatment  consists  in
makino- an  early and free  crucial incision  through the  whole thickness and
extent of the swelling.  If the sloughs that are now exposed be loosened, they
must  be removed, and if not  completely  detached, the  part  must  be covered
with  linseed and port  wine poultices, and when the sloughs  have  cleaned off
the sore that is  left  should be  dressed  with Balsam of  Peru  or  the unguent
Elemi.
  There are two other gangrenous diseases, the malignant pustule, and a peculiar
dry gangrene of the extremities, induced by eating spurred rye, and hence called
ergotism.   These affections, however, are so rarely met with in this country,
that their consideration need not detain us.
                         CHAPTER  XXVII.

                              ERYSIPELAS.

  Erysipelas is an  affection that so frequently and seriously complicates most
other surgical diseases and injuries, that its study is of the utmost importance to
the practical surgeon.  It usually manifests itself as a peculiar and distinct form
of inflammation; as much so  as  any of the other varieties, the adhesive, the
suppurative, the  ulcerative, or the  gangrenous.   Erysipelas,  or, as it may be
termed erysipeloid inflammation, including all those varieties of this  condition
that are usually spoke of as " diffuse," has a remarkable tendency to spread or
diffuse itself with great rapidity by continuity of surface, to change its seat, and
not  to be  limited by any adhesive action.   It may extend itself over any con-
tinuous surface; the skin, the cellular tissue, the mucous and serous membranes,
and the lining membrane of' arteries and veins are all liable  to be affected by it.
Hence, to describe it as a cutaneous disease, as has  often been  done, is in the
highest degree  incorrect and unphilosophical, and evinces a very limited acquain-
tance with its true nature.  Indeed, not only must we look upon erysipelas as a
disease that may affect  any surface, external or internal, but we must consider
the constitutional disturbance that takes place in erysipelas as the essential disease.
This, it is true, is usually complicated with diffuse  inflammation of the integu-
ment, and  then constitutes one of the ordinary forms of erysipelas.   But a con-
stitutional  fever may occur of precisely the same type as that which we observe
to precede and to accompany the local inflammation, without  any such compli-
cation.   This I had especial occasion to observe in a very fatal outbreak of ery-
sipelas that took place in one of my  wards in the spring of 1851.   On that occa-
sion, all the cases in which the cutaneous form of erysipelas appeared were marked
by severe constitutional disturbance, attended by such gastro-intestinal irritation.
But precisely the same type of general febrile symptoms, and the  mame irritation
of the stomach and bowels, occurred in patients in the same ward, in whom  no
local or surface evolution of the  disease took place, as in those  affected by the
ordinary cutaneous form of it.   The true pathology of the diffuse, low, or erysi-
pelatous inflammations has  yet to be made out.   They are all closely connected
with one another, and are evidently blood  or constitutional diseases, under what
ever name they go.  The similarity of causes, of  effects, and of constitutional
disturbance, makes it probable  that they are  all  essentially dependent on one
common condition of the blood, and that the particular local manifestation that 
CAUSES OF ERYSIPELAS.
355
occurs, whether  it be  erysipelas, phlebitis, low  cellulitis, or diffuse  abscess, is
secondary to this, and perhaps in some degree accidental.
  A chief characteristic  of this erysipeloid fever is its incompatibility with the
localization of any inflammation that may exist  at  or  occur after  its invasion
and hence, when it attacks the system, it causes  already existing inflammations
to assume a diffuse or spreading character, extending themselves over any surface
on which they happen  to be situated.  It is especially apt, in this way, to cause
those inflammations to spread which have  not  already been localized,  by the
deposit of adhesive matter.  Hence, recent wounds are  more liable to be affected
by it than granulating  ones, in which the  inflammation has already taken on a
plastic character which  requires to be overcome before the diffuse form can set in.
  The constitutional fever in erysipelas almost  invariably  at first  assumes the
sthenic form, but very speedily  runs into an asthenic or irritative  type, with a
quick feeble pulse, brown  tongue, pungent, hot  skin,  and  muttering  delirium.
The disease is truly an affection of debility; it is in consequence  of the want of
a sufficient degree of  power in the  part, or in  the system, for  the deposit of
plastic matter, and the limitation of the  inflammation by this,  that the  local
affection  spreads itself unchecked along the surface it  invades.  The tendency
that invariably exists in erysipelas to the occurrence of sloughing and suppuration
of the affected tissues, is a further  indication of the asthenic and low character
of the disease.   This  view of  the  nature of the  constitutional  disturbance in
erysipelas is of great importance in reference to the treatment of  the disease, as
it demonstrates  the necessity of not lowering  the patient's powers too much
during the early period  of the affection, when it  often temporarily  assumes a
truly sthenic character.
  Erysipelas is especially apt to become complicated with low visceral inflamma-
tion ; the membranes of the brain, the bronchi  and lungs,  or the  gastro-intes-
tinal mucous  surface,  are  commonly implicated in this way; and it is often
through these complications that death results.
   Causes.—Erysipelas may arise from causes existing in the patient himself, or
from the conditions  by which he is surrounded or to which he  is subjected.
Some persons appear to be naturally predisposed to erysipelas to so great a degree
that the application of cold, or slight stomach derangement, or a trivial superfi-
cial  injury may excite it.   This predisposition to  erysipelas most  commonly
occurs in individuals of a  plethoric  and  gross habit of body; those especially
who have a tendency to  gout appearing to be liable to the  ready occurrence of
the disease.   But this  predisposition is most generally acquired by  habitual de-
rangement of health, and is especially induced by any of the depressing causes
of disease, such as over-fatigue, anxiety of mind, night watching, and habitual
disregard  of hygienic  rules as  to diet, exercise, air, &c.   The habit of body,
however, in which erysipelas  is most frequently met with  as  a consequence of
very trivial exciting causes, is that which is induced by the habitual use of stimu-
lants to excess.  It is  more especially in  that state of  the system characterized
by an admixture, as it  were, of irritability  and of debility,  in  which  no  plastic
lymph is  deposited as the result of inflammation, but in which this  condition is
followed by a rapid tendency to the formation of pus and slough, and to extension
of disease in a  diffuse form,  that erysipelas is so very readily induced.  This
condition of body is met  with amongst  the laboring poor,  as  the result  of the
privation  of the necessaries  of life,  conjoined  with the  habitual  over-use of
stimulants and exposure to the various depressing causes of disease,  arising from
bad food, impure air, &c.   Amongst the wealthier classes  it occurs as a conse-
quence of high living, want of exercise, and general indulgence in luxurious and
enervating habits.
  Some diseased states of the blood appear to predispose, in the highest degree,
to the occurrence of erysipelas.   This is especially  the case in diabetes and in 
356
ERYSIPELAS.
oranular disease of the kidneys attended by  albuminuria.   In these  affections
erysipelas will occur  from the most trivial  causes; a scratch, the sting of an
insect, or any of the minor operations in surgery, more especially about the lower
part of the  body,  will occasion  it.   And not only is it  readily induced  in  this
way, but it will extend in an uncontrollable manner in these states of the system,
there being apparently in them  an utter want of limiting or reparative power in
any inflammation however set up:
  Amongst the circumstances that surround the  patient, and that  tend to  the
production of this disease, season of  the year and atmospheric changes exercise
a marked influence.   Not only  is erysipelas much more frequent in  the spring
and autumn than at other seasons of  the year, but we not unfrequently find it
coming on suddenly on the setting in  of cold easterly winds, or on the occur-
rence of sudden atmospheric vicissitudes.   So also erysipelas often  assumes an
epidemic character, as the result of those peculiar but,  at present, inexplicable
conditions of the  atmosphere, in which  disease generally assumes  a low type,
and  in which epidemic catarrhs, influenza, phlebitis, and  other allied affections
prevail.  Epidemic erysipelas is almost invariably of a low form,  and is very
commonly associated with some  peculiar train of visceral complication  that  dis-
tinguishes the particular outbreak of  the disease.
  But not only is  erysipelas epidemic ;  it is also contagious.   The contagion of
erysipelas, after having been repeatedly denied, can  I think  no  longer be corf
tested.   Travers, Copland, Bright, Nunneley, and others have adduced cases in
proof of its contagious character, and instances have repeatedly fallen under my
own observation, in which  erysipelas, often unfortunately of a fatal form,  has
been communicated to the servants, nurses, or relatives of patients affected by it.
A remarkable proof of the contagious nature of erysipelas occurred in the spring
of 1851, in one of my wards at the University College  Hospital.  The hospital
had  been free from any cases of the kind for a considerable time, when on  the
15th of January, at about noon, a  man was admitted under my care  with gan-
grenous erysipelas of the" legs, and placed in Brundrett  Ward.  On  my visit
two hours after his admission, I ordered him  to  be removed to a separate room,
and directed the chlorides to be freely used in the ward from which he had been
taken.  Notwithstanding these precautions,  however,  two  days after this, a
patient, from whom a necrosed portion  of ilium had been removed, a few weeks
previously, and who was lying in the  adjoining bed to that in which the patient
with the erysipelas had  been temporarily placed, was seized  with erysipelas, of
which he  speedily died.   The  disease  then spread to almost every case  in  the
ward, and proved fatal to several patients who had recently been operated upon.
In several  instances  patients were affected with the constitutional symptoms,
without  any appearance of local inflammatory action, but  characterized by  the
same gastro-intestinal irritation  that marked the other cases.
  But not only may erysipelas spread in this way from  patient to patient, but I
believe that any diffuse inflammation  may give rise to local erysipelas, and in its
turn be occasioned by it—a strong  argument  in favor of the allied nature of all
these affections.   Then again the contact of dead  or putrescent animal matters
with recent wounds may occasion it.  In this way I  believe the disease is  not
unfrequently originated in hospitals by  dressers going direct from the dead house
to the bedside of patients without  taking sufficient care to wash  their hands or
change their clothes.   For this reason  also it is of great  consequence that  the
same instruments be not used for practising operations on the dead, and perform-
ing them on the living body.                                        ,
  The principal exciting cause of erysipelas is certainly  the presence of a wound.
It is  chiefly recent wounds, however,  that are  affected by it;  when once the
adhesive or suppurative inflammation is set up, the wound  is not so liable to take
it on unless it be  in  bad constitutions, the formation of limiting fibrine appear- 
           VARIETIES  AND  SYMPTOMS  OF  ERYSIPELAS.        357

ing to lessen the liability  to the occurrence of the disease.   When erysipelas is
epidemic, it is well for the surgeon not to perform any operation that can conve-
niently be postponed until it is  less rife;  and in no case  should a patient on
whom an operation has recently been performed be put in a neighboring bed, or
even in the same ward, as a case of erysipelas.  The size of the wound has little
influence on the occurrence of erysipelas, which takes place as readily from a
small as from  a  large  one.   The more  severe  forms of erysipelas,  however,
chiefly occur in those cases in which the fascia? of the limbs are opened up, when
the disease may spread through the deeper  intermuscular planes of" cellular tissue.
Injuries about  the head and  hands are those that are most liable to be followed
by this disease.
  But though  we must constantly bear  in mind the constitutional  nature of
erysipelas, it will  be more convenient and practical to describe it as it affects
different tissues and organs.   With this view, we may divide it primarily  into
external and internal erysipelas.
  By external erysipelas is meant that variety of the disease which affects
the skin and subcutaneous cellular tissues.   This form of the affection has been
described with an absurd degree of minuteness so far as the transitory and acci-
dental characters of its duration, shape, and appearance, are concerned, by many
of the writers on  the Diseases of the Skin, who, in  their anxiety to record
minute  shades of difference in appearance, have entirely  lost sight of the  true
nature of the disease.  The division  adopted by Lawrence into the simple, the
cedematous,  and the phlegmonous forms, is  a  practical  arrangement that  is
commonly adopted by surgeons.   I prefer, however, and shall adopt the division
made by Nunneley in his very excellent work on erysipelas, as founded on the
true pathology of the affection.  He arranges  external  erysipelas  under the
cutaneous, the cellido-cutancous, and the cellular varieties.
   The cutaneous  erysipelas  is the  slightest form of the disease,  implicating
merely the skin;  it  comprises many of the species of erythema of  different
writers,  and corresponds to the simple erysipelas of Lawrence.
   The symptoms of this affection are as follows: A patient is seized with rigors,
alternate chills and flushes, followed by headache, nausea, a quick pulse, a coated
tongue, and hot skin; in from twenty-four to forty-eight hours the rash appears,
though  sometimes it comes out simultaneously with the constitutional disturb-
ance.  If there be a wound, the secretions of this  dry  up, and  the margins
become  slightly swollen, and  affected by the red blush.   If the disease occur
idiopathically without a wound, it most commonly appears  upon the face, next
upon the  legs, and lastly upon the trunk.   The rash is of a uniform but  vivid
rosy red hue, sometimes becoming dusky, and always disappearing on  pressure.
It usually fuses away into the color of the healthy skin, but is sometimes dis-
tinctly margined.   It is accompanied by some slight cedematous swelling, which
is often considerable  where  the cellular  tissue  is loose, as in the  eyelids and
scrotum, and  there is usually a stiff burning sensation in the part.   Vesicles or
blebs often form, containing a  clear but  hot  serum, which speedily  becomes
turbid, and dries into brawny desquamation.   The redness may  spread rapidly
along the limb or trunk, or if the face is affected, travel quickly from one side to
the other, causing such swelling of the eyelids as to close them, and giving rise
to much tensive pain in the  ears.  Sometimes the disease  disappears in one part
of the body, reappearing in  another.   This, which is the erratic erysipelas, is
often a dangerous form of the affection, occurring in advanced stages of pyemia,
and  indicating approaching  death.   In these varieties of  idiopathic erysipelas,
Arnott states that the fauces are always involved.   This  affection usually dis-
appears without inducing any serious mischief in the part  affected, but in  some
cases abscesses form, more especially in the loose cellular tissue of the neck and
of the eyelids.  In  other cases again, oedema of the part  continues with  some 
?;58
ERYSIPELAS.
irritability and redness of the skin and peeling of the cuticle; and in some rare
cases the simple erysipelas seems to take on a gangrenous or sloughing character,
especially about the umbilicus and genitals of young children.
   The constitutional symptoms of the cutaneous  or simple erysipelas present
every  variety between the sthenic and  asthenic forms  of inflammatory  fever.
When  the disease occurs in London it certainly  most frequently assumes a low
type.   There is also in most cases a good deal of derangement of the digestive
organs, the tongue being much coated, with tenderness about the epigastrium,
dark offensive evacuations,  and not unfrequently diarrhoea.   When the scalp is
affected, severe headache, with  symptoms of cerebral inflammation, are  commonly
met with.  Most  frequently recovery takes  place by the  gradual subsidence  of
the symptoms; this form of the disease seldom proving fatal unless the scalp  is
affected, and the brain consequently implicated.
   The  cellulo-cutaneous or phlegmonous erysipelas  differs from the variety just
described, in the degree  of  inflammation, and the depth to which the tissues are
affected.  The intensity of this form of inflammation is such as  invariably  to
terminate, if left to itself, in diffused suppuration and  sloughing of the tissues.
In depth it  invariably extends to the subcutaneous cellular  tissue, and, though
generally bounded by the fasciae lying beneath this, not unfrequently  implicates
these if they have been opened  up, extending to  the  intermuscular  cellular
planes, the sheaths of the tendons, and other deep structures of the limb or part.
   The  cellulo-cutaneous or phlegmonous erysipelas is ushered in by the ordinary
symptoms of inflammatory fever, accompanied or followed by the signs of severe
inflammation in the part  affected.  The redness is uniform, of a deep scarlet
hue, and pretty distinctly bounded; the pain is from the first pungent  and burn-
ing, though it may soon assume a  throbbing  character; the swelling, at first soft,
diffused, and admitting of distinct pitting, soon increases, and becomes tense and
brawny, the  skin  being  evidently stretched to  its  full  extent, and  the limb
appearing perhaps to be double its natural size.   Large vesications or blebs con-
taining sero-purulent fluid, sometimes of a sanious tinge,  make their appearance
in many cases.  This is  the condition  that usually continues up to the sixth or
eighth  day after the invasion of the disease,  during the whole of which time the
constitutional symptoms have presented the  ordinary type of sthenic  inflamma-
tory fever; about this time, however, a change commonly takes place,  either for
better or worse.   If, under  the influence of  proper treatment, and  in a tolerably
healthy constitution, the inflammation subsides, resolution  takes  place, with  a
gradual abatement of all the  symptoms.   If, however, as usually  happens, the
disease runs on to  more or less  sloughing or suppuration of the part, no increase
of the swelling, pain or redness takes place, but, on the contrary, some  diminution in
these signs may occur, giving rise to an apparent, though deceptive, amendment
in the patient's condition.   The  skin  becomes darkly congested, and the part,
instead of being tense and  brawny, has a somewhat loose, soft, and boggy feel,
communicating a semi-fluctuating, doughy sensation to the fingers.  This change
from a tense  brawny state to a semi-pulpy condition is indicative of the forma-
tion of pus and slough beneath the integument, and should always be  anxiously
watched for  by the surgeon.   It must be remembered that it occurs without
any material  change in the size, the color, or the  general appearance of the part,
but  can only be detected by careful palpation of it; hence the necessity of the
surgeon daily examining with his own fingers the state of  parts inflamed, and
neither trusting to  the  reports of others, nor to the general appearance of the
diseased structures, for the probable condition of the subjacent tissues.  If an
incision be now made into the affected part, the cellular membrane  will be found
loaded  with an  opalescent  fluid  distending  its  cells, but not flowing from the
wound:  the retention of this  fluid in the cellular tissue giving  a gelatinous
appearance to the sides of the incision, which rapidly degenerate into slough and 
          VARIETIES  AND  SYMPTOMS  OF  ERYSIPELAS.        359

pus.   If the  alteration  in structure have advanced to a stage beyond this, the
cellular tissue will be found to have been converted into dense masses of slough,
lying in the midst of thin and unhealthy ichorous pus.  These have not inaptly
been compared in appearance to  masses of decomposed tow, of  wet chamois
leather,  or to the membranes of a foetus a few months  old; whilst these changes
are going on below the surface,  the skin, at first congested, becomes  somewhat
paler, and assumes a white or marbled appearance, rapidly running into  black
sloughs, and being  undermined  to an immense  extent  by large  quantities of
broken-up cellular tissue and  of  ill-conditioned pus, without any appearance of
pointing, however extensive the  subcutaneous mischief may be.   These destruc-
tive changes expose muscles, fasciae, and bloodvessels,  and may induce necrosis
of the bones or destroy the joints.   They occur most readily in those parts of the
body that possess the lowest degree of  vitality, and hence are more common in
erysipelas of the legs than  in the same affection of the scalp.   If the patient
recover, there  will be tedious cicatrization of the deep cavities  that are left, or
considerable oedema often  of a solid character,  a kind of false hypertrophy of the
part, which may continue  for some considerable time.  In other cases again there
may be such extensive local destruction or gangrene of the soft tissues, with  expo-
sure and death of the bones or suppuration of the joints, that amputation of the
limb may be required  as a means of saving the patient's life.  No operation of
this kind, however,  should ever be practised for the after-consequences of  erysi-
pelas, unless these be  strictly localized, with no tendency to  spread, all specific
constitutional fever  having been  completely removed except such as is of a hectic
character, and dependent on the  exhausting influences of the suppuration and
disorganization of the tissues.
   During the progress of  these local changes, the constitutional symptoms have
assumed corresponding modifications.  At  first of an  active  inflammatory cha-
racter, when suppuration  and sloughing have set in,  the fever often suddenly
assumes an asthenic form, although in some cases there is no diminution in  the
severity of the symptoms, until after an attempt for a few days to bear up against
the exhausting influence of the disease, the constitution gradually gives way, and
death speedily supervenes.  If the patient survive  the stage of sloughing, and
if the discharge continue  abundant, hectic with diarrhoea, gastro-intestinal irri-
tation, metastatic abscesses or pyemia, may carry him off.   If recovery eventually
take place, it may be at the expense of a constitution impaired and  shattered for
years.   This disease is most dangerous in the old and infirm, or in young chil-
dren.  The immediate danger is  always greatest when  the head is affected, from
the extension  of the disease to the membranes of the brain, and the  supervention
of erysipelatous arachnitis.  The remote danger from the effects of suppuration,
necrosis, and  inflammation of the joints is greatest when the lower extremities
are the seat of erysipelas.
   A variety of the cellulo-cutaneous erysipelas has been described as cedematous
erysipelas.  By this is meant not merely that effusion  into  the cellular tissue
which occurs  in all the varieties  of the  disease, but  a peculiar form, specially
marked  by oedema of the cellular tissue, with less inflammation of the skin than
usual.   There is much swelling, which pits deeply, with but little pain or ten-
sion, and but moderate redness of the skin ; the constitutional symptoms are less
marked  than in the  other varieties of  the disease;  it is principally met with in
old people, or  in persons of a dropsical tendency, in whom it occurs  especially
about the legs, scrotum, or labia, sometimes giving  rise, by the  effusion of a
sero-plastic fluid, to  permanent and solid enlargement of these parts.
  The cellular  erysipelas, or, as it is often termed, diffuse inflammation of the
cellular  tissue, or cellulitis, is a disease that has been  particularly  described by
Duncan,  Arnott, Lawrence, and  Nunneley.   It always arises from a  wound or
injury, often,  however, of an apparently trivial character, and  most commonly 
360
ERYSIPELAS.
affects the subcutaneous  cellular  membrane, though occasionally it extends  to
the sub-aponeurotic tissue, and  then is a more severe  and dangerous affection.
Though commonly arising as a consequence  of ordinary injuries, it is especially
apt to follow those in which there has been any inoculation of animal poisons,  as
in dissection wounds, the  stings of insects, and the bites of venomous reptiles.
In whatever way arising,  it is characterized  by the rapidity and extent  of the
sloughing of the affected tissue,  and by great depression of the powers  of the
constitution.  That the diffuse inflammation of the cellular tissue, whether it is
limited to a finger, or implicates  the cellular membrane of half the body, is a
variety of erysipelas affecting this membrane primarily, and the skin secondarily,
there can be no doubt.   The points of resemblance between cellulitis and ery-
sipelas, have been well shown by  Nunneley.   Not only are the local effects pre-
cisely the same in the  two diseases;  the same swelling, tension, infiltration  of
pus, and  formation  of gangrenous shreds  and sloughs,  but the constitutional
symptoms, though differing perhaps in degree, present no variety as to character.
The results also  are identical, there being  the  same  impairment  of structure
locally, the  same tendency to involve parts at a distance, and to the  formation  of
secondary abscesses.   So also these two diseases occur in the same constitutions,
in the same states of the atmosphere, and in the same situation;  one form  of
disorder may produce  the other, and, lastly, the same treatment is  required for
both  affections.
   The symptoms of cellular erysipelas are great swelling, tension,  and pain  in
the limb, which feels brawny in  some parts, cedematous in others.   The skin,'
which is slightly reddened in patches, has a  mottled appearance, and speedily
runs into blackish sloughs.   The  extent to which the disease may spread varies
greatly;  when once it has set  in, it commonly runs rapidly up the whole  of a
limb, extending also to the sides of the trunk; in other cases, again, its violence
appears to be principally expended at a distance from the seat of injury.   Thus,
in a  case of a punctured wound of the finger, the diffuse inflammation  may
principally take place in the  extended planes  of cellular tissue about the axilla
and sides of the chest.   It is important to bear in mind  that this  form of ery-
sipelas sometimes affects the  internal planes of cellular tissue.   This may happen,
for instance, in the fascia; of the pelvis  after lithotomy, or in  the  anterior me-
diastinum, after operations at the  root of the neck.  The sloughing often occurs
with  remarkable rapidity  in the course of thirty-six or forty-eight hours, the cel-
lular  membrane being broken down into ill-conditioned  pus and shreddy sloughs,
more especially when the disease has resulted from the inoculation of an animal
poison.  Death may in such cases  occur in two or three days; in other instances,
again, several weeks elapse before a  fatal  result declares itself.
   The constitutional symptoms are  those of asthenic fever in the most marked
degree, a quick and feeble pulse,  brown  tongue, and muttering delirium, being
early concomitants of this affection.
   The diagnosis of  the  various  forms of erysipelas is  generally  easily made.
From the exanthemata it is  distinguished by the  character of the eruption, its
limited extent, and usual complication with injury.  From inflammation of the
veins, or of the absorbents, the diagnosis is not always so easy, more especially
as the two conditions frequently co-exist.   If it  be a vein that is  inflamed, the
general absence of cutaneous  redness, the  existence of a hard round  cord, and the
tenderness along the course of the vessel, are sufficient to establish the diagnosis.
In inflammation of the absorbents, the redness will be found not to be uniform,
but to consist of a number  of  small  and separate red streaks, running in the
direction of the lymphatics, and affecting the glands towards which they course;
these  two affections, however, erysipelas of the skin and inflammation  of the
absorbents,  are almost invariably conjoined; hence a definite diagnosis is not of
much importance. 
DIAGNOSIS, PROGNOSIS, AND TREATMENT  OF  ERYSIPELAS. 361

  The prognosis in any case of erysipelas depends on a variety of circumstances.
The form of the disease influences greatly the result, the cutaneous variety being
attended with least danger, the cellular with the most.   Much, however,  depends
on other circumstances,  such, for  instance, as  the  seat  of  the affection; that
attacking the head and lower limbs  being the most dangerous; when the head is
affected encephalitis being apt to ensue.   When the legs  are extensively impli-
cated, sloughing of the skin and cellular tissue, with  denudation of the bones
and destruction of the joints, may occur.   The disease, in all its forms, is most
dangerous at either of the extremes of life.  The previous state of health of the
patient also influences greatly the result.   If the constitution be sound,  very ex-
tensive mischief may  be  recovered from;  if, on  the  other hand, it is depressed
or broken by want of  the necessaries of life, by  fatigue, over exertion, or indul-
gence in stimulants, a very slight amount of disease  may probably prove fatal.
The most  dangerous  complication of erysipelas,  and one which, when  it exists
almost precludes the hope of recovery, is a granular state of the  kidneys with
albuminuria.   I have never  seen any patient  laboring under this disease, and
attacked with  erysipelas, escape  with life;  the sloughing and suppuration run-
ning  on unchecked by any treatment  that could  be adopted.  The particular
type the erysipelas may  assume,  and the occurrence of gastro-intestinal or pul-
monary complications, will also seriously affect the  result.
   The treatment of erysipelas must always be conducted with reference to the
low character of the local inflammation, its tendency to run into suppuration and
gangrene, the  asthenic type that the constitutional fever readily  assumes, and
the frequent complication of  visceral inflammations of a congestive form.  The
apparent intensity of the local inflammation must  not lead the "surgeon into the
fatal error of employing  an  over active antiphlogistic  treatment,  more particu-
larly if  the disease be epidemic, when  it  always  assumes a low  type.  In the
treatment of this affection it is especially important to  look to the  future, and to
remember that if active  depletory measures are employed early with  a view of
lessening the present  disease, it  will be  at the risk of inducing more extensive
sloughing, and perhaps to lower  the patient's powers to such a degree as to pre-
vent his bearing up under the depressing influence of the  after-consequences.
   In  the treatment of the cutaneous or simple form of erysipelas, we  must in the
first instance clear out the- stomach  and bowels by a calomel  and colocynth pill,
followed by some saline aperient.  If the patient be young, robust, and the dis-
ease be of a somewhat sthenic character, he should be kept on a mild diet, and
have salines, with small  doses of antimony, administered every fourth or sixth
hour.   If the  patient be advanced in years, and the disease assume a lower form,
no antimony should be given, but effervescing salines or the acetate of ammonia
in camphor mixture may be administered.   If the disease from the  first assume
a low type, or if it subside into this,  the  carbonate of ammonia  in five or  ten
grain  doses should be added to  the preceding mixture;  in which the  decoction
of bark may then  be  substituted for the camphor julep.   In  many of the low
forms of erysipelas, medicines are not well borne by the  patient, the  stomach
rejecting them, and then I  have seen the best possible results follow  the free
administration of the brandy-and-egg mixture, to  which I am in the habit of trust-
ing in the majority of these cases.  During the progress of  the disease, simple
purgatives must be given  from time to time.  When this  form of erysipelas
occurs in persons of a  gouty habit, it may often be  advantageously  treated by  the
administration of colchicum in salines.
  The local treatment of this, as of every variety of erysipelas, is of equal im-
portance with  the constitutional  management.  Warm applications assiduously
continued, especially  poppy  and chamomile fomentations applied by means of
flannels  or spongio-piline, afford the greatest possible relief.   Cold  lotions should
never under any  circumstances be  employed; they not only act  injuriously by 
362
ERYSIPELAS.
lessening the vitality of the part, and thus  favor local sloughing, but they may
chance to  cause a retrocession of the disease, and  the  consequent affection of
some internal organ.  The local abstraction of blood and of serum from the in-
flamed part, by the plan introduced  by Sir  11. Dobson, of rapidly making with
the point of a lancet a large number of small punctures, from a  quarter to half
an inch deep, is of much value, by lessening the tension  and swelling, and con-
sequently  diminishing the  inflammatory  action; a  warm fomentation-cloth or
poultice should be laid over the punctures so as to encourage bleeding, and the
escape of serum.  Astringent applications to  the inflamed surface, such as a strong
solution of the nitrate of silver, are  recommended by some surgeons.  I have
seen them pretty extensively employed by the late  Dr.  A. T. Thomson, but not
with any very marked success.   A boundary line of nitrate of silver is occasion-
ally drawn around the inflamed part, with the view of checking the extension of
the disease.  I have  often done this, and seen it done by others, but never ap-
parently with any benefit;  and have now  discontinued the  practice  as a useless
source of irritation.  The application of a bandage is occasionally necessary after
the disappearance of the  erysipelas, in order to remove the oedema that results.
   In the treatment of the  cellulo-cutaneous  erysipelas, more energetic constitu-
tional and local  means are required than those just described.  In  the  early
stages of the disease, our object is to prevent the inflammation running into gan-
grene of the affected  tissues.   The  fever being  at this  period  commonly of a
sthenic  character, the more active administration of purgatives, antimonials or
effervescent salines is required.   If the patient be young and strong, and more
especially if the head  be seriously engaged,  bloodletting may be had recourse to;
but this should be cautiously practised, lest  the powers of the system be rapidly
reduced.   As the disease  advances, and  symptoms of more or  less depression
come on, it may be necessary to effect that gradual change from a depletory to a
stimulating plan of treatment that has already been described in speaking of the
management of inflammatory fever; in doing this, the pulse and the tongue must
be  our guides;  as the one  becomes  feebler and the  other browner, so must am-
monia, bark, and especially the brandy-and-egg mixture, be administered.   In
the more  advanced stages  of  the disease, when sloughing and  suppuration are
fully established, our  sole  object must  be  by nourishing  diet, and  the  use of
stimulants and tonics, to  bear the  patient through  the depression and  subse-
quent hectic that ensue.
   The local treatment of the cellulo-cutaneous or phlegmonous erysipelas, must
be  conducted on essentially the same plan as  that of the cutaneous variety, though
with the employment of more active means.  The  part  affected must be kept
at rest,  must be  elevated  if it be a limb, and have hot  chamomile and poppy
fomentations assiduously applied;  cold being more prejudical here even than in
the last form of the disease.   In this way the swelling and tension may perhaps
be removed, and  the sloughing of the cellular tissue prevented.   In the majority
of cases, however, other means will be required to effect this, and with this view
none are more efficacious than incisions made into the part;  by  these an outlet
is afforded for the blood  and effused serum  which by distending the vessels and
cells of the part, produce strangulation of its tissues and consequent sloughing.
This mode of practice, originally introduced by Mr. C. Hutchinson, is generally
allowed to be the most effectual means we possess for the prevention of sloughing;
hence the incisions should  be  made early,  before there  has been time  for the
tissues  to  lose  their  vitality.   So  soon, indeed, as they have become brawny,
indurated, and tense,  incisions properly made and placed will afford the greatest
possible relief to the part and  the patient, taking down the tension by their gap-
ing, and the swelling by the exit they afford the blood and serum.   Much diffe-
rence of opinion has existed among surgeons, as to the extent to  which incisions
should be practised  in  these  cases.  Some  recommending that one long cut 
SPECIAL  FORMS  OF ERYSIPELAS.
363
should be made through  the inflamed structures;  others  contending,  on the
contrary, that a number of small incisions better answer the proposed end.   The
objections to the long incision are, that so considerable a wound not only inflicts
a serious shock upon the system, but that the loss of blood from it is often so
great as to be  of serious, and even of fatal  consequence to the  patient, cases
having occurred in which life has been lost from this cause, or the hemorrhage only
arrested by the ligature of the  main artery of the limb,—and also that a single
Ion"- incision does not relieve tension so effectually as a number of smaller ones.
These incisions consequently should  be of limited  extent, from two to  three
inches in length;  at most they should not extend deeper than  into  the gela-
tinous-looking  subcutaneous  cellular tissue,  unless it happen  that the  disease
have extended beneath  the  fascia, when they may also be carried  through it.
Mr. South recommends  that the incisions should be so  arranged in fours, as to
enclose a diamond-shaped space, and  states that in this way the
greatest relief is given to the tension of the part; after the incisions  |
have been made, the part should be well poulticed and fomented so
as to facilitate  the  escape  of  serum.  As it is not the object of the surgeon to
draw blood in  these cases, any undue amount of hemorrhage should be arrested
by plugging the wound.   After suppuration  and sloughing have  taken place, as
indicated by a boggy feel  of  the parts, free incision should be made in order to
let out the pus and sloughs.   After  this the skin will  be found  to be  greatly
undermined, blue,  and  thin, with matter bagging in the more dependent parts;
if so,  egress  must  be  made  for it by free  counter-openings.   During the
after-treatment frequent dressing is necessary so as to prevent an accumulation
of pus; and the sloughs must be removed as  they form.   Care should be taken
not to destroy any of the  vascular connexions of the skin with subjacent parts,
but in order to get proper cicatrization it will  often be found necessary to lay
open sinuses, or to divide  bridges of unhealthy  and  blue  integument stretching
across chasms  left  by the removal of the gangrenous cellular tissue.   If the loss
of  substance be great,  the cicatrix  that forms  may be weak, imperfect, or so
contracted as to occasion great deformity of the limb.  In other cases again, the
diseased state  of the bones and joints may be  such as to call for ultimate amputa-
tion, either in  consequence of the local deformity and  annoyance, or in order to
free the constitution from  a source of hectic and of irritation.   Under all circum-
stances, the patient's health will usually continue in  a feeble and shattered state
for a considerable  time after recovery from  this form of erysipelas,  requiring
change of air and great attention to habits of life, a nourishing diet, &c.
   In  the treatment  of  the cellular variety of erysipelas, it is  usually necessary
to  administer  stimulants  early;  ammonia, wine, or brandy, may be required
from the very  first.  The  surgeon must judge of this by the constitutional con-
dition of the patient, and more  particularly by the state of his pulse and tongue.
The local treatment is precisely of the same kind as that adopted in phlegmonous
erysipelas, except that the incisions require to be made earlier and perhaps more
freely;  in all other respects,  there is no difference between the general manage-
ment  of the  two forms  of the disease.

               SPECIAL  FORMS OF EXTERNAL ERYSIPELAS.
   Erysipelas of newly-born  infants is occasionally met  with, more  particularly
in lying-in-hospitals, or in situations where the mother and child are exposed to
depressing causes of disease.    It usually makes  its  appearance a few  days after
the birth, at first about  the abdomen and genitals, but spreads rapidly over the
whole of the body, being  characterized by a dusky redness, which rapidly runs
into gangrene  of the affected  tissues.   It has been supposed to arise from  inflam-
mation  of the  umbilical  vein, or of the umbilicus itself.  It is an  extremely
fatal affection, owing to the feeble  vitality of the child, and  presents but few 
364
ERYSIPELAS.
points for treatment;  change of air and of nursing, with the administration of a
few drops of Sp. ammoniae or brandy from  time to time, being all that can be
done.
  Phlegmonous erysipelas of the head is of very frequent occurrence from slight
injuries  or operations about the  scalp and face,  more particularly in  elderly
people and those of unhealthy constitution.  In this form of erysipelas there are
two special sources  of danger;  one is  from sloughing  of  the  occipito-frontalis
muscle, the other from  inflammation  of  the  membranes  of the  brain.    The
occipito-frontalis sloughs, in consequence of the pressure to  which it is subjected
by the swelling of the planes of cellular tissue between which it lies ;  and the
encephalitis occurs apparently  by the  extension of the inflammation inwards.
In the  treatment  of  this affection more  active  antiphlogistic means,  such as
venesection with salines and antimony, are required than in the management of
other forms of erysipelas.  With the view of preventing  sloughing of the muscle,
a free crucial incision should be made through the scalp down to the bone, the
head, of course, having been shaved at the onset of the disease.
  Bagging of matter must be prevented by free counter-openings, and the appli-
cation of pads and bandages wherever it is likely to occur.   However much the
scalp may be undermined, or the bones of the cranium exposed, adhesion usually
takes place, and the vitality of the parts is preserved.
  Erysipelas of the scrotum, the "inflammatory oedema,"  so well described by
Liston, is of  frequent occurrence, as  the result  of wounds, ulcers,  and other
sources of irritation in this neighborhood.   In this affection the  scrotum swells
to a  large size, being  uniformly red, but with  a semi-transparent glossy appear-
ance, pitting readily on pressure, and feeling somewhat soft and doughy between
the fingers; the integuments of the penis are also greatly  swollen and cedema-
tous, and sometimes the  inflammation extends  to the cellular tissue of the cord.
The chief characteristic of this form of erysipelas is its tendency to run  into
slough without any previous brawny or tense condition of the parts, the  dartos
becoming so distended with  sero-plastic fluid that the circulation through it is
arrested  and  its tissue  loses its vitality.  When an incision is made into it in
this  condition it scarcely  bleeds, and the sides of the wound present a yellowish-
white gelatinous appearance.   The treatment  of erysipelas of the scrotum is
simple; it consists in making a free incision about four inches in length  from
behind forwards on either side of the septum, taking care, of  course, not to go
so deep as to wound the testes; the part must then be supported on a pillow, and
well poulticed and fomented.   If this incision be not made at once, a great part,
or even the whole of the scrotum may slough away, leaving the testes and cord
bare; under these unpleasant circumstances, however, the  parts will  often with
great rapidity cover themselves with  a new integument.  The oedema of the
penis usually subsides of itself,  or by making a few punctures  in it.   Should its
integuments,  however, threaten to slough, a free incision  must be made into it,
or the prepuce be slit up.
  Erysipelas  of the pudenda is occasionally met with in ill-fed unhealthy chil-
dren in whom cleanliness is neglected.   The  parts become of a dusky or livid
red,  swell considerably, and quickly run into  gangrene, which spreads  up the
abdomen or down the nates.  It may prove fatal by inducing peritonitis or ex-
haustion.   In the treatment, ammonia, bark, and the   chlorate of potass, with
good nourishment, and a little wine, are the principal means to be employed, at
the same time that yeast or chlorinated poultices are applied locally.
  Erysipelas of the fingers, or as it is commonly  called  "whitlow," is a frequent
affection in old and in young people, either occurring spontaneously in cachectic
constitutions, or arising from the irritation produced by scratches, punctures, or
the inoculation of  the part with  poisonous  or  putrescent  matters.   It is most
common in the spring of the year, when, indeed, at times it appears to be epi- 
SPECIAL  FORMS  OF  ERYSIPELAS.
365
dcmic, large  numbers of persons  suffering  from it without any very apparent
local cause.
  That whitlow is truly an  erysipelatous affection of the fingers appears to be the
case for  the following  reasons :  1st. Because the causes,  whether of  season,
infection, or  local irritation, appear  to be  the same in  both affections.   2dly.
The constitutional disturbance is always very severe for so slight a disease, and
assumes the same character of speedy depression that we observe  in erysipelas.
3dly.  The inflammation of the affected finger is  invariably  diffuse, never being
bounded by adhesion, but always tending to terminate in suppuration and slough-
ing.  And, lastly, so  soon  as  the disease spreads beyond  the affected finger, or
to the back of the hand, it assumes  a  distinctly erysipelatous appearance  and
character.
   The inflammation of whitlow is in many cases confined to the pulp of the finger,
commencing  in the dense cellulo-fibrous tissue forming this, and often arising from
a very slight injury, as the prick of a pin or splinter, but not unfrequently with-
out any traumatic cause.  The part  becomes  extremely painful, hard, red, and
swollen; it then  suppurates to a limited extent, with some sloughing of the cel-
lular tissue.   In many cases the ungual phalanx, which is imbedded  in the  cellulo-
fibrous digital pulp, necroses when this sloughs; there  is usually some inflamma-
tion of the lymphatics of the arm accompanying this affection, and  not unfre-
quently a good deal of constitutional fever and irritation.
   In the more  severe cases of whitlow the  inflammation, which is of  an exces-
sively painful character, owing probably to the tension of the parts, extends to
the sheaths of the tendons, and then constitutes an affection that is fraught with
danger to the utility of the finger or hand.   In these cases the whole finger
swells considerably, becomes red and tense, with much throbbing and shooting
pain;  the inflammation rapidly extends to the dorsum of the hand, which be-
comes puffy,  red,  and swollen, representing the ordinary characters of erysipelas.
Although the palm be greatly swollen, it usually preserves  its natural color, or
becomes of  a dull white, owing to the greater  thickness of the  cuticle in this
situation.   Pus rapidly forms, both in the  finger and hand, and finding  its way
into the sheaths of the tendons, will spread up the forearm under the annu-
lar ligament.  There is usually no fluctuation to be felt in the finger, even though
pus may have formed, but in  other parts of the hand it may readily be detected
in  the usual  way.  In these cases there is always much sloughing conjoined with
the suppuration,  the cellular tissue of the finger and hand, the  tendons or their
sheaths, and the  palmar fascia, being all more or less implicated.   In many cases
the joints of the fingers are destroyed, and the phalanges necrose, or if  this do
not happen,  the  tissues of the part  may be so matted together as the result of
sloughing and suppuration, that rigid and contracted fingers, or a stiff and com-
paratively useless condition of the hand, may be permanently left.
   In the treatment of this affection, the patient should be well purged, and kept
upon a strictly antiphlogistic plan during the early stages.  At the  same time the
inflamed finger should be freely leeched, and then alternately poulticed and soaked
in  very hot  water for twenty-four or forty-eight hours, being kept during the
whole of  this time in an elevated position.   In this way the  inflammation may
be sometimes cut short at its  onset;  should  it,  however, continue to progress,
the finger becoming hard,  with much throbbing, a free longitudinal incision must
at once be made  along either  side of it, so as to relieve tension and prevent slough-
ing.  This, though a painful procedure, should never be omitted, on account of the
importance of the preservation of the full utility of the part.   The incision is best
made from the proximal towards the distal end of the finger, so that if the patient
make an attempt to withdraw the hand during the operation, he will rather facili-
tate the cut  being  made than otherwise.  In making these incisions, however,
the sheaths of the tendons should,  if possible, be avoided;  if these be  opened, 
366
ERYSIPELAS.
 the  tendons will probably slough, and the finger be left in  a  permanently ex-
 tended and rigid state.   The finger must then be well soaked in hot water, and
 poulticed.   In this way the inflammation maybe arrested, and sloughing happily
 prevented.   Should, however, matter have formed, this must be  let out  as it
 accumulates, and all hardened and sodden cuticle peeled from the part.   After
 the opening has been made, and  any sloughs that  have formed come  away, it
 not unfrequently happens that a large and fungous granulating mass sprouts up;
 this will, however, gradually subside, as  the swelling of the finger goes down
 and the inflammation abates.  If the nail  become loosened, it had better be re-
 moved, as it may otherwise keep up irritation.   It must not, however, be torn
 off if adherent, but then merely scraped and cut away so far as loose.   When
 the whole  of a finger is affected, the hand should be placed on  a pasteboard
 splint so soon as the inflammation has been  somewhat subdued, lest  contraction
 of the affected finger ensue, which may  eventually extend to  the neighboring
 ones.
   When the joints are implicated, destruction of the cartilages commonly ensues,
 but  yet,  by position, and rest on  a  splint, a tolerably  useful, though stiffened
 finger may be left.   When the  bones are implicated, some operative procedure
 usually becomes eventually  necessary.  If the ungual phalanx alone be necrosed,
 it may be excised through an incision on the palmar side of the finger, the  pulp
 and nail being left.   In this way I have often preserved a finger that must other-
 wise have been removed. Amputation of the finger at the metacarpophalangeal
 articulation will usually be  required when the second or proximal phalanges are
 involved, though here, partial operations by cutting and scraping away the dis-
 eased bone, may sometimes be usefully done.   During the later stages of these
 affections, tonics, good diet, and stimulants will be required for the re-establish-
 ment of the health.

                          INTERNAL ERYSIPELAS.

   By internal erysipelas is meant those forms  of diffuse inflammation which
 affect the mucous or serous surfaces, or the lining membranes of arteries, veins,
 and lymphatics.
   The mucous surface that  is chiefly affected by this disease, is that covering the
 fauces, the pharynx, or the larynx.
   Erysipelas  of the fauces may occur in consequence of the disease  spreading
 from the head and face to these parts, or  it  may commence as a primary affection,
 occurring perhaps at the same  time that the rash appears on the cutaneous  sur-
 face, or on some distant part of the body.  When the fauces are erysipelatous,
 they present a bright crimson or scarlet color, with some swelling and thickening
 of the  soft palate and uvula.  There  is also most commonly some  huskiness or
 complete loss of voice, and  occasionally some croupy symptoms.   At the same
 time there is a good  deal  of low constitutional fever, with a pungent hot  skin
 and quick pulse.  This form of erysipelas is of a peculiarly contagious character,
 and occurs not unfrequently in the attendants of those who are laboring under
 some of the other varieties of the disease;  of this I have seen numerous instances.
In many cases, also, it is  epidemic, spreading through a house, and affecting al-
most every inmate.   In the treatment of this affection, the best results  are ob-
tained by sponging the inflamed  parts freely with a strong solution of the nitrate
of silver;  and, if there be much constitutional  depression, administering full
doses of ammonia, with camphor or bark.  Should the disease go  on to slough-
ing, constituting some  of the  forms of  " putrid sore throat," which not unfre-
quently happens, the mineral acids and bark, with chlorinated port-wine gargles,
and the brandy-and-egg mixture  for support, will be found most useful. In many
cases, this_disease continues limited to the palate and fauces; but in others, it
extends either upwards or downwards.   It may extend upwards  through the 
INTERNAL ERYSIPELAS.
367
nares, out of the  nostrils, and thus spread over the face and head.  It may ex-
tend downwards,  affecting the gastro-intestinal membrane, or more frequently
implicating the larynx.
  Erysipelatous laryngitis, as described by Ryland, Budd, and others, is an ex-
tremely dangerous affection.   The inflammation in  these  cases commencing in
the fauces, rapidly spreads to the mucous  membrane and loose submucous cellu-
lar tissue, external to, and within the larynx, giving rise to extensive cedematous
infiltration of these parts with sero-plastic fluid,- which, by obstructing the rima
glottidis, may readily suffocate the patient.  In consequence of this special  ten-
dency to oedema, the disease has by  many writers been termed " cedematous
laryngitis."   After  death, in these cases, the  submucous cellular tissue of the
fauces, that about the base and fraena of the epiglottis, and especially that which
covers the posterior part of the larynx, will be found to be distended with serum
or a sero-puriform fluid.   This infiltration occupies the rima of the glottis, and
extending into the interior of the larynx, gives rise  to such swelling that its
cavity is nearly obliterated.   Great as the swelling may be, however, in all these
parts, it never spreads below the true vocal cords.   This fact, which is  of con-
siderable importance, is owing to the mucous membrane coming  closely  in con-
tact with, and being adherent to,  the fibrous tissue of which these are composed,
without the  intervention of any submucous cellular tissue.  The progress of this
cedematous inflammation of the mucous  membrane and loose submucous tissue
in these situations, is often of an amazingly rapid character, the  swelling being
sufficient to  induce suffocation at the  end of thirty-six or forty-eight  hours, or
even sooner.   If  the patient be not carried off in this  way, there will be a great
tendency to  suppuration and sloughing of the affected tissues, leading perhaps
eventually to death from absorption of pus, and low constitutional fever.
   The symptoms  of this affection are strongly marked :  the patient, after being
attacked with erysipelas of the  fauces, attended by some difficulty and pain in
deglutition, with huskiness of the voice, is seized with more or less difficulty in
breathing, coughs hoarsely and with a croupy sound, and complains of tenderness
under the angles of  the jaw and  about the larynx.  The difficulty in breathing
increases, and may speedily threaten  the  life of the  patient, giving rise to in-
tense fits of  dyspnoea, in one of which he will probably be suddenly carried off.
On examining the throat from the interior of the mouth, the fauces will not only
be observed  to be much and  duskily reddened, but by  depressing  the tongue the
epiglottis can be felt, and perhaps seen, to be rigid and erect.
   In the treatment of this affection, local  means  are of the  first importance.
The tongue  having been well  depressed, the posterior part of the  larynx, the
epiglottis and its fraena must be well  scarified by means of a hernia knife, with
which this operation may be  most readily and safely done.   The patient should
then be directed to inhale the steam of hot water, and  a large number of leeches
may be applied under either angle of the jaw, to be followed by large and hot
poultices.  At the same time, the bowels  must be kept well  opened, and the
patient treated antiphlogistically or otherwise, according  to the condition of the
constitutional fever.   Most frequently, in these cases,  I have found  antimonials
of great service in the early stages, followed at a  later  period by support  and
stimulants.   A few hours after  the engorged tissues have been unloaded by
scarification,  the fauces,  pharynx, and upper part  of  the larynx  should  be  well
sponged out with a strong solution of the nitrate of silver (3i. to _h) which must
be applied freely,  coagulating the mucus, and taking down the increased vascular
action.   If,  notwithstanding  the  employment of these means, the dyspnoea in-
crease, the face becoming pale, livid,  and bedewed  with a clammy perspiration,
it will be necessary, in order to§ save  the  patient from impending suffocation, to
open the  windpipe.  In doing this I prefer the operation of kryngotomy, for
reasons that will be mentioned when I come to speak of the diseases  and  ope- 
368             PURULENT  INFECTION,  OR  PYEMIA.

rations of the air-passages.   In order that this operation should be successful, it
must not, however, be too long  delayed, and should not be looked upon as a last
resource; if done in time, and time in these cases is most precious, owing to the
rapid progress of the  disease, the  patient's life may probably be saved ; but if
deferred too long,  congestion of thel ungs  will have  come  on, the blood  will
cease to be properly arterialized, and the patient will sink from a slow asphyxia,
even though air be at last freely admitted.  If the patient survive to the stage
of sloughing, chlorinated gargles and support must be our chief reliance.
   Erysipelas of the serous membranes is of common occurrence in surgical prac-
tice, being frequently met with in  the arachnoid and peritoneum.   These, like
all other serous membranes, are liable to two distinct forms of inflammation, one,
which  is of a sthenic  character, having a tendency to the formation of plastic
lymph, the other, which is of a diffuse or erysipeloid form, being always accom-
panied by the exudation of a plastic unorganizable fibrine.
   Erysipelatous arachnitis commonly occurs as a consequence of injuries of the
head and erysipelas of the scalp.  In these cases there is usually a flushed coun-
tenance, bright  staring eyes, low muttering delirium, alternating with a coma-
tose condition, and rapidly terminating in death;  the constitutional symptoms
are those of a low irritative fever.  On examination after death, the arachnoid and
pia mater will be found greatly injected with blood,  forming a close red net
work of vessels  over the surface of the brain, the substance of which is usually
somewhat injected, the ventricles being distended with a reddish-colored serum.
If examined at  a later period  in the disease  than this, the inflamed arachnoid
will be found to be covered with a  layer of opaque puriform lymph of a greenish-
yellow color and slimy consistence.
   Erysipelatous peritonitis is not unfrequently met with in aged and cachectic
subjects after the operation  for hernia, or as a consequence of various  diseases
and injuries of the pelvic or abdominal organs.   In this form of peritonitis, the
symptoms are often of a latent character, the disease being chiefly indicated by
obscure  pain  diffused over  the abdomen with tenderness  on pressure, and an
anxious  depressed countenance, a hot skin, and a small rather  hard pulse.   On
examination after  death, the subperitonial cellular tissue will be found injected,
the peritoneum opaque in parts, covered with filmy patches of grayish  lymph, and
usually containing a largish quantity of opaque dirty-looking turbid fluid, mixed
with shreds and flocculi of lymph.  This, though closely resembling pus in ap-
pearance, is serum with lymph  intermixed, and is of a peculiarly acid, acrid, and
irritating character.   It is this form of peritonitis that is so dangerous to dis-
sectors ;  inoculations of the  fingers with  any of this  fluid being often  produc-
tive of the most  serious and even fatal consequences.
   The erysipelatous  inflammations  of the  lining  membranes of the vascular
system, will be fully discussed when we come to consider diseases of these parts.
                        CHAPTER  XXVIII.

                PURULENT INFECTION, OR  PYEMIA.

  By pyemia is meant a dangerous and often fatal affection, supposed to depend
upon the admixture of pus with the blood.  This disease is closely allied to some
of the  lowest and worst forms of erysipelas, with which  indeed it is  commonly
associated, and to which it presents great similarity in its causes, symptoms, and
effects. 
SYMPTOMS  OF  PYEMIA.
369
  Like  erysipelas, pyemia commonly occurs at those seasons of the  year, and
under those atmospheric conditions in which diseases of a low type are prevalent,
frequently as the result of overcrowding in hospitals, and it is in unhealthy and
cachectic constitutions that  it usually manifests itself.   Though it is  least fre-
quently met with during  the earlier periods of life, yet it may make its appear-
ance at  any age, and I have seen very young children carried off by  it.
  Pyemia is  never,  I believe, an idiopathic or primary affection, but invariably
occurs subsequently to an injury or wound of some kind by which inflammation
is excited, which has in  most cases reached the age of suppuration before the
pyemic symptoms come on; or it occurs in connexion with some low form of sup-
purative inflammation.   Thus we often see  boils, carbuncles, diffused abscess,
erysipelas of the skin, or erysipeloid inflammation of the  veins or absorbents
precede  its occurrence.  Wounds of veins, of bones, and  of joints, are the in-
juries that are especially  apt to be followed by this disease.
   Pyemia is  characterized specially by two series of phenomena.  The first is a
state of great depression  of  the powers of the system;  the second, the formation
of abscesses in various parts of the body as the disease advances.  The symptoms
are  as follows:  The  patient is seized with  rigors, usually of a very severe and
continuous character, though sometimes short and  transient, sometimes occurring
irregularly, at others being  repeated almost  periodically twice  or thrice  in the
twenty-four hours, for some  days in  succession; in some cases  these  rigors are
not  attended by any sensations of cold,  but in others they are, and then alterna-
ting with much febrile disturbance resemble very closely an ague fit; any open
wound that may exist at this time usually becomes foul, sloughy, and  ceases to
secrete pus, though I have seen it continue healthily granulating throughout the
 disease.   The skin is hot, and has a peculiar pungent feel.  The breath has that
 peculiar sweetish, saccharine, or fermentative smell that is commonly noticed in
all febrile diseases of  a low type.  This odor of the  breath, and indeed of the body
 generally, often occurs early in the disease, and must then be taken as  a very un-
favorable sign.  The secretions are arrested, the pulse is quick and feeble, the
 face is usually pale, with a very anxious drawn look, but sometimes  flushed and
 the  eyes bright; there is hebetude and  dulness of the  faculties with slight noc-
 turnal delirium, but perfect  consciousness on being spoken to; about this period,
 patches of erratic erysipelas  frequently make  their appearance on the surface,
 and the skin always assumes  a dull,  sallow,  and earthy, or a bright yellow,
 icteric tint, which may extend even to the conjunctivae.   The symptoms now
 indicate an extreme depression of the vital powers, the pulse becoming small and
 fluttering, the  tongue brown, with sordes about the teeth, and low delirium;
 usually from the sixth to the tenth day, but sometimes earlier, diffuse suppura-
 tion begins to take place in  different tissues, joints, and organs.  This  may occur
 in the  viscera without occasioning any material  pain; if seated in the cellular
tissue, or in  the substance of muscles, there is much doughy swelling, with some
redness; if in the joints, the swelling is often considerable, the pain usually in-
tense and of a very superficial and cutaneous  character, the patient  screaming
with the agony he suffers.   These pains, which are chiefly seated in the knees,
ankles, hips, and shoulders, often simulate rheumatism very closely.
   The  progress of the disease is usually from bad to worse, sometimes rapidly,
but  at other times not uninterruptedly so, there being remissions and apparent,
though not real, improvement.   The patient rapidly wastes, the body becoming
shrunken, the muscles soft, and  the  skin loose and  pendulous.   Great debility
also sets in.  The abdomen becomes tympanitic, diarrhoea or profuse sweats come
on;  pneumonia or pleuritic effusions declare themselves;  delirium, from which
the  patient is  easily roused, alternates with sopor, and at last he sinks from
exhaustion.  Death usually  takes place about the tenth or twelfth day, though
                                      24 
 370             PURULENT INFECTION,  OR  PYEMIA.

 it may occur as early as the fourth, or the patient may linger on for six or seven
 weeks.
   In other cases pyemia occurs in a very insidious  manner, without rigors, but
 merely with prostration, and  some  low fever of an intermittent kind;  after a
 time the skin assumes a yellow tint, as do the conjunctivae.   The urine is very
 high-colored, and perhaps the peculiar odor in the breath or body may be noticed.
 But the patient continues in a quiet state, his wound cleans, suppurating health-
 ily, and goes on well. He gets, however, symptoms of low pneumonia or pleurisy,
 with, perhaps, pain and fulness in one joint, where abscess forms, and  then  the
 disease fully declares itself.
   The  formation   of  numerous purulent deposits,  "secondary or metastatic
 abscesses," as  they are often termed, is  one of the most  marked features of
 pyemia.  These abscesses usually contain a somewhat thin and oily-looking pus;
 at other times, however, it  is thick and laudable.   The more oily-looking fluid,
 though opaque and yellow,  and closely resembling true pus, will, on microscopic
 examination, be found  to differ from this in the absence of the true nucleated
 pus-corpuscle, though it contains an immense number of  granular cells (Figs. 8
 and 9).   After removal it  often forms a firm fibrinous coagulum.  These  puru-
 lent collections vary greatly in size  and in situation,  being found in  the viscera,
 in the cellular and muscular structures,  in the serous membranes, and in  the
 joints.
   Pyemic abscesses differ from ordinary purulent  collections,  not only in  the
 peculiar character of the pus  that they contain, but more particularly in  the
 rapidity with which they form, a few days commonly sufficing for them  to obtain
 a large size.  So,  also,  their very  widely-spread character, and the insidious
 manner in which they occur,—the  tissues, as  it were, breaking down without
 any inflammation,—constitute the distinguishing features of these collections.
  The visceral abscesses vary  in size from a pin's head to a walnut;  in  many
 cases  the organs affected are studded with them.   These collections  are  most
 frequently met with in  the  lungs, being seated on the surface of the organs, or
 in the interlobular fissures, next in the liver, and then in the spleen ;  they  are
 usually  surrounded by  a darkly-inflamed  and condensed  layer  of tissue, which
 forms an  imperfect wall to the collection.   They may occur  in other organs.
 Thus, my friend, and late house-surgeon, Mr. Gamgee, has on several occasions
 observed them in the prostate.
  When  the pus is infiltrated into  the cellular tissue  and muscles of the limbs
 and trunk, it will form  immense diffuse collections of a thin and serous matter,
 commonly mixed with  shreds of the cellular membrane of the part.  These
 collections are most frequently met with, perhaps, in the axilla,  down the  flank
 and about the back, in  the iliac fossa, thigh or calf,  and may either be confined
 to the subcutaneous, or extend to the deep  intermuscular cellular planes in these
 regions; or  may even  form in the muscular substance  itself, being  diffused
 between  the fasciculi which are softened  and disintegrated.   Most commonly
 the presence of these collections is indicated by patches of cutaneous or erratic
 erysipelas, and by  a doughy, cedematous, and boggy state of  the  superjacent
 integuments.
  Accumulations of pus in  the serous and synovial  membranes are common in
 this disease;  the arachnoid, the pleura,  or the  peritoneum may  all  be affected
 in this way.  More frequently, however, some of the joints, especially the kneea
 and  shoulders, become filled  with a thin, yellow, purulent  liquid.   These
 arthritic abscesses  are usually  indicated by intense pain, often of a cutaneous
 or superficial character, with fluctuation and swelling in the articulation  affected.
  Not only are the  appearances just mentioned commonly met  with in cases of
 death from pyemia, but  we find the  viscera, perhaps  more particularly the brain
and lungs, inflamed, and, not  unfrequently, a diffused erysipelatous redness of 
CHANGES  IN  THE BLOOD IN PYEMIA.            371
 some membranous surface, as of the arachnoid or gastro-intestinal mucous mem-
 brane.
   The diagnosis of pyemia is not always easy in the earlier  stages, when  the
 rigors, depression, and other signs of constitutional disturbance may be  looked
 upon as  common to other intercurrent diseases.   As the affection  declares itself,
 however, the continuance and severity of the rigors, the extreme want of power,
 the icteric tinge of the skin, the peculiar faint  and sickly odor  of the breath,
 and the  occurrence of metastatic and visceral abscesses, indicate the true nature
 of the attack.
   The question necessarily  arises, to what are  the symptoms  and destructive
 effects of pyemia  due?*  There can be little doubt  that they are owing to  the
 alterations that take place in the blood itself.  It  is only in this  way  that  the
 remarkable diffusion of the  disease, the variety of tissues affected, and the wide-
 spread  tendency to suppuration that characterizes  it can be explained.  That
 the blood undergoes important  changes in this disease is unquestionable; it is
' thin, dark-colored, and, after having  been drawn from the body, forms a loose,
 spongy coagulum, from  which a moderate quantity of rather turbid or  milky-
 looking  serum  separates. On examination under the microscope it will be found
 that, besides the ordinary red globules,  the blood contains, often in large quan-
 tities, corpuscles, that in some cases  closely resemble the ordinary white ones of
 the healthy  blood, and  at others present such exact similitude to the pus-cell,
 that  the most practised eye fails in detecting a  difference.   These corpuscles
 may be  few in numbers, and at  other times so abundant  that  they  occupy  the
 field  of  the  microscope to  the  exclusion  of the  red.   The existence of these
 corpuscles in the blood, which I believe will invariably be found on careful ex-
 amination,  more  especially in  that  taken  from the larger veins,  constitutes
 apparently one, if not the essential  element of the disease.  That they are true
 pus-corpuscles, in many cases, would  seem to be probable from their microscopic
 appearances; in others, again,  they  do  not present  the  true  characters of the
 pus-cell, differing from  it in the shape, or in the absence of  a nucleus, and in
 their more irregular outline; resembling indeed more closely the white corpus-
 cles, or  some of the ill-developed granulation or exudation-cells  that are met
 with in  cold or lymphatic abscesses occurring in cachectic constitutions.  What-
 ever  differences of appearance these  corpuscles  may present, they can  best  be
 compared to those  pus-cells that are found in  many unhealthy abscesses,  and
 more especially  in the diffuse purulent collections  occurring in the  cellular
 tissue or the joints in this very disease;  and like these I think  we must  look
 upon them as products of inflammation, though  perhaps of a  low and aplastic
 form.
   The question that next presents itself is, how do these corpuscles find their
 way into the blood ? and how do the other changes that occur in the physical
 characters of this fluid  take place ?  By some surgeons it has been supposed
 that the pus is actually  and  bodily absorbed from the surface of the suppurating
 wound,  and so admixed with  the blood.   This  explanation,  however,  is  not
 tenable,  as there is not only  no proof, but no reason to believe in  the possibility
 of the absorption of a pus-corpuscle in  its state of integrity from the surface of
 a wound.  Then, again, it has been supposed that the  pus having trickled, or
 in some other  way found an entrance into the open mouth of a divided vein, as
 upon the surface of a  stump or in a sawn bone, has gained access  to the general
 circulation.   But  it is difficult to understand how pus can possibly become ad-
 mixed with  the general current  of the blood in this way; for if the vein  be
 sufficiently open to  allow of the entry of one fluid, it would certainly be so to
 admit of the escape of the other.   The theory that has  the  most advocates at
  »I would refer the reader to a very excellent analysis of the general doctrines at present  entertained
 as to the cause of Pyemia, by Mr. Gamgee, published in the "Association Journal," for 1853. 
372             PURULENT  INFECTION,  OR  PYEMIA.
the present day is that the pus enters the circulation as a consequence of phle-
bitis, being formed directly by the lining membrane of an  inflamed  vein, and
thus  poured at the moment of its evolution  into the current of blood  passing
along the vessel.   This dependence  of pyemia on suppurative phlebitis, more
especially of a diffuse character, has been  strongly advocated  by Hunter, Arnott,
Berard, and others, and affords an easy solution to the difficulty, and has acquired
considerable weight from the fact that in  many cases these affections  are found
co-existing.  I am by no means prepared  to deny that the pus does in  all proba-
bility in very many cases become directly admixed with the  blood  in  this way,
and that suppurative phlebitis is consequently  in these instances the cause of the
pyemic symptoms.  This explanation  would indeed be conclusive, if it could be
shown that phlebitis was the only,  or even the most frequent form of diffuse in-
flammation occurring in connexion with pyemia, and that it always occurred as a
precursor and concomitant of the blood affection.  But  this I believe  not  to be
the ease.   I have had  opportunities  of examining the  bodies of a considerable
number of patients who have died of  pyemia,  and I have certainly often found
evidence of other diffuse inflammation as well as of phlebitis; and in some  cases
no inflammation of the veins could be detected on the most careful  investigation
specially directed to this point;  and hence I cannot but come to the conclusion
that pyemia, though  frequently co-existing with, may  occur independently of
suppurative phlebitis, and cannot in  all cases  be necessarily considered a conse-
quence of that  disease.
  Tessier was the first who maintained that pyemia was always independent of
phlebitis, being a true  blood disease.   The doctrine, however, is  irreconcilable
with  the established fact, as pointed  out  by Sedillot,  that the injection of pus
into  the blood  produces a disease identical with pyemia;  that this affection is
always preceded by local inflammation, and usually by  suppuration, and that  a
distinct connexion has been pointed out by Hunter, Arnott, and Berard between
suppurative phlebitis  and pyemia.  Besides this, the presence  of cells in the
blood resembling the pus-corpuscle admits of proof.
  In the very excellent essay published by Mr. Henry Lee on this  subject, that
surgeon expresses his opinion that the introduction of pus into the  system  from
an inflamed or injured vein is rarely the first step in purulent infection, but  must
have been preceded by some change that has taken place in the blood,  by which
its coagulating  power has been impaired.   Mr. Lee's views  are supported by a
number of ingenious experiments.
  How are we  to account for the changes that the blood undergoes, and which,
whether resulting from  suppurative phlebitis or not, are the essential causes of
the pyemic symptoms ?
  The explanation that I would suggest  as to the cause of the presence of the
true  or imperfectly formed pus-cell in the blood in these cases is the following.
For pyemia to  occur, I believe it to be invariably necessary that a  local inflam-
mation previously exist  in some part of the body.  This may either be external
or internal; it may be limited in size to that of a boil, or may be as extensive as
the surface of a  sloughy stump.   In  all  cases this inflammation is of, or tends
to assume, a suppurative character; and  in all, the constitution is broken, and
ot that kind in which the corpuscular or aplastic lymph commonly forms.  It is
not difficult to suppose that the blood in circulating through the part so diseased,
instead  of  undergoing those peculiar  changes  that are  impressed  upon it in its
passage through tissues that are sthenically inflamed, and of which  the most re-
markable is  the formation in it of a large quantity of plastic filamentous fibrine,—
as evidenced by the hard firm coagulum, by the formation of the buffy coat, and
by the tendency to the  deposition of coagulable lymph,  as well as  by the occur-
rence of constitutional fever of the sthenic type—may undergo alterations in
composition of equal extent, though of a far different kind.   It appears  not im- 
TREATMENT OF  PYEMIA.
373
probable that the fibrine formed in the blood in these low inflammations, occurring
in broken constitutions  and at unhealthy seasons, may assume that corpuscular
or aplastic character which we have  already seen to be the invariable result of
these conditions, and  that  the  corpuscles, which are met with intermixed in
greater  or lesser quantity with the blood in pyemia, and that bear a sufficiently
close  resemblance to  granulation  or exudation-cells, to all the various forms of
the unhealthy, and occasionally to the typical variety of the pus-corpuscle, are
in reality the conditions under which superfibrination of the blood  with  corpus-
cular lymph would necessarily show itself.  That, consequently, instead of being
formed  from without, and absorbed  or poured into the blood, they are  actually
generated in that fluid itself during its passage through the unhealthy-inflamed
tissue, not however by any conversion of the blood-globule into a lymph or pus-
cell, but as a consequence of those  changes which we know, by their effects, to
be impressed  upon the blood by contact with inflamed tissues, but with  the
precise  nature of which we  are still unacquainted.   It is also by these blood-
changes in  pyemia that we may account for  the remarkable constitutional de-
pression that exists; for if,  as there is every reason to believe, the  admixture of
plastic fibrine  with the blood will occasion sthenic inflammatory fever, the forma-
tion of  aplastic lymph  in that fluid may occasion a correspondingly low type of
constitutional  disturbance.
   As the blood circulates through an inflamed vein, not only would those changes
take place in it that occur in its passage  through other tissues, but  it would thus
become mechanically mixed  with  the pus  and  exudation-matters poured out in
large quantity by the lining membrane of the  vessel; and hence we may  explain
the greater liability to the occurrence of pyemia after or in combination with sup-
purative phlebitis than in connexion with any other inflammatory affection else-
where situated.
   When once these corpuscles are  admixed with the blood, it is  probable that
abscess  is a necessary result from their mechanically occluding the  capillaries, as
Cruveilhier long ago showed experimentally to be the case.   The pus-cells, being
larger than the blood-corpuscles, become arrested in the capillaries of organs, and
thus constitute points of irritation, around which inflammation is set up, and in
which suppurative action takes place ; these changes being first induced in those
organs,  the capillaries of which are of a very small calibre, as in the lungs.
   The tendency to suppuration of joints and to the formation of diffused collec-
tions in the muscles and cellular tissue, can  scarcely however, be accounted for
in this  way; and are probably dependent on other causes, amongst which  the low
crasis of the blood is the most powerful.
   The  treatment of pyemia is of the most unsatisfactory character.  It doubt-
less happens that patients occasionally recover from this disease, but such a re-
sult must be looked upon as a happy exception to its commonly fatal termina-
tion.   The only plan  of treatment that holds  out any reasonable hope of success,
appears to me to be the stimulating and tonic one.  I have certainly seen service
done, in some cases, and indeed recovery effected, by the administration  of large
doses of quinine; as much as five grains being given every third or fourth  hour,
with the best  effect.   A very serious case of pyemia, lately under my care at the
hospital, occurring after amputation  of the arm, and accompanied not only by all
the symptoms of that disease in a very marked manner, but by pleuritic effusion,
swelling and tenderness over one hip, and secondary hemorrhage from the stump,
got well by perseverance in the tonic and stimulating plan of treatment.   If the
depression is very great, the carbonate of ammonia in ten or fifteen grain doses
may be  given  from time to time; such nourishment as the patient will take, with
a liberal allowance of dietetic stimulants being also administered.
   In the case of a superficial vein being inflamed it has been recommended by
some of the French surgeons, as Bonnet, Berard, and Laugier, that the actual 
374
TUMORS.
cautery should be freely applied along the course  of the  vessel, and they state
that the best results have followed this practice.   As abscesses form, they must
be freely opened; and the diffused and purulent collections, forming in the cel-
lular tissue must be evacuated.
                         CHAPTER  XXIX.

                                TUMORS.'

  The frequency with which tumors  fall under the observation of the surgeon,
the great variety in their characters, and their important relations, local  as well
as constitutional, render their consideration one of great moment.   According to
Hunter, a tumor is " a circumscribed  substance produced by  disease, and  dif-
ferent in its nature and consistence from the surrounding parts."  This defini-
tion, though not perhaps accurately correct in some forms of  tumor, which do
not differ in their nature from neighboring parts, is yet substantially a good and
convenient one.   By  a tumor  may also he said to  be meant a circumscribed
mass, growing in some tissue or organ of the body and dependent on a morbid
excess or deviation of  the nutrition of the part.  The tumor  thus  formed in-
creases in size by an inherent force of its own, irrespective of the growth of the
rest of the system, and differs essentially from the normal structure and appear-
ance of the part of the body in which  it grows.   In order to constitute a tumor,
it is necessary that the normal form of the part be widely departed from,  a mere
increase in its size  so long as it preserves  its usual shape being  scarcely consi-
dered in this light.  Thus if the  tibia be uniformly enlarged to double its na-
tural size, it would be  said to constitute a hypertrophy, not  a tumor; but, if a
comparatively small rounded mass of bone  project  directly forwards from its
tuberosity, it would be said to be a tumor and not a mere hypertrophy.
  Surgeons invariably divide tumors  into  two great classes, the non-malignant
and the malignant; besides these there is an intermediate group that  may be
termed the semi-malignant.
  The non-malignant, innocent, or benign tumors are  strictly local.   They re-
semble more or less completely the normal textures of a part, and hence are very
commonly, though not perhaps with strict propriety, termed analogous.   They
usually grow slowly, are more or less  distinctly circumscribed, being often en-
closed in a cyst, and have no tendency to involve neighboring structures in their
own growth; any change that they induce  in contiguous parts being, not by the
degeneration or conversion of these into their own structures, but simply by the
effects produced by their size and pressure displacing  or atrophying them.  They
are sometimes single, but  not unfrequently multiple, developing  either simulta-
neously or successively; but if  in  the latter mode, without  any connexion with
preceding growths.  If removed by operation they do not return.   But if left to
the natural processes of nature they may slowly attain  a great size, remain sta-
tionary, and at last atrophy, decay,  or necrose.  They never degenerate  into
malignant  structures, though in their natural processes of decay they often so
closely resemble these  that  mistakes have  not unfrequently been committed on
this point.
  Malignant tumors differ  widely from those  last described.   They cannot be
considered as local diseases,  as in many cases they result primarily from consti-

  aIn Paget's Lectures on Surgical Pathology, vol. ii., will be found the most philosophical account of
tumors in this or any other language. 
VARIETIES  OF TUMORS.
375
tutional vice, or if local in the first instance, having a tendency rapidly to affect
the constitution.   They are essentially  characterized by an extreme  vegetative
luxuriance and an exuberant vitality.   They proceed from a germ which, in a
manner at present unknown to us, is formed in some organ or tissue, where it
developes by an inherent  force of its own irrespective of neighboring  parts, pro-
ducing a mass which differs entirely in  structure and appearance from anything
observed  in  the normal  condition of the body; and hence, not unfrequently
called heterologous. ^ This term  however cannot be  considered strictly accurate,
inasmuch as  the microscopic elements  of which this mass are composed have
their several analogues in the normal structures of the body.   This mass, which
may either be infiltrated in  the  tissues, or localized by being confined to a cyst,
increases  quickly in size; not uncommonly indeed  the  rapidity of the growth
may be taken as a. measure of the malignancy of the tumor.   As it increases in
size, it tends to  implicate the neighboring structures in its own growth, and to
affect distant organs through the medium of the lymphatics or the blood; if re-
moved by operation  it has a great tendency, under certain conditions, local and
constitutional, to return in its original site or elsewhere, though  it does not ne-
cessarily do so.   If  left to its own development, a malignant  tumor  will inevi-
tably soften, necrose, and ulcerate, often with much  pain, profuse hemorrhage,
and the induction of a peculiar state of constitutional cachexy, which speedily
and necessarily terminates in death.
   Interposed between these two classes, we find a third group that partakes more
or less of the characters of both;  these may be termed  semi-malignant tumors.
   Mr. Paget has pointed out, that the difference between an innocent and malig-
nant tumor does not depend so much on the  visible  structure of the  growth, as
upon  its origin and vital properties.  Thus he has shown that some tumors that
present all the ordinary physical appearances of  one of the normal constituent
tissues of the body,  the fibrous, under  certain circumstances  may take on  the
characteristics of malignancy; whilst, on the other hand, some perfectly innocent
cartilaginous-looking tumors, differ in  structure  from the normal tissue which
they so closely  resemble.   Paget has  also very  fully described varieties of the
fibroplastic as well as of  the fibrous tumor, which though preserving throughout
a uniform character, microscopical and otherwise, that is not considered malig-
nant, have nevertheless destroyed the patient by repeated recurrence after removal,
and by ultimate  ulceration, sloughing, and contamination of neighboring tissues.
He makes the important observation that in different persons and under different
conditions the same disease may pursue  very  opposite courses, appearing in some
to be of an innocent, in others of a malignant type; and he  makes the very
interesting practical remark, which agrees entirely  with the result of my own
observation, that the children of cancerous parents may be the subject of tumors
apparently innocent in structure, but certainly resembling malignant growths in
the rapidity of their progress, their liability to ulcerate  and to bleed, and their
great disposition to return after removal.  These various considerations appear to
render it necessary to establish the third subdivision, of semi-malignant tumors.
  Innocent and malignant tumors  are occasionally met with in the same person,
four or five different  kinds of growth even occurring in one individual.  I have
seen in one patient a scirrhous breast, an enchondromatous tumor of the leg, an
atheromatous  cyst on the back, with scrofulous glands in the neck.   Malignant
and benign formations may even be found in  the same mass; thus I have known
encephaloid and  enchondroma met with  together in a tumor of the testis.   This,
however, must not be taken  as any evidence of the possibility of the conversion
of one into the other, and indeed there  is no proof that a non-malignant can be
converted  under  any  circumstances into  a malignant tumor; a fibrous growth may
degenerate and  assume all the character of malignancy, at  last destroying  the
patient, but there is no evidence that  it can ever be changed into a cancerous 
376
INNOCENT  TUMORS.
 mass.   A malignant tumor may, however, be deposited on the  site of a non-
 malignant growth that has been removed:  thus  I have seen a scirrhous  nodule
 deposited in the cicatrix left after the removal of a cystic sarcoma of the breast.
   Besides these various forms of tumors, others are met with of a constitutional
 and specific character, such as those that occur in scrofula and syphilis.
   We have already  seen  that  tumors naturally arrange themselves under the
 innocent, the malignant, and the semi-malignant varieties.  We must now study
 the characters of each of these  groups a little more closely.

                  NON-MALIGNANT  OR INNOCENT TUMORS.

   The  innocent tumors may, I think, be most  conveniently arranged in three
 great classes.
   1st.  Encysted tumors of all kinds.
   2dly.  Tumors dependent on the simple  increase of size of already  existing
 structures, in the tissues  or organs in which they  occur; as, for instance, fatty
 tumor in adipose tissues, exostosis in connexion with bone, &c.
   3dly.  Tumors dependent on the new growth of already existing.structures, in
 situations  where they  are not  normally found;  as, for instance, a cartilaginous
 tumor in the midst  of cellular tissue, or a fibrous tumor under a serous mem-
 brane.

                            I.  ENCYSTED TUMORS.

   Encysted Tumors arrange  themselves into two great classes.   1st. Those
 that are  dependent  upon the gradual accumulation of a secretion in a naturally
 existing duct or cyst, with dilatation  and hypertrophy of its walls: 2dly. Those
 that result from the new  formation of a closed cyst in the cellular tissue of the
 part, and the distension of it by the secretion from its lining membrane.
   1st.  The  encysted tumors arising from simple distension and  gradual hyper-
 trophy of the walls  of a  duct  or  cyst are met  with in three forms.   1st.  As
 encysted tumors of  the skin and  subjacent cellular  tissue occurring in various
 parts of the body, and dependent on the closure of the excretory ducts of the
 sebaceous glands: 2dly. As formed by the accumulation of secretions in, and the
 closure and  dilatation of,  the ducts of other secreting glands  and organs, as in
 the sublingual or mammary gland :  And, 3dly.  Those formed by the retention
 and modification of the secretions  in cysts without excretory ducts, as in the
 bursas.
   Encysted  tumors occurring from the obstruction of the excretory duct of the
 sebaceous glands, include the various forms of atheromatous tumors that are met
 with on the surface of the body.   These are usually situated upon the scalp, face,
 neck, or back; sometimes, however, they occur elsewhere ;—thus I have removed
 a very large one from the forepart of a girl's arm, and others from the labia and
 groin.   In size  these tumors vary from  that of a pin's head to an orange; the
 smallest occur on the eyelids, the largest on the shoulders and scalp.   They  are
 often very numerous, especially about the head, where as many as thirty or forty
 may be  met with at the same time; and  most frequently they  occur  in women
 about the middle period of life : they  are smooth, round, or oval movable under
 the integument,  either semi-fluctuating or elastic, though sometimes solid to the
 touch.   In some parts where the  sebaceous follicles are large,  as on the back a
 small black point can often be  detected  on the surface of the tumor through
 which  an aperture may be found leading into  its interior, and  admitting the
 expulsion of  its contents.  In  structure they are composed  of a cyst which
 varies greatly in  thickness, being sometimes thin, filamentous, and soft • at others
 so thick, hard, laminated, and elastic, that it is almost impossible  not to  believe
it to be a new formation; these cysts attain their  greatest density  on the  scalp. 
ATHEROMATOUS TUMORS.                   377
In structure they are composed of cellulo-fibrous tissue, with an epithelial lining,
and generally appear to be a  dilated and hypertrophied state of the sebaceous
follicles, though not improbably, as Paget  supposes, they may at times be new
formations.   They are usually attached by loose and lax cellular tissue to the
subjacent  parts;  but, if thin,  are  often  pretty closely  incorporated  with the
superimposed skin; if inflammation is set up around them they  become  more
solidly fixed.   The contents of  these cysts are very various, most usually consist-
ing of a soft, creamy, pultaceous, or  cheesy-looking mass, of a yellowish-white
color, which  has  sometimes in  old cysts become dry and laminated, looking not
unlike parmesan.   In others, again, of old standing and large size, the  contents
may be found to be semi-fluid, the more liquid parts being  of a brown, green, or
blackish tint.  These  various  contents  are  essentially  composed of  modified
sebaceous  secretion, such as epithelial scales, fat, granules, eholesterine,  granular
matter, and rudimentary hairs in  various proportions (Fig.  125).
   The growth of these tumors is  often  very slow, but  not unfrequently after
remaining stationary for years, they take on a rather rapid increase.  The tumor
itself, though painless, may give rise to uneasy sensations by compressing nerves
in its vicinity; it  usually continues to grow slowly until the patient being  annoyed
by its presence, gets it removed by operation.   If left  untouched, it occasionally,
though rarely happens, that the sebaceous matter exuding through the aperture
on its surface forms a kind of scab or crust, which by  a process of sub-deposition
becomes conical;  and being gradually pushed up from  below, at the same time
that it assumes by exposure a dark brown color, forms an excrescence that looks
like a horn, and is usually  considered to be  of that character.  These "horns"
have  been met with  on the head, on the buttock, and  occasionally in other
situations, and  have  been  well described by Mr. Erasmus Wilson; some  time
ago a  woman applied to me with one about an inch and a half  long  growing
from the upper lip.
Fig. 125.                                 Fig. 12G.
  In other cases again, these tumors inflame and  suppurate;  the skin covering
them  becomes adherent and  reddened, ulceration takes place,  and if the cyst be
small and dense, it may be thrown off by the suppurative action in the surround-
ing tissues.  If of larger size,  ulceration of the integuments  covering  it takes
place, and the sebaceous  matter  is exposed; this may then putrefy, become
offensive,  and break  away in  unhealthy suppuration.   In other cases, again,
peculiar changes take place in this tissue, large granulations are thrown out in
it, and the atheromatous  mass  appears to vascularize, becoming  irregular  and
nodulated, rising up in tuberous growths with everted edges, exuding a fetid,
foul  discharge, becoming  adherent to subjacent parts,  and assuming  a semi- 
378
INNOCENT tumors.
malignant  appearance, forming at last a sore perhaps as large as a saucer, as
in the preceding figure of a case sent to me by Dr. Bryant (Fig. 126).
   The only diseases with which these tumors can  be  confounded  are  abscesses
and fatty growths.   From an abscess ah  encysted sebaceous tumor may be dis-
tinguished by its history, slow growth, situation, elasticity, and mobility, and the
existence of the dilated orifice of the sebaceous  duct, through which some of
the contents can be squeezed,  the microscopical examination of which will serve
to confirm  the diagnosis.  From a fatty tumor these growths may be diagnosed
by their firmer and more regular feel, and in case of doubt by the evacuation and
examination of their contents.
   The treatment of a tumor  of this  kind simply consists in its removal,  after
which it is never  reproduced.  This  may most  readily be  done by transfixing
and cutting it across with the  scalpel, and then seizing the side of the cut  edge
with a pair of forceps, pulling  the cyst out of its loose cellular bed.   This plan
may commonly be  adopted with those seated about  the head, face,  or neck.
When about the back, trunk,  or limbs, they usually require to be dissected out,
more  especially if incorporated with the skin, or adherent by former inflammation
to the subjacent parts.  In doing this, care  should be taken  that the whole of
the cyst is extirpated ; the wound that is left should then  be dressed lightly, and
speedily heals.  If, however, any portion of the cyst be  left behind, a trouble-
some  fistula may remain.   When  occurring upon the scalp, a  large number of
these  tumors may in this way be removed at one sitting; as, however, there is
always some danger of erysipelas following operations in this situation, it  is only
prudent  to select a favorable season of the year, and not to operate if the tumor
be in  any way irritated, at the time, or thie health out of order.   Erysipelas is
especially apt to occur after these  operations in elderly people of a stout make
and florid complexion.
   The horns and semi-malignant  ulcers that result  from  these  growths  may
require excision.  If, however, the ulceration be connected with the cranium by
its base, or be very extensive,  as in the case depicted  above, it will be safer to
treat it by  the application of a weak solution of the chloride of zinc, or by occa-
sionally touching it with fused  potass.
   Various  forms of encysted tumor may arise from the closure of the ducts of
other  excretory organs ; as for instance  ranula by the occlusion of the salivary
ducts,  encysted hydrocele by the closure  of the tubuli testis,  or tumors  of the
breast by the obstruction of the lacteal ducts.  These affections, however, con-
stitute special diseases, the consideration of which must be deferred to subse-
quent chapters.  The general  principle of treatment in these kinds of affection,
consists either in restoring the freedom of the outlet by the excision of a portion
of the wall, or obliterating the  cyst  by making  an incision into it, and allow-
ing it to granulate from the bottom.
   Cysts may arise by the distension of cavities which are unprovided with any
excretory duct; as, for instance, the bursas mucosae, which often attain  a  very
considerable size under these  circumstances.   The  structure of these cysts be-
comes greatly altered;  sometimes  the walls are thin and expanded; in  others,
they acquire a thick cellulo-fibrous, almost ligamentous, appearance.    Inside,
they are often warty-looking, from the deposition of imperfectly-organized fibrine,
often  arranged in a laminated  form.   Not unfrequently attached to these walls,
and floating  in the interior, are  a number of granular, melon-seed-like  bodies,
grayish or yellow  in color, semi-transparent, elongated  or  irregular  in  shape,
usually rather hard, but at others soft and flocculent.   These appear to be com-
posed of masses of imperfectly-organized  fibrine, somewhat resembling in struc-
ture granulation-cells, and often  form in  large quantities, so as to block  up the
interior  of the cyst, converting it into a solid tumor.   The fluid contents of
these  cysts are usually thin and serous, of a yellowish or brownish color.  In 
CYSTIC TUMORS.
379
their progress, these cysts  are  found to increase up to a certain size, when they
usually thicken and harden, in consequence of the fibrinous transformation just
described; or else  inflame and suppurate in an unhealthy manner.  They may
occur in any of the situations in which bursas naturally exist, or are accidentally
formed, and which will be mentioned hereafter, but are most commonly met with
upon the knee-cap, the nates, or the first joint of the great toe.
   The  treatment of these cysts consists in attempting their absorption  by the
use of stimulating  plasters;  or, if this fail, in the removal of their contents by
tapping. _ Their cavities are  then  closed  by exciting inflammation and suppura-
tion within them, by the introduction of a seton, by injection with stimulating
solutions, or by the subcutaneous section.  If these means fail, excision will be
required, more especially if  the tumor  have assumed a dense and fibrous cha-
racter.
   2d.  Cysts  occasionally are met  with as new formations, filling  by their own
secretion.  They occur in the general cellular  tissue, and in  connexion with the
sheaths of tendons, but most frequently about  the generative  organs, more espe-
cially in the ovary, in the broad ligament of the uterus, or in the breast.  These
cysts vary most widely in  size, from that of a millet-seed to tumors weighing
many pounds, and  filling up the  greater part  of the abdominal cavity.   When
small, they are usually thin-walled, and are often imbedded in  a matrix composed
of imperfect hypertrophy of the  organ   in which they are  situated, as  in  the
breast and testes;  when large, as  in the  ovary, the  walls are thick, firm,  satiny,
and often very tough.  Projecting into their interior are solid masses, consisting
of cauliflower-like growths, occasionally  filling up the whole inside of the cysts
with compact solid white layers.   These " intra-cystic" growths  cause by their
increase in size, the gradual absorption of the more fluid contents, until,  at last,
their development is arrested by the cyst-wall.
   These cysts may be divided  into the simple  and the compound.   The simple,
or, as  they are commonly called, serous cysts,  are met with in  almost every
situation, being composed of a thin expanded wall, containing a  slightly viscid,
serous fluid.
   The compound,  or, as they are often called, proliferous  or  mu.ltilocular cysts,
are especially met with in the ovary, and have been studied with great care by
Hodgkin.  Of these  there are two varieties, the first consisting of an aggrega-
tion of  simple cysts closely packed and  pressed together; the second composed
of cysts having others growing from their walls.  The cavities of these  multi-
locular cysts  present the greatest possible variety in their contents;  fluid, from
a limpid serum to a semisolid jelly-like matter, and of every shade  from light-
yellow to greenish-black, or dark-brown, is  met with in them; solid intracystic
growths, cancerous  masses, or the  debris of epithelial and cutaneous structures
are also found in them.
   Encysted tumors, containing hair and fatty  matters (pilocystic tumors), are
occasionally met with.  These would, in many instances,  appear  to  be  the re-
mains  of a  blighted ovum enclosed in  the  body,  as they are  congenital, and
usually contain some foetal  debris,  such as portions of bone, teeth, &c.  The
hairs in these tumors  are connected with, and grow from, cuticular structures in
which sebaceous follicles are  commonly distinctly observable.  The fatty matter,
which they contain in large quantity, and which may either be solid or perfectly
fluid, is in all probability the result of fatty degeneration of the  soft tissues of
which they are composed.   These  tumors are most frequently met with  in  the
abdomen, especially about the ovaries, mesentery, and omentum; they have also
been observed in connexion with the testes, having probably descended into the
scrotum with  this  gland.   A very remarkable  case of this kind  lately occurred
at  the  University College Hospital under Mr.  Marshall.   They have also been 
380
INNOCENT  TUMORS.
 found about the face, but never, I believe, in connexion with the thoracic cavity
 or extremities.
   The sanguineous cyst, or hsematoma, is a peculiar variety of the simple form,
 and has been  described by Paget as  especially occurring about  the neck, the
 parotid, the anterior part of the thigh, the leg, the shoulder,  and the pubes.  It
 is especially characterized by containing fluid blood, more or less altered in ap-
 pearance.  He describes these  cysts as being formed in three different ways :
 either by hemorrhage into a previously-existing  serous  cyst, by transformation
 from a nsevus,  or by a vein becoming occluded and dilating into a cyst.  These
 sanguineous  cysts may sometimes  resemble  in general appearance encephaloid
 disease.  A remarkable case of this kind was sent to me by my friend, Dr. Henry
 Bennet—a tumor about the size of an orange, of nodulated appearance,  existing
 in the leg of a  woman below the knee, where it had  been gradually increasing in
 size for about a couple of years.   So  close was the resemblance  to malignant
 disease presented by the  tumor, that the limb had been condemned for ampu-
 tation by some surgeons who had previously seen  the case; as, however, the
 growth, on examination, turned out to  be a  sanguineous cyst, as its walls  were
 thin and adherent, and as it extended too deeply into the ham to admit of ready
 removal, I reduced it by successive tappings, and then  laying it open, allowed it
 to granulate from the bottom.   When  practicable, however, the cyst should al-
 ways be dissected out.

     II.  TUMORS ARISING FROM SIMPLE INCREASE  OF SIZE OF  ALREADY
                            EXISTING  TISSUES.

   These tumors differ  from  simple hypertrophy of the part " in this, that to
 whatever extent the  hypertrophy may proceed, the overgrown part always main-
 tains itself in normal type of shape and structure, while  a tumor is essentially a
 deviation from  the normal type of the body  in which it grows."   (Paget.)
   This  section comprises, 1st, tumors connected with the integumental struc-
 tures, as warts, polypi, &c. : 2d, lobular hypertrophies,  with more or less modi-
 fication of glandular structure, as in the breast: 3d, fatty tumors : 4th, vascular
 tumors : 5th, tumors of nerves: and 6th, tumors of bones.
   Simple tumors of this kind  that develope on the  integumental  structures,
 whether cutaneous or  mucous, are warts and condylomata.   These  essentially
 consist in an increased deposit of laminated cuticle usually with some  augmented
 vascularity of the cutis.  They occur with especial frequency in the mucous, the
 muco-cutaneous, and  the more perspirable surfaces; thus the prepuce,  the vagina,
 the axilla, and  the cleft of the nates are their chosen  seats.   When occurring
 on the skin, they are usually hard  and horny where the cuticle is naturally dryj
and then constitute true warts; but where the skin is perspirable, and the cuticle
moist, they are  flattened, expanded, soft, and  white, and are then termed condy-
lomata or mucous tubercles.  When situated on the mucous membranes, they are
usually pointed, somewhat pendulous, or nodulated on the surface, very vascular,
and bleed readily when touched.
  Closely allied to some of these  warty structures  is a peculiar  pinkish-white
fibro-vascular tissue, which is occasionally met with in old cicatrices as an out-
growth of these, and not unfrequently recurs after removal; this disease is termed
cheloid.
  The general principles of treatment of these affections consist in  their removal
 by excision,_ ligature, or caustics, according to their  size, situation, and attach-
 ments. Excision is usually preferable when they are seated on mucous surfaces;
 the ligature should be used if they are large and pendulous, and caustics should
be employed when they are seated on the skin or a muco-cutaneous surface.
  Pendulous sarcomatous growths, forming large tumors commonly called "wens," 
                SARCOMA — POLYPI — FATTY  TUMORS.             381

may occur on  any part of the surface.  They are smooth, pedunculated, firm,
somewhat doughy, but non-elastic, pendulous, and  movable, slowly increasing
without pain, often to a very great size.   It is in warm climates, and in the Hin-
doo and Negro races, that  they attain  their greatest development, having been
met with fifty,  sixty,  and even seventy pounds  in  weight.   They are  chiefly
seated about the genital organs, enveloping the scrotum, penis, and testes in the
male, or depending from the  labia of the female.  That remarkable enlargement
of the leg occurring in the Mauritius, and some  parts of the West Indies, and
hence  termed Barbadoes leg, is an affection of this kind.  In structure these
growths appear to be a  simple  hypertrophy of the fibro-cellular element  of the
part affected, being composed of a loose reddish stroma, moist with a serous fluid.
In the treatment of these affections, pressure and iodine application may be tried
in the earlier stages, with  the view, if possible, of checking their growth; at a
later period they must, if large, be removed by operation, though this procedure
is at times an extremely severe one owing to the great magnitude  they attain.
   Polypi are  pendulous masses growing from any  mucous  surface,  but more
especially from the nose, ear, throat, uterus, and rectum.   The term polypus is
applied very indiscriminately  to various pendulous tumors growing from mucous
membranes.   The true mucous or gelatinous polyp is composed of the elements
of this membrane expanded and spread out, and consists of a loose fibrous stroma
covered by epithelium more or less distinctly ciliated, the cilia being often beau-
tifully seen when recent specimens are  examined under the  microscope.   The
so-called fibrous or medullary polyp consists of other  forms  of tumor growing
from, and covered  by mucous  membrane.   The true mucous polyp grows rapidly,
being a soft and vascular reddish-purple or brown-looking mass, and may expand
greatly, giving rise to serious  symptoms of obstruction in the passage in which
it is situated, bleeding freely when touched, destroying the bones by its pressure,
and  producing great mischief and disfigurement. It is especially in the nose and
the uterus that it attains to a large and dangerous size.  The treatment consists
in removing it according to its situation, its degree of vascularity, and the  nature
of its attachment by avulsion, ligature, or  excision.
  Hypertrophy of Glandular Structures.—This forms an important series of spe-
cial  affections,  chiefly occurring  in the lymphatic  glands, the breast, and  the
testes.  The part becomes chronically enlarged and indurated, often without any
signs of inflammatory action,  though in other cases as the result  of this condi-
tion.   On examination, the structure of the gland will either be found to have
undergone an imperfect and ill-developed  hypertrophy in some of  its lobules, or
to be expanded and infiltrated with plastic matter, the  consequence of chronic
inflammation;  or else to have undergone tuberculous deposition when occurring
in strumous subjects.   The principle of treatment in these tumors consists in an
endeavor to remove the mass  by frictions with the preparations of iodine, or by
the application of stimulating and absorbent plasters.  If these means fail, me-
thodical pressure may  sometimes advantageously be employed, and, as a last
resource, extirpation by the knife.
  Fatty tumors constitute an important class of surgical diseases, as they occur
very extensively in almost every part of the body, and  at all ages, though they
are most commonly met with about the earlier periods of middle life.   In the
majority of cases they appear to originate without any evident cause; in other
instances again they can be distinctly traced to pressure or to some local irrita-
tation, as to that of braces or shoulder-straps over the back and shoulders.  In
one  case I have known  the disease to be hereditarily transmitted to the members
of three generations of a family.
  Fatty accumulations occur under two forms, one   diffused,  the  other circum-
scribed ; it is only the latter variety that is termed the adipose tumor.  The dif- 
382
INNOCENT TUMORS.
      fused form of fatty deposition occurs in masses about the chin or nates without
      constituting a disease, though it may occasion much disfigurement.
         Fatty or adipose tumors may form in all parts of the body as soft, indolent
      inelastic, and doughy swellings, growing but very slowly;  being either oval or
      round, but not unfrequently lobukted, and occurring most frequently in the sub-
      cutaneous fat about the back and shoulders ; but occasionally met with between
      the muscles, in the neighborhood of joints, of serous membranes, as of the pleura,
      and of mucous canals.  A very curious circumstance connected with these tumors
      is that they occasionally shift their  seat, slowly gliding for some distance from
      the original spot on which  they grew; thus, Paget relates cases in which fatty
      tumors shifted their position from the groin to the perineum or the thigh.
         They may attain a large size, but only occasion inconvenience by their pressure
      or bulk; they rarely ulcerate or inflame, nor do they undergo any ulterior changes
      of structure.
         These fatty growths have been divided into three varieties, according to their
      structural differences.  The most common form of fatty tumor, that called lipoma,
      is a mass of yellow, oily, fatty matter and cellular tissue, enclosed in a fine thin
      capsule, having small vessels ramifying over its surface.  This tumor  is usually
      more or less lobukted, often remarkably dentated,  and sending out irregular pro-
      longations that extend to some little distance into the surrounding cellulo-adipose
      tissue.  Another variety, the cholesteatoma of Miiller, is of much less frequent
      occurrence; it is a smooth, laminated,  white and dry fatty mass,  contained in a
      cyst, and apparently composed of crystalline fat enclosed in meshes of cellular
      tissue.  The third  variety of fatty tumor  consists of masses occurring in the
      ovary, or in multilocular cysts in other situations.
         In the treatment of fatty tumors little can be done except by extirpation with
      the knife, by which the patient is speedily and effectually ridded  of  the disease,
      the wound always healing by granulation.   It is true that we have the sanction
      of Sir B. Brodie's high authority for the administration of the liquor potassac in
      these cases, under which treatment this eminent surgeon states that fatty tumors
      have  occasionally disappeared.
         Fibro-cellular  tumor.—This growth, described  cursorily by many  writers as
      the cellular tumor, has been more fully examined  by Paget.  It  is  not of com-
v     mon occurrence, and when met with it is most frequently found in the scrotum,
      the labium, the  deep  muscular interspaces of  the thigh, and on  the scalp, in
      which situations  it may form  tolerably large masses,  attaining  sometimes to a
      weight of many pounds.  When occurring about the scrotum and labium, these
      tumors must not be confounded with  elephantiasis of these  parts,  from which
      they may be distinguished by being limited and circumscribed masses, and not
      mere  outgrowths.   They occur only in adults who otherwise are in good health,
      and grow quickly, forming soft, elastic, rounded, and smooth tumors; they are
      not attended by any pain.   After removal  they  are found to possess a thin cap-
      sule,  to be of a  yellowish  color, and to contain a large  quantity of  infiltrated
      serous fluid,  which may be squeezed out abundantly.   As these tumors are of a
      perfectly  innocent  character, no hesitation  need be  entertained  about their
      removal.
         Tumors dependent on an increase of the vascular tissue, as aneurism by anas-
      tomosis,—of the nervous tissue, as  some  kinds of neuromata,—and  of osseous
      tissue, as exostoses, and never extending beyond the  structure primarily impli-
      cated, constitute such special affections, that it will be more convenient  to reserve
      their consideration until we come to speak of the particular diseases of the struc-
      tures to which they belong; and it will be sufficient for the present to indicate
      their existence as pertaining to this  group. 
FIBROUS TUMORS.
383
III.  TUMORS DEPENDING ON  THE  NEW GROWTH OF STRUCTURES, IDENTICAL
       WITH, OR VERY CLOSELY RESEMBLING, NORMAL TISSUES IN SITUATIONS
       WHERE THEY ARE NOT NORMALLY FOUND.

   This  class is  an important one,  inasmuch as  it contains not  only  innocent
growths, but some that  are  of a semi-malignant character.  The fibrous, the
fibro-plastic, and the enchondromatous tumors are  those that are chiefly met with
in it.
   Fibrous Tumors.—These growths are by no means so common as many of the
affections that have already been described; they  are met with in various situa-
tions, as in the  testes and mamma,  uterus  and antrum, about  joints,  in the
periosteum, in the subcutaneous cellular tissue, and in connexion with nerves.
The situations in  which  they are most frequent, and where  their structure is
most typical, is in the neck, especially in the parotid region, in the uterus and
the antrum.  In shape these  tumors are irregularly oval or rounded,  they are
smooth, painless, and  movable, they grow slowly, but may attain an enormous
size equal to that of a cocoa-nut or  watermelon.   Liston removed one from the
neck, which is  at present in the  Museum of the College of Surgeons, that
weighed twelve pounds;  they have, however, been found weighing as much  as
seventy pounds.   They are almost in-
variably single,  and  when  cut  into
present a white glistening ligamentous
structure, being composed of nuclea-
ted  fibres  like those of ligamentous
tissue (Fig. 127.)  These tumors may
remain  stationary for years, and this is
the condition in which they are often
presented to the surgeon.  Eventually,
however, they are apt to undergo dis-
integration, becoming infiltrated, cede-
matous, and softening in the centre,
or at various points of the circumfe-
rence ;  they then  break  down into a
semi-fluid mass,  the integuments co-
vering them inflame, slough,  and an
unhealthy  suppuration   mixed  with
disorganized portions of  the tumor  is
poured  out, leaving a large and un-
healthy sloughy chasm  from  which
fungous sprouts may shoot up : readily bleeding on the slightest touch and giving
the part a  malignant appearance; the patient eventually falling into a cachectic
condition, and becoming  exhausted by the hemorrhage and discharges.  In other
cases again, these  tumors may degenerate into a spongy calcareous mass of a
brownish color and hard consistence; but they never undergo proper ossification.
More rarely the interior of these growths softens and undergoes absorption, so  as
occasionally to form  cysts of large  size, containing fluids of various shades  of
color.   Paget relates the case of a very large cyst of this kind formed by the
hollowing  out of a fibrous tumor of  the uterus being twice  tapped by mistake
for ovarian dropsy.  The treatment  of these tumors is in a great measure pallia-
tive, but when  so  situated as to admit of removal, as in the neck, under the
angle of the jaw, or in the antrum, they should always be extirpated.
   The next class of tumors, though resembling closely in structure the fibrous,
is  of a  semi-malignant  character, showing a great tendency  to  recur after re-
moval ;  these are the malignant fibrous, the recurring fibroid, and the fibro-
plastic tumors.
  The malignant fibrous tumor closely resembles in its general appearance and
Structure of Fibrous Tumor. 
384
INNOCENT  TUMORS.
microscopic elements the ordinary fibrous growths, but its great characteristic is
its  recurrence after removal, with much  tendency to ulceration, sloughing, and
hemorrhage, forming not only in its original locality, but in internal parts of the
body at a distance from it.
  The fibro-plastic tumor was first described by Lebert, and has  been investi-
gated by Paget, who finds it  to stand  intermediate  in structure between the
fibrous and  fibro-cellular, resembling  pretty closely that of granulation-cells in
the process of development into fibro-cellular tissue.   It is found about the jaws,
in the bones, in the cellular tissue of the neck, and the mammary  gland.
  These tumors, called sarcomatous  by Abernethy, present peculiar characters.
On  making a section of them they cut in a uniform, smooth, and somewhat
elastic manner; are semi-transparent, shining, and juicy-looking, of a greenish-
gray, bluish or pinkish  color, often  spotted  or stained with  discolored marks,
varying in tint from a blood to a pinkish, brownish, or livid  red hue, which,
if extensive, gives them a fleshy look; their  structure is usually brittle.  They
most commonly occur in young people, without pain and without  any known
cause.    In the majority  of  cases they  may  be safely removed without the
prospect of recurrence, but occasionally and  without  any apparent reason, they
return after removal.  Paget relates two cases in  which the  disease appeared
to be malignant, one in which it returned in the breast after operation, the other
in which it occurred in the neck and presented decidedly malignant  characters.
  The recurring fibroid tumor has  been described by Paget  as closely resem-
bling in general aspect the common fibrous tumor, whilst in its microscopic struc-
ture it is very like the fibro-plastic tumor, its  most  marked  character being its
tendency to recur after removal.   Of this peculiar and hitherto undescribed dis-
ease, he relates two cases, one a tumor of the upper part of the leg, which, be-
tween 1846 and the end of 1848,  had been removed five times, reappearing for
the sixth time after the last operation, when, attaining a large size,  and becoming
ulcerated, amputation was deemed advisable;  this operation, however, was fol-
lowed by death.   The examination  of this  tumor presented  "  very  narrow,
elongated, caudate, and oat-shaped nucleated  cells, many of which  had long and
subdivided terminal processes."   In  the second case, a tumor  of  the shoulder
had been removed, and returned four times between May, 1848, and December,
1849, reappearing in the following year for the fifth time, the patient, notwith-
standing, appearing at this period to  be a strong and healthy man.  He also
relates a case by Giuge, in which  a similar tumor was five times removed from
the scapula, its sixth reappearance being followed by death.   The most interest-
ing of all, perhaps, is a case by Dr. Maclagan, in which, after three removals, no
further recurrence of the disease  took place.   It is  a remarkable  circumstance
that these recurrent tumors appear according to Paget, to become more malignant
in their growth in the later than in the earlier recurrences, acquiring more and
more the characters of true malignant disease, becoming more painful, rapidly
degenerating,  and giving rise to an ulcerating fungus, which eventually proves
fatal by exhaustion and hemorrhage.
  Enchondroma,  or the cartilaginous tumor, carefully studied  by Miiller, and
investigated by Paget, is  an  exceedingly interesting affection, whether we re-
gard the peculiarity of its  structure, its  comparatively frequent occurrence, or
the large size that it occasionally assumes.  It occurs under two distinct forms;
most commonly as  an innocent growth, but in other cases assuming a malignant
tendency and appearance.   These  two forms present different signs :  in the first
case, the enchondroma occurs as a hard, smooth, elastic, ovoid, round, or flattened
tumor, of small, or but of moderate  size, seldom exceeding that of  an orange,
and  growing slowly without  pain.  In  the  second  form, it  approaches in its
characters to malignant disease, growing with extreme rapidity,  and attaining an
enormous size  in a few months; under these  circumstances, it  would appear to
have occasionally been  mistaken for the rapidly spreading forms of encephaloid 
VARIETIES  OF  CANCER.
385
 disease.  When these growths attain a tolerably large size, though occasionally
 whilst they are still of but moderate dimensions, a process of disintegration may
 take place in them, they soften, break down, and liquefy in their interior, causing
 the skin which covers them to become  duskily inflamed, eventually to slough,
 and to form fistulous  openings, through  which  a  thin jelly-like  matter is  dis-
 charged.  ^ In some cases it would appear that large tumors of this description,
 softening in the centre, and becoming  elastic and  semi-fluctuating, have  been
 mistaken for cysts, and  have been tapped on this supposition.   In small enchon-
 dromata an opposite condition  occasionally occurs, the tumor becoming indurated,
 and undergoing ossification.
    In structure these tumors always resemble the purest foetal cartilage, and pre-
 sent a beautiful appearance in the large  size and distinct character of the car-
 tilage-cells imbedded in the clear blastema.
    Most frequently they occur in  connexion with some  of  the short bones, more
 particularly in those of  the metacarpus and the phalanges  of the fingers, pre-
 senting hard rounded  knobs in these situations,  where,  however, they seldom  at-
 tain a greater magnitude than a walnut or a pigeon's  egg.   When  large, they
 are commonly met with in or  upon the head of the tibia,  or the condyles of the
 femur,  forming in these situations  rapidly increasing growths of considerable
 magnitude.   They may also occur in the parotid region, in the muscular  inter-
 spaces of the thigh and  leg, in the testes.   When connected with the bone, they
 may either  spring from the  periosteum, gradually  enveloping, absorbing, and
 eventually destroying, the  osseous structures, though  at  first not incorporated
 with them.   This is their usual mode of origin when occurring in the femur  or
 tibia:  when seated on the short bones, especially on the  metacarpus and  pha-
 langes,  they commonly spring from the interior of the osseous structure, expand-
 ing, absorbing, and involving its walls in  the general mass of the  tumor.  Most
 frequently these enchondromatous masses occur in  childhood, or shortly after
 puberty, appearing as it were to  be an  overgrowth of  the cartilaginous element
 of the osseous system  at this period of life.
   The treatment consists either  in excision of the tumor or amputation of the
 affected part.  Excision may be practised when the tumor is seated in the paro-
 tid region, or otherwise  unconnected with bone.  When  forming a part of the
 osseous structures, it cannot well  be got rid of without the removal of the  bone
 that it implicates by amputation.   If, under these  circumstances, excision  of
 the tumor only be  attempted, it will be  found that the  whole mass cannot  be
 removed,  and that it rapidly grows again, or  that the wound formed by the ope-
 ration remains fistulous and open.    Most  commonly a permanent cure is effected
 by the  ablation of  the  tumor in one or other of these  ways, but  cases have
 occurred  of  the  more rapidly growing form of the disease recurring, after  its
 removal, in a softer state than before, and with a close approximation to malig-
 nancy in appearance  and action.   It  is worthy  of remark, as showing the  con-
 nexion between enchondroma and malignant disease, that cartilaginous masses
 have been met with in the midst  of encephaloid tumors of the bones and testes.

                           MALIGNANT  TUMORS.8
   Having now considered innocent tumors, that have no tendency to contaminate
 neighboring  structures,  or to  return after  removal;  and  the semi-malignant,
 which, under certain obscure conditions, local or constitutional, as yet  undeter-
 mined, have a disposition to recur after operation; we next proceed to the study of

 » It is not my intention to enter largely into the general history of malignant diseases, as space will
 not admit of my doing so; I would therefore refer my readers who wish for further information on this
interesting subject to the works of Abernethy; the papers by Lawrence; the admirable and magnificent
'•Illustrations of the Elementary Forms of Disease," by Sir R. Carswell; to the excellent and copious
monograph by Dr. Walshe; and to Mr. Paget's philosophic Lectures on this subject.  In these different
sources will  be found nearly all the information at present possessed by the profession on the important
and interesting subject of Cancer. 
386
MALIGNANT  TUMORS.
the malignant growths which have, as it were, a natural and constant tendency to
affect the  system, to implicate neighboring structures, and  to return in their
original site, or at a  distance from it, after extirpation.
  By malignant tumors are meant the various forms  of cancer.  This differs
from  all normal  structures by being distinctly  and  essentially a new product,
never, under any circumstances, existing in a healthy system,  and possessing
vital properties and  an organization that is peculiar to  itself.  Cancer presents
itself in four if not five varieties, which differ  so much from one another in
appearance, in rapidity of growth, in consistence, color,  and structure, as at first
sight almost to appear to constitute essentially different diseases, but yet having
so close a family resemblance, and presenting so many points of identity, that
physiologically and pathologically speaking, they must be considered as  mere
varieties of the same class of tumOrs.  The varieties of cancer generally admitted
are the scirrhus, or the hard cancer; encephaloid, or the soft cancer; colloid, or
gelatinous  cancer; melanosis, or  the black cancer; and, lastly, those  affections
which are  classed together under  the  term  of epithelial cancer, cancroid or
diseases.
  These various forms of cancer differ from one another in appearance and con-
sistence; the scirrhus being hard, firm, semi-transparent, of a bluish or  grayish
color; the encephaloid being brain-like in appearance, soft, and hemorrhagic; the
colloid resembling glue,  or honey in its comb; the melanosis being black, some-
times solid, at others liquid; and  the epithelial form  occurring as nodules or
ulcers, presenting peculiar characters.   They vary also  in the rapidity of their
growth, in  their vascularity, and in the order of their malignancy, in all of which
respects they may be arranged as follows : 1st. Encephaloid;  2d. Scirrhus; 3d.
Melanosis;  4th.  Colloid;  5th. Epithelial cancer.
  Great as the differences amongst them are, however, the points of resemblance
are still more striking;  thus, one form of cancer may take the place of another,
or be associated with it;  encephaloid occurring after the removal of scirrhus, or
being associated  with melanosis;  or  colloid and scirrhus being met with together
in the same tumor.  This identity of seat and of recurrence, which tends more
than anything else to establish a common origin amongst these tumors, has been
specially pointed out by Carswell.   Then, again, these tumors are all of a truly
malignant character, having a tendency to induce a peculiar and similar condition
of system  that goes  by the name of the  cancerous  cachexy.   In  chemical  com-
position, also, they are all very nearly identical, being principally composed of
albumen.
  The microscopic characters of the different forms of cancer have of  late  years
attracted considerable attention amongst pathologists.   They consist, in all the
varieties, essentially  of the same  elements, though these may differ somewhat in
appearance, and in relative preponderance, in the different  forms of the affection.
In all there is a fibrous stroma or basis, firmer and closer in some, as in scirrhus,
                                     than in the  others.   This yields by scrap-
                                     ing or pressure a turbid fluid, termed the
                                     cancer juice, in which  granules, cells, pig-
                                     mentary, and  fatty matters, are found in
                                     varying proportion.  The granules, which
                                v     are  minute, sometimes  amorphous, at
                                '^*%  others presenting that peculiar vibratory
                                     condition termed the molecular movement,
                                     are met with in all the varieties of cancer,
                                     though they occur in largest quantity in
                                     scirrhus.  The cells, to which great impor-
Ceiis from Scirrhus of Breast "(rapidly reeurring). tance has been attached by various observ-
                                     ers,  and which have  often  been looked
 
VARIETIES OF  CANCER.
387
upon as characteristic, or pathognomonic, of the disease, though perhaps  erro-
neously so in the strict accep-
tation of  the term, present,
however, such peculiar  char-
acters, that it is almost impos-
sible to  mistake them.  They
are spherical, fusiform or spin-
dle-shaped, elliptic or caudate,
having often two or three ter-
minations,  are usually  com-
pound  and nucleated  (Fig.
128).   These various appear-
ances are presented by them
in all forms of the  disease;
it is, however, more especially
in the  encephaloid variety
that they assume a large size,
and present their  most mark-
ed fusiform and caudate shapes
(Fig. 129).  The  pigmentary
cells  are principally, if not
altogether, found in melanosis.
  Much diversity of opinion
exists amongst surgeons  as to
the value  that   should be
attached to these  microscopic
Fig. 129.
Cells from Encephaloid of Tongue (rapidly growing).
 signs  in  determining the true nature of many tumors; some being guided by
 these  appearances  alone, others looking upon them as uncertain  and fallacious,
 and trusting  rather  to the general characters of the growth.  The latter, how-
 ever, appears  to  me  to be too limited a view of the subject, for although the
 unaided eye of an experienced surgeon  may in many cases recognise the  true
 character of a tumor, and the microscope in some few instances fail to reveal it,
 yet there can  be no doubt that in many cases, it  is only by the aid of this instru-
 ment that the real  nature of the growth can be determined.
   It is doubtless true that every one of these  microscopic elements may sepa-
 rately occur in the  normal tissues of the body, some in those of the adult, others,
 as the caudate and fusiform corpuscles, in the embryo, in whose  skin these are
 largely met with:  but though this be the case, it does not  appear that they are
 ever found in any tumors, except those of a malignant nature; and in these it is
 rather by the  aggregation of these appearances,  than by any single one in parti-
 cular,  that the true character of the disease is determined.  In these examina-
 tions, however, the experienced surgeon will find that the appearances presented
 to the naked eye will assist him much in pronouncing upon the malignant or
 cancerous character of the tumor.   It is  certainly a remarkable circumstance,
 that the  " recurring," or semi-malignant diseases, as well as those that are truly
 cancerous or positively malignant, present under the microscope structures that
 closely resemble those of tissues in process of development,  either in the form of
 imperfect exudative matter and fibro-cellular tissue, as in the fibro-plastic tumors,
 or in the similarity presented by the corpuscles of encephaloid, to some of those
 of the integuments  in the embryo.
  The general characters that attend  the progress  of these several forms of
 cancer present numerous points of resemblance.   When once formed, the tumor
 continues progressively to increase in  size with  a degree of rapidity, and to an
 extent that  varies  according to its  kind; the  scirrhous tumors  growing most
slowly, and attaining but moderate dimensions; the encephaloid and colloid often 
388
MALIGNANT TUMORS.
with great rapidity, and  to  an immense size.  When the full growth  of the
tumor is attained, the process of decay commences.   The  mass softens at some
point, the skin covering which becomes duskily inflamed and ulcerated, an irre-
gular sloughy aperture forming, through which the debris of the mass are elimi-
nated in an ichorous or sanious fluid, having often a peculiar fetid smell.  The
ulcer then pretty  rapidly increases with everted edges, a  hard and  knobby, or
soft and fungating surface, and the discharge of a dark fluid, often attended by
hemorrhage, and occasionally with  sloughing of portions of the mass.   Coinci-
dent with the implication and ulceration of the skin, there is usually deposit in
the lymphatic glands  with great increase of pain, and most commonly with the
supervention of the constitutional cachexy;  though in some cases this condition
precedes the cutaneous implication.  This  cachexy  appears to be  the result of
the admixture of cancer germs with the blood, and their circulation through the
body;  or to some other modification in the condition of the blood induced by
the action of this growth on the economy.   The exhaustion resulting from the
ulceration, sloughing, and consecutive hemorrhage also commonly increases this
cachectic state.  In many instances it  is not marked until after  the skin has
become affected, and in others it does not supervene until  ulceration is actually
set up.   In this cachexy the countenance is peculiarly  pale, drawn and  sallow,
so that the patient has a very anxious and care-worn look.   The general surface
of the body commonly acquires an earthy or yellowish tint, and not unfrequently
large spots of pityriasis or chloasma make  their appearance on  various parts of
it; the appetite is impaired, the voice  enfeebled, the muscular strength greatly
diminished, and the pulse weak.  The patient complains of pains in the limbs,
of lassitude, and of inability for exertion; he emaciates rapidly, and frequently
suffers  by the  occurrence of cancerous  deposits  in internal organs; and at last
dies from exhaustion,  induced by the conjoined effects of weakening discharges,
general debility, and pain.
   These general characters,  however,  present certain varieties of importance,
according to the form  of cancer that occurs.
   The  scirrhus, or hard cancer, is most commonly met with in the  breast and
lymphatic glands.   It occurs in two forms, either as a circumscribed mass, or
infiltrated in the tissue of an organ.  In either case  it forms a hard, craggy, in-
compressible, and nodulated tumor, at  first  movable and unconnected with the
skin, but soon acquiring  deep-seated attachments, and  implicating the integu-
ment.   It  grows slowly,  seldom attaining a larger size than  an orange.   It is
painful, aching generally, at times with much radiating and shooting pain through
it; these sensations vary  according to the part affected,  and to the sensibility of
the individual.   The pains are especially severe after the tumor has been han-
dled, and at night are of a lancinating  neuralgic character.   It  may thus con-
tinue in a chronic state for a considerable length of time, slowly increasing,
gradually extending its deeper prolongations, and implicating the more super-
ficial parts.  In some cases,  more particularly in  elderly people, scirrhus gives
rise to  atrophy of the organ in which  it is  seated, causing  wrinkling and puck-
ering of the surrounding skin which becomes adherent to the tumor, which may
thus continue in a very chronic state.
   The  ulceration usually takes place by the skin becoming adherent by one point
to the tumor, either by dimpling in, being as it  were drawn down towards it, or
else by being pushed forwards, stretched, and implicated in one of its more pro-
minent masses.  It then becomes of a dusky and livid red, somewhat glazed,
and covered by a fine  vascular network.   Softening occurs at one point, where
a crack or fissure forms; a clear, gummy drop of fluid exudes from this, and dries
in a small scab upon the surface; this is followed by a somewhat bloody discharge
of a thick and glutinous  character; and the small patch of skin from which it
issues  becoming undermined, speedily  sloughs  away, leaving a  circular  ulcer. 
SCIRRHUS  AND  ENCEPHALOID.
389
This  gradually enlarges, becoming  ragged and sloughy, with craggy  everted
edges, having irregular  masses rising from its  surface, and discharging a fetid
sanious pus.   The pain increases  greatly, and the lymphatic glands  becoming
involved the cachexy is  fully developed, and the patient is destroyed by it, or by
the secondary visceral deposits.  In old  people, ulceration of scirrhous masses
often assumes an extremely chronic character, the  growth in them not beino-
endued with the same vitality as in the young.   The ulcer in these cases is flat,
sloughy, of a grayish-green color, hard,  and rugged,  with  puckered edges, much
wrinkling  of the surrounding skin,  and exhaling  the usual fetid odor.   In
younger persons, and especially in stout women  with florid  complexions,  this
disease usually makes rapid progress.  So also, if inflammation be accidentally set
up in the neighboring tissues, cancerous infiltration takes place in them, in con-
sequence probably of the  products of  inflammation effused around the tumor
undergoing cancerous transformation almost as soon as deposited.   I had lately
under my care an old  man with a cancerous  tumor of the leg, which,  after
remaining stationary for seven years, became accidentally inflamed, and has since
then increased with very great rapidity.   Occasionally, but very rarely, scirrhous
masses slough out, leaving  a large ragged cavity, which may even cicatrize, and
thus a spontaneous cure has been known to have occurred.
   The secondary deposits from scirrhous tumors  may take place in the  viscera,
or the lymphatic glands;  in  the  former situation, they are usually of an ence-
phaloid character, in the latter they assume the  scirrhous  form.
   After a scirrhous tumor has been  removed, though still feeling firm under
the fingers, it is not so  hard as when it was in the  body, owing, as Dr.  Walshe
observes, to the escape of  its fluids and consequent loss of  turgescence.   On
cutting it with a scalpel it usually  creaks somewhat as it is divided, and presents
a whitish or bluish-white glistening surface, intersected by white bands, which
apparently consist partly  of new  structure, partly  of included cellular tissue.
This  section has not inaptly been compared  to the appearance presented by a
cut through a turnip or an unripe pear, hence termed napiform and apinoid by
Walshe;  and, from  its  reticulated character, carcinoma  reticulare, by  Miiller.
On examining the fibrous  stroma, or  network, which forms the basis of the
tumor, it will be found  to be  composed of fibrous or fibro-cellular tissue.  The
soft grayish-blue granular material seated in the meshes of this, may be squeezed
or scraped off in  a liquid state as cancer-juice.   This is composed of a multitude
of nucleated corpuscles, granules, granular cells, and globular, caudate, or  spindle-
shaped bodies.
   The encephaloid, or soft cancer, or as it is  often termed medullary sarcoma,
is  the most malignant and rapidly  growing form of this disease.   It is met with
in the globe of the eye, in the nares or other cavities of the face, in the articu-
lar ends of bones, the testes, and the breast, and often attains an  enormous size,
equal to that of an adult head, or of half the body.  It occurs  in two stages,
either as a tumor, encysted or infiltrated, or as a fungus after protrusion through
the skin.
   It  commences as  a tumor,  which,  though occasionally somewhat hard, is
usually from the first, or at all  events soon becomes,  soft and elastic, being more
or less lobukted, growing rapidly, and having a semi-fluctuating feel.   The skin
covering it is at first pale and loose, with a large network of  blue dilated veins
spreading over it.   As the tumor enlarges, the skin becomes  adherent,  dis-
colored, of a purple-brown tint, and at last ulcerates at one point; from this a
large  fungous mass,  rugged,  irregular, dark-colored, and. bleeding profusely,
rapidly  sprouts forth, constituting the affection to  which Mr. Hey  gave the
appropriate  term of fungus hsematodes; when once this  condition  has  been
reached death rapidly ensues from exhaustion and hemorrhage.   Pulsation has
been met with in particular forms  of very vascular encephaloid; in these cases 
390
MALIGNANT  TUMORS.
also  a loud bruit has been detected that may be heard on the application of a
stethoscope,  synchronous with  the pulsation and the  heart's  action.  These
symptoms have been most frequently met with in encephaloid tumors connected
with bones, and may, unless care be taken, cause  the disease to be confounded
with aneurism.
  The constitutional cachexy in encephaloid occurs early, and is well marked,
and  secondary affections of  the  lymphatic glands  and viscera often occur, occa-
sionally of a scirrhous character.
  After removal the tumor is found to be very vascular, displaying on injection
a close network of vessels.  On a  section being made, it commonly presents  a
soft pulpy white mass, closely resembling cerebral substance, stained and blotched
with bloody patches, varying in  color from a bright-red to a maroon-brown, and
dependent on blood that has been infiltrated into its  substance.  In other cases
again, its  section has been compared to that of a raw potato or a piece of boiled
udder.  On closer examination its tissue  will be found to consist of a stroma of
delicate fibres supporting the  soft medullary or brain-like  structure; this may
be seen to be composed in a great measure of large quantities of corpuscles, nu-
cleated, compound, and granular, fusiform, angular, clubbed,  or caudate, often
with two terminations.
  The colloid, gelatinous, or alveolar cancer, may occur in distinct masses, often
of very large size, or be infiltrated  in  the tissue of organs; as it  is most com-
monly met with in the  viscera, it does not so often fall under the observation of
the surgeon as the other varieties of cancer.   Yet it may occur superficially, as is
shown by  a preparation in the University College 3Iuseum of a scirrhous breast
containing colloid.
  In structure it consists of cells filled with a clear  semi-transparent yellowish
gelatinous or honey-like material, resembling indeed  exactly the structure of a
honeycomb.   The septa forming these cells are distinctly  fibrous, and regular in
their arrangement.   The gelatinous matter contains caudate and nucleated cells
in considerable quantity, presenting the  same characters  as those  of the other
varieties of cancer.
  Melanosis, or black cancer, has been specially studied by Sir Bobert Carswell,
who  arranged it  under the  heads of punctiform  melanosis, in which the dark
pigmentary matter occurs-in the shape of minute points or dots scattered over a
considerable extent of  surface.   The tuberiform melanosis, occurring in tumors
which vary in bulk from a  millet-seed to an egg or an orange, always assuming
a globular, ovoid, or lobukted  shape, and being principally  met with in the
cellulo-adipose  tissue, or on  the  surface of serous  membranes.    The stratiform
and liquiform melanosis, which occur principally upon serous membranes, or in
accidental cavities, where the  black pigmentary matter looks not unlike Indian
ink.   Melanosis most frequently presents itself to the  surgeon in connexion with
the eye, occasionally in  the skin  and subcutaneous cellular tissues,  and rarely in
the bones.  It resembles somewhat in its general progress and characters the
encephaloid form of cancer, ulcerating and throwing  out  dark  fungous masses;
occasionally indeed, as Carswell  has pointed out, it is distinctly associated with
the other varieties of this disease.   In  microscopic  structure  it somewhat  re-
sembles encephaloid, consisting of a stroma, with caudate, granular,  and com-
pound cells, but containing  a  large quantity of pigmentary matter in granules,
molecules, and masses.
  The diagnosis^ of  the different forms of cancer is not always  easily made.
Scirrhus when in tumor may very readily be  confounded with fibrous tumors
and various chronic  glandular masses, or with the indurated atrophy of a part;
in many of which cases indeed  the diagnosis cannot  be correctly effected until
after removal.   In other cases, however, the rugged  feel, the lancinating pains,
the tendency to the implication of the lymphatics, or to affection of the general 
DIAGNOSIS  AND CAUSES  OF  CANCER.
391
health, will commonly serve to establish the  diagnosis.  When ulcerated, the
previous condition of the tumor, the general character of the sore, and the micro-
scopic examination of the debris, may serve to  establish its true character.
  Encephaloid in tumor, may be confounded with abscess, cysts, fatty, erectile,
and  sanguineous  tumors, and when pulsating, with aneurism.   In these cases
careful palpation, the existence of elasticity, without fluctuation, and the pre-
sence of the large and  tortuous veins ramifying over the surface of  the  mass,
may establish its  true character.  When it is fungating, it might be confounded
with the sprouting intra-cystic growths, that sometimes  spring from the interior
of a  cystic tumor.   Here  however a microscopic examination of the debris, as
well as the existence  or not of contamination of neighboring lymphatics, will
establish the true nature of the affection.
   The causes of  cancer are often exceedingly obscure.   In  many cases it un-
doubtedly is of an hereditary character, not  that the disease itself is existent at
birth, but that the tendency to it is in some way connate; that  tendency mani-
festing itself at those periods of life and in those organs in which cancer usually
developes itself.  It  may, however, actually be  a congenital affection ; thus it has
been met with  in the eye at birth, and in the Museum of University College, is
a preparation of a small melanotic  tumor existing  in the cerebellum of a child
that only lived three days after birth.   It may occur at all  periods of life from
the earliest ages ; and will evince itself  in  persons from eighty to ninety years
of age.  According to Dr. Walshe, the mortality from cancer goes on steadily in-
creasing till the eightieth year; hence the  popular belief that the middle period
of life is most obnoxious to it, would appear to be an erronous one.   All forms
of cancer are not  however  met with in equal  frequency at all ages;  the ence-
phaloid being the most common in the young,  and scirrhus in the middle-aged
and  elderly.   Colloid rarely occurs  before  the age of thirty.    Cancer often
appears without any exciting cause, when it is evidently as in hereditary and
connate cases,  the result of some peculiar constitutional condition, the nature of
which is altogether unknown to us, but under the influence of which the peculiar
growth characterizing it springs up.  In many cases, however, it can  be traced
to some exciting  cause,  being immediately occasioned by a blow,  injury, or other
violence, or by a long-continued irritation of the part, that  eventually becomes
affected.   Thus in women a blow on the breast often gives rise to cancer, and
the irritation of a broken tooth may occasion it in the tongue.   It is a question
whether external  causes of this kind can give rise to the production of cancer
without the  previous existence of  constitutional predisposition  to the  disease.
That cancer even when  apparently excited by  local  causes, may  in reality be of
constitutional origin, cannot admit of a doubt;  more especially in those  cases in
which it is  hereditary, or in which it  makes its appearance almost simultaneously
in different parts of the body with a strongly marked cachexy.   So also cancerous
tumors occurring in  full-blooded and florid  people as it  were from a superabun-
dance of material in  the system, as  in  stout  ruddy women  about the middle
period of life, is  far  more rapid in its progress, and much more  constitutional
in its character, than the slowly-spreading form of the disease in elderly persons.
But in many other instances it certainly appears to be local in its origin,  as when
it slowly occurs after  the infliction of some  violence, and without any evidence
of constitutional disturbance or contamination.   It is true that it may  be argued
that the cancer could not be excited locally in  these cases unless a tendency to
it already existed in the system.  But this appears to me to be a begging of the
whole question ; there is no proof of the existence of any constitutional affection
at the time of the occurrence of the disease, or until it has existed for a sufficient
length of time for the lymphatics to  be affected and the blood to be  poisoned ;
and it certainly appears to  be more reasonable  to look upon the  local  disease as
the primary affection, occurring  originally in  a  healthy constitution, but  after 
392
MALIGNANT  TUMORS.
a time infecting the system generally, than to regard the mere local manifestation
as in itself a proof of the constitutional nature of the disease.  It is true that
we are ignorant of the manner how a cancer-germ can be produced by the local
action of the  part in which it is generated, but we are as little acquainted with
the  essential mode of  production  of an exudation-cell or of  a  pus-corpuscle,
which we know to be the result  of strictly local actions;  and it seems to me that
the  difficulty is in no way solved, but simply pushed back a bit by the  attempt
to prove that in all cases of cancer-formation, a constitutional cause or predisposi-
tion exists, which impresses the cancerous  character upon local  actions taking
place in such a system.   The cases in which cancer appears to be primarily and
strictly  a local affection, influencing the constitution secondarily, are by no means
of unfrequent occurrence—we commonly see, for instance, a woman in perfect
health receive a blow upon the  breast, which gives rise to some passing incon-
venience at the time; after a lapse of some weeks, though still with an unimpaired
state of health, she notices a  small lump of a scirrhous character.  This may
continue stationary, or but slowly increase for months or years, and it is not
until the lymphatics become enlarged, and  the glands in  the  axilla indurated,
that  the constitution begins to suffer, and a  tendency  to  secondary deposit to
manifest itself.   In fact in  such  cases  as  these  there would seem  to be no
evidence whatever of any affection  of the constitution, or of any general predis-
position to cancerous disease, until after sufficient time has elapsed for the germs
to be absorbed, and the  blood to be poisoned by them.

                         TREATMENT OF CANCER.
   The treatment of cancer may be considered to be of a constitutional and of a
local character.  All curative constitutional treatment is,  I believe,  utterly useless
in cases of cancer, no constitutional remedies appearing  to  have  any influence
on the progress of this  disease.   I am not acquainted with  any case of cancer,
either from my own  observation,  from conversation with  other  surgeons, or
from published statements,  that afford satisfactory evidence  of any internal
remedy having cured this disease.   It is true that many so-called cases of cancer
have, at various times, been stated to have been cured  by different medicines,
but it must be borne in mind,  that  in a less  advanced  state of  pathological
knowledge than exists at  the present  day, almost all hard chronic tumors were
called scirrhous, and  many intractable ulcers,  cancers;  mistakes  which are not
unfrequently committed, and sometimes unavoidably so, even with the improved
means of diagnosis that  we at present possess.   Not  one of  the many remedies
that have been vaunted  as being specific in this  disease, and by  which cures
have been stated to have been effected, has obtained the confidence of the pro-
fession, or  has, on further trial,  corresponded in  its  effects to  the statements of
those who introduced it.   I  therefore think it but waste of time  to discuss the
supposed advantage to  be  derived  from  hemlock, iron, arsenic, and  iodine, in
the treatment of cancer.  But though curative treatment  can effect nothing in
these cases, much may be effected towards the alleviation of the patient's suffer-
ings, and perhaps even towards retarding  the progress of the disease, by proper
palliative treatment.  With this view, the diet should be mild, nutritious, easy
of digestion, unstimulating, and sufficient to support the  strength under the
wearing influence of pain and discharge; and the preparations of opium, of conium
and  hyosciamus, must be freely  administered in  order to relieve  the patient's
sufferings, and to procure rest.
   The local means are those upon which the  surgeon places the greatest reliance
in these affections.  In  order to prevent the rapid extension of "the tumor, it is
of great importance to subdue all local excitement going on within and around
it;  in proportion to the amount of action existing in the part the  disease will
usually  extend; any inflammatory  condition of  the  neighboring  tissues being 
TREATMENT OF  CANCER.
393
 especially prejudicial in this respect.  Hence, under these circumstances, the
 occasional application of a few leeches will often be of considerable service, and
 ice, as recommended by Dr.  S. Arnott, may be useful with the same view.   No
 counter-irritation, however, ought ever to  be employed in the vicinity of the can-
 cerous part, as it only excites action in and around it, and hastens the process of
 ulceration.   If the  tumor be painful, and the skin  covering it  still unbroken,
 great relief may be obtained by the application of belladonna plasters.   In some
 cases I have found powdered conium, spread  on cotton wadding, useful in  the
 same way.  As ft is of importance to  prevent, as long as possible, any breach of
 surface, the application of these sedative  plasters and powders, should be perse-
 vered in with the view of supporting  the integument.
   When the tumor is ulcerated, the fcetor must be diminished by the application
 of weak solutions of the chlorides, to which opiates may be advantageously added
 with a view of lessening the pain.
   Caustics should never be  employed unless  the  tumor is ulcerated, and then
 they can but very rarely indeed be had recourse to with  any  prospect of success.
 It is only when the  ulcer is so situated that it cannot be attacked by the knife,
 that they can be used with  any prospect of advantage, and even then they are
 very apt, in most cases, to irritate and produce extension of the disease, by ex-
 citing inflammatory action around it; occasionally, though very rarely, some small
 tumors or tuberiform masses  may be enucleated, as it were, by forming a sulcus
 around them with the caustic.  Caustics are the agents that are usually employed
 by empirics, who profess to cure  cancer by secret means, and without having re-
 course to operative procedures, and it  may doubtless be the case that such  indi-
 viduals occasionally,  though  very rarely,  indeed,  effect  an accidental cure, by
 exciting so much inflammation in and  around  a tumor as to lead to its sloughing
 and consequent elimination.   It  has  been said that cancers  removed by caustic
 are less likely  to  return  than if extirpated by the  knife;  of this, however, I
 believe there is no evidence.   The most  convenient caustics to employ in the
 few cases admitting of their use,  are the chloride of zinc, made into a paste with
 two parts of flour; or the Vienna paste, composed of fused potass and quicklime
 moistened with alcohol, and thinly applied over the part  to be destroyed.
   The local means of a more directly  curative character that are commonly had
 recourse to in  the treatment of  cancer, are compression of  the  tumor,  and its
 removal by the knife.
   The treatment by  compression is a plan  that has  been alternately greatly ex-
 tolled and much depreciated.   It was  fully tried at  the  Middlesex Hospital, by
 Mr.  Young, thirty-five years  ago, and unfavorably reported upon by Sir Charles
 Bell at that time; it consequently fell into disuse in this country, but was  re-
 vived by  Kecamier  in  France, and employed largely by  him.   Although he
 published a favorable account of this practice, it made but little progress amongst
 French surgeons, the only one who seems to  have used it to any extent, being
 M. Tanchou, who  employs a peculiar  topical medication conjoined with  it.   In
 this  country  the practice fell  into complete  oblivion, until Dr. Arnott, about
 twelve years ago, invented a mode of employing pressure by  means of an elastic
 air-cushion; since which  time it has been pretty extensively  employed  with
 varying degrees of success.
   In employing pressure,  Young principally had recourse to plasters and ban-
 dages.   Kecamier  used amadou applied with an elastic roller, and Tanchou re-
 commends spring pads, under which  small bags or  pieces of cotton-wadding,
 impregnated with  various medicinal substances, are placed, so as to protect  the
 skin and act upon the  tumor.  Dr. Arnott's plan consists of pressure exercised
 by a  Mackintosh air-bag, held in its place by straps, and pressed upon by a truss-
spring, the  pressure  exercised  by which may  be made to vary from two  and  a
half to twelve or even sixteen pounds.   These different plans should not  be  em- 
394                      MALIGNANT  TUMORS.

ployed indiscriminately, but may all  be of service in particular cases.  I have
employed them all, and have occasionally found some advantage from  each.  In
those cases in which the apparatus invented by Dr. Arnott exercises too strong a
pressure, or is too weighty, I have found Tanchou's elastic pad, or the amadou
applied with an  elastic  roller, to give a degree of support that can be usefully
borne.
  The first question that necessarily  arises in  reference to the  employment of
pressure  in these cases, is whether it can effect a cure.  This it could only be
expected  to do  by producing  atrophy and  the subsequent absorption of  the
strictly local forms of cancer.  The only case  on record with any pretension to
a conclusive character in this respect, is one related by Dr. Walshe, in his excel-
lent  "Treatise on Cancer," of the cure of a tumor of the breast, believed to be
cancerous, by compression.  But even  this instance I cannot look  upon as by any
means conclusive; for although no one  can entertain a higher opinion than I do
of the very remarkable diagnostic tact possessed by Dr. Walshe, yet I think there
can be no doubt in the mind of any surgeon that it is absolutely impossible to
determine in many cases, by any amount of diagnostic skill, the true nature of a
chronic tumor of the breast, and that in fact we constantly see  the most  expe-
rienced practitioners find after the removal of the tumor that it was of a different
character to what they had  previously anticipated.   This  difficulty attaches to
Dr. Walshe's case, and  I think that we possess no proof that the tumor  of  the
breast, which underwent absorption  under the  pressure of Dr. Arnott's  appa-
ratus, was of a truly cancerous character, and  that  it might not  have been a
chronic mammary tumor or  some similar growth, that we  know will  disappear
under this kind  of treatment.
  But if  compression cannot be shown ever to have cured a cancer, can  it  not
retard the progress or relieve the sufferings attendant upon  this disease ?   I  be-
lieve that in some cases it  may certainly do both, though  in others it is as un-
questionably injurious.   It appears occasionally to retard the growth of the tumor
when applied in the early stage, simply by preventing its  expansion, and per-
haps, by  diminishing the supply of blood sent to it by compressing its nutrient
vessels, and by causing absorption of surrounding inflammatory  infiltration; in
these cases likewise it relieves the pain  by lessening the turgescence of the part.
In other  cases, however, I have known  it to act injuriously  by pressing out and
diffusing the tumor more widely, appearing to increase the tendency to implica-
tion  of neighboring parts, and occasioning great suffering.   When the tumor is
ulcerated, or if  the  skin covering it is inflamed, pressure cannot be employed
with any advantage; and most  commonly irritable, sensitive patients cannot sup-
port  the constriction of the chest that it induces.
  Operation.—With regard to the question of removing cancers by  the knife,
much  difference of opinion  exists amongst surgeons, for  though  all  deprecate
indiscriminate recourse to this means in  this affection, some go sofar as to dispute
the propriety of ever operating for this disease, whilst others restrict  the opera-
tion  to certain cases of a favorable character.   These  questions are necessarily
of considerable  importance, and require attentive consideration.
  The objections that have been urged against  the general propriety of operating
in cases of cancer, do not apply so much to the operation itself, the risk attend-
ing which is not greater than  that of other operations of similar magnitude, as
to the liability of the patient speedily suffering from  a return of the  disease, so
that  an operation that  is at least unnecessary will have been performed.   That
this  objection is in  a  great  measure a valid one, is undoubted;  the experience
of all surgeons tending to establish the fact that the majority of patients operated
upon for cancer, died eventually, and usually within a limited time, from a recur-
rence  of the  disease.   Thus,  Sir A.  Cooper  states, that  in only nine  or  ten
cases out of a hundred, did the disease not return in three years; and Brodie has 
OPERATION  FOR CANCER.
395
found that it generally proves fatal in two or  three years after the operation.
After removal of the tumor, the disease may return in the cicatrix, even  before
this is healed : in the neighboring lymphatic glands  with or without the cicatrix,
having been involved, or in internal organs.  When it returns in the cicatrix, it
usually makes its appearance  in the form of small  hard nodules of a  purplish-
red color, and covered with a very thin integument, which  speedily runs into
ulceration, presenting the ordinary characters of the  cancerous sore.  The disease
is especially apt to recur if the skin have become involved, if the  lymphatic
glands are enlarged, or if there be constitutional cachexy before the operation;
so also, if the tumor is growing rapidly at the time of removal, and especially if
the patient be robust and strong, with a florid complexion.
   In determining the question of operating in  cases of cancer, several points  of
great importance present  themselves for the consideration of the surgeon.  He
has first  to consider whether the operation  is likely to free his patient completely
from the affection;  or,  in  the event of its not doing so, whether at least life may
not  be  prolonged by the removal of the cancerous tumor; and,  lastly,  even
though  the patient  be eventually carried off as speedily as he otherwise would
be, whether his sufferings may not be much lessened by the removal of the local
affection.
   That in some cases a cancerous tumor  may be removed with  every expecta-
tion of the patient being completely freed from  the  disease, cannot, I  think, be
doubted; although it may be true that such instances are not of frequent occur-
rence.   Yet they occasionally fall under the observation of surgeons, and would
certainly tend to prove that  the affection is not in all cases of a constitutional
character, and that  if we can  happily succeed  in  removing it during  its local
condition, there  is a good prospect that the patient may be rescued from a return
of the affection.   The evidence  of Sir B. Brodie  on this point is  extremely
valuable; writing  in 1846, that  eminent surgeon  states, that " So long ago  as
1832, I removed a breast  affected with a scirrhous tumor, and the lady is still  in
good health—at  least, she was so last year.  Since the operation she has married,
and had  children.   Last year I was called to see a lady on account of another
complaint, on  whom I performed the operation thirteen years ago, and found
that she  continued free from  the old  disease; and, very lately, I have heard  of
another lady, whose scirrhous breast I removed six years ago, and who continues
well."   The evidence of Mr. Fergusson is also very positive on  this point, and
he speaks in a manner with which I  perfectly agree.  He says, " Nevertheless,
as excision gives the only chance of security—a  point on which most parties seem
to agree—an operation should always  be resorted to, provided the knife can  be
carried beyond the supposed  limits of the disease; and,  moreover, I deem  it
one of the duties of the practitioner to urge the patient to submit to such a pro-
ceeding."  The  opinion  of these  eminent surgeons, supported  as it  is by the
general practice  of the profession,  tends to show that in some cases, at  least, the
disease may apparently be extirpated from  the  system by  excising the  tumor
before the constitution has become implicated.  But even though, in many cases,
we  may  not  expect to accomplish so  desirable a result  as this, and to cure the
patient completely by operative procedure, may  we  not  reasonably hope to pro-
long his life, or,  to relieve the sufferings to which he is subjected, by this means.
I am decidedly of opinion that we  may do so, and though a patient may at  last
be carried off  by some of the recurrent forms of cancerous disease, his life may
have been prolonged, and  much suffering may have been spared him by a timely
operation.  This is more particularly  the case  in encephaloid cancer, in which
early removal of the disease is unquestionably successful, in many cases, in pro-
longing life.   The observations  of Mr.  Paget, on this point,  are  peculiarly
valuable.  He states the average duration of life of those patients laboring under
this form of  disease, in whom the primary affection is removed, to  be about 
396                      MALIGNANT  TUMORS.
thirty-four months; whilst the average life  of those  in  whom  the disease  is
allowed to run its course, is scarcely more than one year.
  But I think that the introduction of anaesthetic agents  into operative surgery
has very materially altered the bearings of this important question.   So long as
an operation was a source of great pain, and of much consequent anxiety and
dread, a surgeon might very properly hesitate in subjecting his patient to severe
suffering with so doubtful a result.   But now that a patient can be freed by a
painless& procedure from a source of much and constant  annoyance, discomfort
and sufferino-, the surgeon may feel himself justified in thus affording him a few
months or years of comparative ease, though he may be fully aware that at the
expiration of that time the affection may return,  and will certainly prove fatal.
But even then, his condition may be much improved, for the recurrent is often
less distressing to the patient than the primary disease, for, as it often takes place
in internal  organs, it  is not attended with  the same amount of local pain and
distress.
  But  in discussing the propriety of operating in a case  of cancer, the surgeon
can have little to do with general or abstract considerations.   He has to deter-
mine what had best be done in the particular case that he  is actually considering,
and  it  will  serve him little in coming to a conclusion as  to the line of practice
that he should adopt, to refer to the statistics of the gross results of operations,
or to general comparisons between the results of cases that are not operated upon
and  those that  are.   The whole question  narrows itself to the point as to what
should best be done in order to prolong the life, or relieve the suffering, of the
individual whose case is being considered.   In order to  come to some definite
conclusion on this, it is necessary to classify the different  cases of cancer, and to
arrange them under  the heads of  those  in which no operation is justifiable;
those in which.the result of any such procedure would be very doubtful; and,
lastly, those in which an operation is attended with a fair  prospect of success.
   The operation ought never to be  performed in  those cases in which there are
several cancerous tumors, existing  in  different  parts  of  the body  at  the same
time.   Here the disease is evidently constitutional, and could not be eradicated
by  any series of operations.  Then, again, if the  cancerous cachexy is strongly
developed, or if the disease  be hereditary, it is useless to remove a local affection,
as the malignant action will certainly manifest itself elsewhere, or, perhaps, even
speedily return in the cicatrix.   So  also if the tumor  be  of very rapid  growth,
and  be still increasing, there would  appear to be so vigorous a local tendency to
cancerous deposit, that it will speedily develop itself again  in the cicatrix.  If
the tumor be so situated that it cannot be completely and entirely extirpated by
cutting  widely  into the surrounding parts, it ought not  to be meddled with;
otherwise the affection  will to a certainty return  in  the cicatrix  before it has
closed.  If the whole of the affected organ, as a bone, cannot be removed, or, if
the skin and glands be involved,  it  is useless to attempt  the  extirpation of the
growth, as a speedy relapse may be  confidently looked  for.  In the very chronic
and indurated cancers of old people, it is often well not to interfere, as  in these
cases the affection makes such slow  progress, that  it does not appear in -any way
to shorten life, and the mere operation might be attended with serious risk at an
advanced age.
   Those  cases in which the  result  of an operation is of  an extremely doubtful
character, but in which no other means offer the  slightest prospect of relief to
the  patient, have next to be considered.   Cancers of the eye and of the testes
belong to this category, for though more liable to return than similar affections
of any part of the body, yet they may be considered fit cases for operation, inas-
much as in no other way has the patient the slightest chance of being relieved
from his disease.   In those cancers that are  already ulcerated, the surgeon may
sometimes  operate in order to give  the patient ease from present  suffering, or, 
                         EPITHELIAL CANCER.                      397

perhaps, as in  some cases recorded  by Brodie, with the view of prolonging  the
duration of life ; but he can have little expectation of effecting a permanent cure.
Lastly, if the tumor be of so large a size, or be so situated that its removal can-
not be undertaken without  so serious an operation  as to occasion  in itself con-
siderable risk, the propriety of operating is always very doubtful.
  Those cases of cancer in which an  operation is, in my opinion, not only per-
fectly justifiable, but should  be urged  upon the patient  as affording the  best
prospect of preserving his life, are,  in the first place, those in which the disease
has appeared to originate from a strictly local cause in persons otherwise in good
health, in whom there is no cachexy or hereditary taint.   If the tumor be of a
scirrhous character, slow in its  progress, single, distinctly circumscribed^ without
adhesion to,  or implication of the skin or glands,  and more especially if it be
attended with much pain, or with immediate  risk to life from any cause, and if
the whole of the growth, together with  a sufficient  quantity of the neighboring
healthy tissues can  be removed, most surgeons  of authority in these matters
would consider it to  be a fit case for operation.
  In all encephaloid cancers also, for the reasons already mentioned, early opera-
tion should, I think, be practised with the view of prolonging life.
  An important question in  connexion with operations for cancer  is the  period
of the growth at which they may be done with the  most perfect success.   Most
surgeons were,  formerly, in favor of removing the affection as early as possible,
feeling, that as  it is  difficult to  say when the  local  form of  the disease  becomes
constitutional, it is safer to remove it  as soon as its true nature  had been ascer-
tained ; and  this  certainly appears  to be the  proper course to pursue with  the
medullary form of the disease.   But with regard  to scirrhous  cancer, the opi-
nion is gaining ground that in many cases there is a better prospect of success if
the operation be delayed :  and it is stated by Tanchou, by Hervez de Chagoin,
and Leroy d'Etiolles, that the result of  those cases  operated on after the cancer
has  lasted for some time, is more favorable than that of those in which an early
operation has been done; the cancer often  appearing to be arrested in its deve-
lopment and to localize  itself as it becomes more  chronic,  and having  conse-
quently a less tendency  to speedy return after removal.   It may also be reason-
ably supposed that the  more active varieties of  cancer, those that possess  the
greatest amount of vegetative activity and of reproductive power, may have  got
into a condition unfavorable to operation,  or even  may have  carried off  the
patient  before  any period of arrest  in their growth has occurred, during which
their extirpation could be practised with a fair prospect of success.  But these
are points on which it is at present impossible, I believe, to form a definite opinion,
as the facts before the profession are too limited to enable  us to come to any safe
conclusion on the subject.

                           EPITHELIAL CANCER.4
  The epithelial  cancer  differs remarkably from the other forms of this disease,
but yet, though its points of difference  are  numerous, its resemblance  in many
particulars to the other varieties of cancer is so great, that it cannot consistently
be arranged in a different class.
  This  affection is chiefly met with in  the  neighborhood of the  outlets of the
body, upon the muco-cutaneous  surfaces, being commonly seated upon the  lips,
the tongue, the cheek, the scrotum, the anus, and the uterus.   It commences
either as a small tubercle, which rapidly ulcerates, or appears from the first as an
intractable ulcer of limited size, with hard and everted edges, and a foul surface,
it slowly spreads, and appears at first to be local, but after a time contaminating
the glands in the neighborhood, it induces cachexy, and destroys the patient by
  1 For a most admirable account of the principal varieties of these affections I would refer to Dr.
Hughes Benuetrs Work on Cancerous and Cancroid diseases. 
398                      MALIGNANT  TUMORS.
exhaustion.   It seldom, if ever, occurs secondarily in the viscera, but extensive
deposits in the lymphatic glands in the vicinity of the parts affected, even deep
in the iliac  and pelvic regions, invariably occur after the disease has lasted for
some time.  On examination an epithelial cancer will be  found to be composed
                                                   Fig. 131.
Fig. 130.
Corpuscles from epithelial cancer
       of lower lip.
Corpuscles from chimney-sweep's cancer.
 of a fibrous basis, with a large quantity of  condensed and morbid  epithelial
 scales closely packed upon it.  These scales so closely resemble those of the epi-
 dermis and epithelium, that  they cannot be distinguished from them, but their
 arrangement is different; they are packed  together  in masses or balls, assuming
 a concentric arrangement, hence termed " concentric globes " (Figs. 130, 132),
 and in these present a somewhat fibrous appearance.   According to Mr. Simon,
 however, this fibrous structure  is  deceptive, depending upon the  scales being
 much attenuated and woven  together.  In many cases they are intermixed with
 globular bodies,  and in others  with cells of  various shapes, resembling those
                                    found in the more truly cancerous diseases
                                    (Figs.  130,  131); and indeed so close is
                                    the resemblance between the  compound
                                    nucleated cells commonly met with in  epi-
                                    thelial  cancers with those of the other can-
                                    cerous affections  that I know of no  way
                                    of distinguishing them from  one another,
                                    and must look on  these 'growths as of a
                                    hybrid character.
                                      The treatment of epithelial cancer is
                                    more  satisfactory than that of the other
                                    varieties  of carcinomatous disease which
                                    we have just been considering, inasmuch as
                                    this partakes  more of the  characters of a
                                    local and less of a constitutional affection
                                    than any other form  of cancer.   Hence
                                    free  removal by excision, or complete de-
                                    struction by caustics, will not  uncommonly
                                    permanently rid the patient of this affec-
tion.   Excision should always be preferred whenever practicable, and should be
done as soon as the nature of the disease is recognised, the part being thoroughly
extirpated, together with a good margin of healthy tissue on either side of  and
beneath it,  so that no cancer-germs  may be left  from which new  growths  can
spring.  When the neighboring lymphatic glands are but slightly enlarged, the
operation may be  done equally, the  glandular enlargement, which maybe depen-
dent on irritation, gradually subsiding.  If, however, it  be more  considerable,
the affected gland must be extirpated, but if there be a chain of enlarged glands,
more especially in the deeper cavities, no operation should be undertaken, as the
disease will  then have become constitutional and  cannot be  fully removed.   In
some instancesthe disease  being so situated, as in some parts of the face, or in
the deeper cavities of the body, that it cannot  be dissected out,  the application
Concentric globes from epithelial cancer of
     lower lip, greatly magnified. 
REMOVAL  OF  TUMORS.
399
of caustics will  be useful in procuring its  removal; but  if these agents are
employed, care  should be taken  that they be freely applied, so as thoroughly to
destroy the whole of the morbid textures.  The best preparations for this purpose
are the chloride  of zinc paste, the  potassa fusa, the  Vienna paste, and the acid
nitrate of mercury.   All  of these may be  applied successfully, though they
should not be used indiscriminately.  The chloride of zinc and the Vienna paste
are most useful when the ulcerated surface is large and  indurated at base or
edge.   The acid nitrate of mercury should only be employed when the sore is
small, superficial, irregular, and without much induration.   In epithelial cancer
constitutional treatment is, I believe, as ineffectual as in the other varieties of the       *
affection.
   When a recurrence takes place after operation for epithelial cancer, it is either
by a fresh  deposit of cancerous matter in the cicatrix, or else by  the neighboring
lymphatic glands, which had been contaminated before the operation, continuing to
enlarge,  and at last ulcerating, and thus destroying  the  patient.   Secondary
deposits do not take place in  this as in the other forms of carcinoma.

              OPERATIONS  FOR THE REMOVAL OF TUMORS.
   In describing the different forms of encysted tumor, the operative procedures
necessary for their removal have been  adverted to.  We may now conveniently
consider the steps that are generally necessary for the extirpation with the knife
of solid tumors from the soft  parts.  In the  removal of tumors the first point to
be attended to is the arrangement, shape, and direction of the necessary incisions.
These should not only have reference to the size  of the growth, extending well
beyond it at either end, but must also  be planned with due regard to subjacent
parts of importance.   As a general rule, they should be carried in the direction
of the axis of the limb or part, and parallel to the course of its principal vessels;
they must not only extend over the whole length of the tumor, but also a little
beyond it at either end: no  cross-cuts should be made, if they can possibly be
avoided; and this may usually be done by the proper position and extension of
the linear incision.  In most cases, no skin should be removed; but if the inte-
gumental tissues be  very abundant and  loose, an elliptical portion of them may
be excised together with the  tumor.  The flaps covering it  should then be freely
but cautiously dissected back, so as to expose the sides and base of  the growth;
as these are approached, and the surgeon gets in  the  neighborhood of its more
important and deeper connexions, increased care will be necessary, as it not un-
frequently happens that the tumor is in more important relations with deep-
 seated bloodvessels and nerves of a large size than would  at first appear.   The
deep dissection had best be  commenced and carried out from  that part of the
base of the tumor into which the principal bloodvessels appear to enter; they are
thus early  cut, and being once ligatured give no further trouble, as they would
do were  they divided from the direction of their branches towards the trunk,
when at each successive stroke of the knife  a fresh portion of  the vessel would
be touched.  In carrying  on this deep  dissection  the operator should proceed
methodically from one side of the tumor to the other, the assistants holding aside
the skin so as to give as much room as possible, whilst the surgeon himself seiz-
ing the mass with his left hand and dragging it well forwards, uses the knife by
successive  strokes, but in a  leisurely and careful manner, avoiding all  undue
haste, until he completely detaches it from its  connexions.  The safety of  con-
tiguous important structures will be best secured by keeping the edge of the knife
constantly  directed towards the tumor, if this be of a non-malignant character;
by attention to this rule, I have seen Mr. Liston remove tumors  with remarkable
facility and ease  from the neighborhood of most  important parts.  If, however,
the growth be of a malignant character, the incisions must be made wide of the
disease into the healthy structures  around;  if this be not done, slices of the 
400                     SCROFULA,  OR  STRUMA.

tumor may be left from which fresh growths rapidly sprout, or cancer-cells may
impregnate the neighboring tissues  through which they are scattered, and may
eventually become so many fresh centres of malignant action.   After the tumor
has been removed, it  must be carefully examined with the view of ascertaining
whether it is  entire, and if any portions  have been left behind, these  must be
properly dissected out.
  In some cases it will  be found, after dividing the fascia covering the tumor,
that the attachments of the growth are not  so firm, or as deep as had been pre-
viously expected; then it may often be  removed in a great  measure  by sepa-
rating the cellular tissue  with the handle of the knife, merely dividing those por-
tions of the deeper  attachments that are  of a peculiarly dense character.  The
surgeon should never undertake the removal of tumors that cannot be wholly and
entirely extirpated,  as the part left behind will always grow with greatly increased
rapidity, often  assuming  a fungous character; this  is  especially the case with
malignant tumors, the rapidity of increase of which is greatly augmented by par-
tial  operations.   Should, however, the surgeon  have  been deceived as to the
depth and connexions of the  mass, and  should he  find after commencing his
operations that it is so situated as not to admit of entire removal, he must, under
the circumstances, do his best, and cut off or remove by the ligature as much of
the growth as he can expose with safety.
  The wound  that is left after the removal of a tumor, usually unites partly by
adhesive inflammation, and partly by the second intention; it should be lightly
dressed, the edges being brought together with strips of plaster and water-dress-
ing,  and if large, supported by a compress and bandage.
                          CHAPTER XXX.

                       SCROFULA, OR STRUMA.

   By scrofula is meant a peculiar constitutional condition, either hereditary or
acquired, that leads to the formation of, and in its full development is character-
ized by the presence of, tubercle.   It  is, however, only  when fully developed
that scrofuk gives rise to the local deposit of tuberculous matter.   The constitu-
tional condition that tends to this is sufficiently characteristic; but although we
may recognise its existence, and speak of the individual possessing such a con-
stitution as having  a scrofulous tendency or diathesis, he  can  scarcely be consi-
dered to labor under the fully formed disease unless tubercle be deposited in some
of his tissues or organs.
   The scrofulous diathesis is a  peculiar constitutional  state that is often erro-
neously confounded with general debility.  It may, and often does co-exist with
this, but is by no means synonymous with weakness of constitution.  Debility
often exists without any scrofulous tendency or taint, more particularly in indi-
viduals of the nervous temperament; many delicate people, though weak, being
perfectly healthy, and showing no disposition to this peculiar affection;  on  the
contrary, the scrofulous constitution is often conjoined with much muscular power
and mental activity.   But though no weakness may be  manifested in  either of
these respects, scrofula is invariably conjoined with debility or perversion of the
nutntive activity of the body.   This is especially manifested in certain tissues,
such as the mucous and the cutaneous; and in those organs, the vitality of which
is low, as the lymphatic glands, the bones, and the joints.   In  these, scrofula is
especially apt to influence the products of nutrition and of inflammation, more 
SCROFULA  OF TISSUES AND  ORGANS.
401
particularly during the earlier periods of life whtfn these actions are most ener-
getic, in such a way as to render its existence evident to the surgeon.   It is this
tendency to the occurrence of particular diseases, and to the engrafting of special
characters on affections of certain tissues, that  may be  considered  as specially
indicative of the existence of the scrofulous diathesis; of that condition which,
in its extreme of development, gives rise to the deposit of tubercle in organs and
tissues.  The existence of this diathesis is marked by the presence of a peculiar
temperament, by special  modifications of the seat, form, and products of inflam-
mation, and, lastly, by the development of tubercle.
   The scrofulous temperament assumes two distinct forms, and each of these pre-
sents two varieties.  The most common is  that which occurs in persons  with
fair, soft, and transparent skin, having clear blue eyes, with large pupils, light
hair, tapering fingers,  and fine white teeth; indeed, whose beauty is often great,
especially in early life, being dependent rather on  roundness of outline  than  on
grace  of form; and whose growth is rapid and precocious.  In these indivi-
duals the affections are  strong, and the procreative  powers considerable;  the
mental activity is also  great, and is  usually characterized by much delicacy and
softness of feeling, and  vivacity of intellect.   Indeed,  it would appear in such
persons as these that the nutritive,  procreative, and mental powers are  rapidly
and energetically developed  in  early life, but  become proportionately early ex-
hausted.  In another variety of the fair scrofulous temperament, we find a coarse
skin, short and rounded  features, light gray eyes, crisp and curling sandy hair,
a short and  somewhat ungainly stature and clubbed fingers, but not uncommonly,
as in the former variety,  great and early mental activity, and occasionally much
muscular strength.
   In the dark form of the scrofulous temperament we  usually find a somewhat
heavy, sullen, and forbidding appearance ; a dark, coarse, sallow, or  greasy-look-
ing skin; short, thick, and harsh curly hair; a small stature, but often a power-
ful and  strong-limbed frame, with a certain degree of  torpor or languor of the
mental faculties, though  the  powers of the intellect are sometimes remarkably
developed.   The  other dark strumous temperament  is characterized by clear
dark eyes, fine hair, a  sallow skin, and by mental and physical organization that
pretty closely resembles the first described variety of the fair strumous diathesis.
   In all  these varieties of temperament the digestive organs will be found  to
be weak and irritable.  This condition, which  I believe is invariably  associated
with struma, and the importance of which has  been  pointed out by Sir James
Clark, must be regarded  as one of the most essential conditions connected with
scrofula, and as tending  greatly to that impairment of nutrition which is so fre-
quent in this state.  This gastric irritability is  especially characterized by the
tongue, even in young  children, ~being habitually coated towards the root with a
thick white  fur,  through which elongated papillae  project, constituting the
" pipped" or " strawberry tongue ;" the edges and tip, as well as the lips, being
usually of a  bright red  color.   This state of the tongue is aggravated  by stimu-
lants, high living,  and  the habitual use of purgatives.   In the  fair varieties the
bowels are usually  somewhat  loose, but in  the  dark forms of struma there  is  a
torpid condition of the intestinal canal.   In all cases  the action of  the  heart is
feeble, the blood is thin and  watery, and  there  is a tendency  to  coldness, and
often to clamminess of the extremities.
  One of the most marked  characteristics of struma is certainly the peculiar
modification that inflammation undergoes, whether  we regard the course that it
takes, the form that it  assumes, its products, or its seat.  The course of inflam-
mation in strumous subjects  is always slow, feeble, and  ill-developed,  the more
active and sthenic  conditions being  rarely met  with.   In its form  it is usually
congestive, ulcerative,  or suppurative,  and in its products it is characterized by
litle  tendency to adhesion, by the  production of thin, blue, weak, and ill-deve-
                                     26 
402
SCROFULA,  OR  STRUMA.
loped cicatrices, and  by the formation of thin, curdy pus, with  much shreddy
corpuscular lymph.
   The seat of strumous  inflammation varies greatly, the peculiar modifications
of course, form, and products are assumed, according to the part  that it affects.
The tissues implicated by  it are chiefly the skin  and mucous membranes, the
joints, and the bones, occasioning a great variety of special diseases, according
as one or other of these structures are affected.  It is as the result of, or in con-
nexion with, these local affections that the general symptoms of struma become
most marked.  Whatever  the variety of temperament  may be,  the individual
usually emaciates, becomes sallow, cachectic, and debilitated, and  at length falls
into a state of hectic or marasmus.
   When affecting the skin, scrofula declares itself  under a variety of cutaneous
eruptions,  especially  the different forms of eczema of  the scalp,  and various
                               ulcers on the surface, usually weak, and largely
                               granulating, with  considerable swelling  of sur-
                               rounding parts, and a tendency  to the  forma-
                               tion  of thin blue and  glazed cicatrices (Fig.
                               133).
                                 The mucous membranes are  commonly  ex-
                               tensively affected,  and often present the earlier
                               forms of scrofulous disease  in childhood; this
                               is more especially  the  case with those of  the
                               eyelids and nose.    The conjunctiva becomes
                               chronically inflamed, with  perhaps ulceration
                               of the cornea; the mucous  membrane  of  the
                               eyelids may be permanently congested and ir-
                               ritated, with loss of lashes, constituting the dif-
                               ferent forms of psorophthalmia.   The  mucous
                               membrane  lining  the nostrils becomes chro-
nically congested, red, and swollen, giving  rise to habitual sniffing of the nose,
and to a  sensation as of a constant  cold.   Occasionally that lining the antrum
becomes  irritated, and may then occasion an enlargement of this cavity, or the
discharge of unhealthy pus into the nostrils.  The tonsils are  often found chro-
nically enlarged and indurated, with occasional tendency to fresh  inflammation;
and the larnyx may become the seat of various forms of  aphonia, dependent on
congestion  of its lining  membrane.  The state of  the gastro-intestinal  mucous
membrane  has  already been described when speaking of the state of the tongue
and that  of the genito-urinary organs is also marked by a  tendency to debility and
irritation, indicated by the occurrence of discharges from the urethra under the
influence of very slight  exciting  causes, and that  are often  very permanent in
their character.  The  occurrence of calculus of the bladder, especially in children,
may also occasionally be attributed to the scrofulous diathesis.
   Perhaps the  most important local diseases arising under the influence of this
agency are those of the bones and joints.  The bones are liable  to  the occur-
rence of various  forms  of  caries and  necrosis; more especially  those that are
spongy in their texture,  as the short bones of  the  foot  and the  articular ends
of long bones.   The  joints are liable to  that large  class of affections that are
commonly  included under  the term of white swelling, and which consists of
thickening, disorganization, ulceration, and suppuration  of the  synovial mem-
branes and cartilages.
   Lastly, some of the glandular organs are peculiarly prone to scrofulous disease.
Enlargement of the lymphatic glands, more particularly by the side of the neck
and under  the  angles  of  the jaw, is of such frequent occurrence,  and is usually
so early a sign, that the surgeon in determining whether an individual is scrofu-
lous or not, commonly passes his hand over the glands in this situation in order
Fig. 133.
 
CAUSES  OF  SCROFULA.
403
to ascertain their condition and size; these glandular enlargements are especially
apt to run into unhealthy and chronic suppuration. The testes and the mammae
are occasionally affected;  and other glandular structures, though sometimes im-
plicated, are  by no means  so  commonly found diseased as those that have just
been  mentioned.
   The occurrence  of tubercle must be looked upon as the great characteristic of
scrofula, and when it occurs it may be  considered a sure sign of this affection,
which has then reached its ultimate development.   In those  cases in which the
scrofulous diathesis exists without  having given rise to this product, it must be
considered as not having been called into full and active operation, having merely
manifested itself in the minor  forms of disease, such  as ulceration  of the  skin
and of the mucous surfaces.
   Tubercle,  though sufficiently well marked  by its appearences  and progress,
cannot be looked upon as a specific affection, but  must be considered to  be a
prevented or unhealthy development of the nutritive materials destined for the
repair of the body and the restoration of the blood.  According to  Mr. Simon,
it consists of a disease of the lymph, or nascent blood.  It is a  " dead concretion,"
a  "fibriniform  product insusceptible of development."   "The scrofulous dia-
thesis," says Mr.  Simon, " consists in a peculiarity of blood-development, under
which the nascent blood tends to molecular death by superoxydation."  Accord-
ing  to  Dr.  Williams,  " Tubercle is   a  degraded condition of the nutritive
material from which the  old  textures  are renewed, and the new ones formed,
and it differs from fibrine or  coagulable lymph not in kind  but in  degree  of
vitality  and capacity of organization."
   Tubercle  essentially occurs in two  forms, as semi-transparent gray granula-
tions, smooth and  cartilaginous  in look, somewhat hard, closely adherent, and
accumulated  in groups, often with a good deal of inflammatory action in the
surrounding tissues.  These gray granulations, usually about the size of a small
pin's  head, appear to consist of modified exudation-matter.   They have a tendency
to run into masses, and to form the true yellow tubercle, which is  met with  in
opaque, firm, but friable concretions of a dull whitish or yellowish color, homo-
geneous in structure, and without any appearance of vascularity.
   The microscopic characters of tubercle  present  no very specific appearances.
We find that this product presents under the lens, a homogeneous stroma, which
chiefly occurs in the gray granulations  ; a granular matter which is  principally
met with in yellow tubercles; drops of molecular  oil;  and,  lastly,  considerable
quantities of imperfectly developed exudation-cells, more  or  less  disintegrated,
stationary, or degraded.
   The progress of tubercle is most commonly to disintegration and liquefaction,
at the same time that it gives  rise, by its irritation, to inflamniation and suppura-
tion in the surrounding tissues, hence it commonly leads to abscesses, the pus of
which is always curdy and shreddy.  In some cases, tubercle may become indu-
rated, and undergo a species of calcification.
   The causes of scrofula, unless this be of a hereditary character, though  very
various  in their nature, are usually such conditions as  influence injuriously the
nutrition of the body.
   The hereditary nature of scrofula is  well known, both to the public and to the
profession, for although the disease  is not commonly connate, yet the tendency to
it  is,  and the characteristic nature  of the  affection often manifests  itself at an
early  period  notwithstanding  every effort to prevent its development.  That a
parent may develope a tendency to mal-nutrition, to  mis-development of the
blood, just as he may a peculiar feature or mental  condition,  is undoubted.   It
is by the hereditary transmission of peculiar combinations and modifications  of
action in the  organization  that hereditary diseases  develope themselves at certain
periods  in the  life of the offspring, when the injurious results of  the morbid 
404
SCROFULA,  OR  STRUMA.
actions that have been transmitted  have had time to be produced.  There are
certain conditions which, though not scrofulous, are supposed to have a  tendency
to develope this disease in the  offspring to which they are transmitted; thus,
dyspeptic parents  are said, and I believe with reason, commonly to have  strumous
children; so also, the offspring  of very old or very young people, often  exhibit a
proneness to scrofulous affections.   The influence of  intermarriage is still a mat-
ter of doubt, though I believe that it exercises but little influence in this respect;
and it is commonly  stated that  the inhabitants of small communities who  inter-
marry closely, such  as those of  the Isles of Portland and of Man, are not more
liable to scrofula than other individuals.
   The  most powerful occasioning  cause of scrofula, and that which in most
civilized countries is likewise most frequent, is mal-nutrition, arising either from
want of food, or the administration of improper food in the poorer classes; or, from
over-feeding, and  over-stimulation of the digestive organs amongst  the  children
of the wealthier orders of society, thus inducing chronic irritation of the mucous
membrane of the stomach,  interference with the digestive powers  and  conse-
quently with nutrition.  The influence of food that is innutritious in quality or
insufficient in quantity, has been shown by Mr. Phillips, in his excellent Treatise
on Scrofula, to be the most immediate cause of this disease; and when conjoined
with the injurious effects of the confined atmosphere of towns, of close and over-
crowded rooms, and of want of  light and exercise, may be considered  as suffi-
cient to occasion the disease in those cases in which no predisposition to  it exists,
and greatly to develope any hereditary tendency to it in the system. It is to the con-
joined influence of agencies such as these that we must attribute the prevalence of
scrofula amongst the lower orders of town and rural populations.
  Scrofula is often called into immediate action by the debility induced by pre-
vious diseases, such as measles, scarlatina, hooping-cough, &c.  It usually developes
itself at an early age, though seldom before the child has reached its second year.
It is most commonly about the period of the second dentition that the  affection
declares  itself, and it is rare to meet  with it for the first time after the ages of
twenty-five or thirty-five.  According to  Phillips, when it  is  fatal it usually
proves so before the fifteenth year; 60 to 70 per  cent, of the deaths occurring
before this age.   Sex does not appear materially to influence the disease, though,
according to the same authority, the deaths  of males from scrofula exceed  those
of females, in this  country, by 24  per cent.  If, however, we are to regard
phthisis as an allied affection, people who are scrofulous in early life often becom-
ing phthisical at a later period, these  numbers may require correction.
  The  treatment of scrofula consists as  much in endeavoring  to  prevent the
occurrence or  full manifestation of the disease, as  in removing it  when  it is
actually  existing.  Indeed, the  preventive treatment is perhaps of most conse-
quence, and by proper attention to it I have no  hesitation in saying  that the
development of the  affection, even when  hereditary, may be stopped;  and the
child of strumous parents, presenting perhaps the features indicative  of the dia-
thesis, may pass through life without  the disease  having  an opportunity of
declaring itself.  In  order to accomplish this, however, the preventive plan of
treatment must be commenced early, and continued uninterruptedly for a consider-
able time, even for years.
  The preventive  treatment of scrofula may be said in general terms to consist
in close and continuous attention to hygienic rules.  The diet must be especially
attended to, nourishing food, but of the lightest quality, and in  sufficient quan-
tity being  given.  A great error is often committed in overloading  the  stomach
with heavier  food than it can digest, under the impression that strong food is
necessary to give the patient strength.   In consequence of this error, the  irrita-
bility of the mucous membrane  is kept up, and nutrition is imperfectly and badly
performed.   The use of stimulants, whether wine or beer, should be very sparing, 
TREATMENT  OF  SCROFULA.
405
and the mild and weaker should be preferred to the heavier and stronger kinds of
malt liquor ;  the bowels must be kept regular with the  simplest aperients;  the
clothing should be warm, and must cover the whole of  the  surface, and  the
patient should if possible be kept in well-ventilated rooms.  He should be allowed
sufficient exercise in the open air, not carried to the point of fatigue, and should,
if his circumstances will permit, have change of air from time to time, alterna-
ting a sea with an inland climate.  Bathing, also, whether in sea or river, with
the habitual  use of the tepid or cold sponge-bath, and  friction  of the surface
with horse-hair gloves or a rough towel, so as to keep the skin in healthy action
and its cutaneous circulation free, should be regularly practised.
   The curative treatment  should be  specially directed, like the preventive, to the
general improvement of the nutrition, and through it to the augmentation of the
constitutional vigor of  the patient;  all those hygienic means  that have just been
alluded to being continuously  carried out.
   The more strictly medical treatment of scrofula consists in the administration of
tonics  and alteratives  with the  view of improving the patient's constitutional
powers.  Before they  are administered, however, it is always  necessary  to  see
that the digestive organs are in a healthy condition.  When the tongue is covered
with a  white, thick, creamy fur, having elongated papillae  and  red edges,  the
mucous membrane being in a state  partly of irritability and partly of debility,
neither purgatives nor  tonics can be  largely administered;  the one irritating, the
other over-stimulating the morbidly sensitive mucous membrane.   Under these
circumstances the patient should be confined to the mildest possible diet, which
must principally consist of milk, boiled fish,  white meats, and light pudding, no
stimulants of any  kind being allowed except  a small quantity  of  weak bitter
beer; and, unless  the  patient have  been accustomed to the use of  stimulants,
this even had  better  be dispensed with.   Small  doses of mercury  with  chalk,
of soda and rhubarb, should be occasionally administered at bed-time, with some
of the compound decoction of aloes  on the following morning, and a few  grains
of the carbonate of soda  or potassa  may be given twice  or thrice a day in some
light bitter  infusion, as of cascarilk or  columba.  In many cases of strumous
disease, more especially those affecting the joints and bones, the liver will be
found to be enlarged and  sluggish in its action, the patient every now and then
becoming bilious, sallow, and jaundiced; under these circumstances, small doses
of blue-pill, carried  off with the  compound  decoction of aloes or  a rhubarb
draught, will be found necessary from time to time.   When all gastric irritation
has been removed in  this way, or if it  have  not existed in the usual marked
degree from the first, the patient being pale and flabby, with a  weakened  condi-
tion of the pulse, of the skin, and of the mucous surface, then  tonics may be
administered, and the  more specific treatment adopted.
   The great  remedies  which are employed with  the view of removing scrofula
and curing the  affections it induces, are iron, iodine, the preparations  of potas-
sium and cod-liver oil.  These are all extremely useful, either  singly or conjoined,
as they serve to carry out distinct indications in the  management of this affec-
tion.
   Iron  is most useful  in  pale flabby anemic subjects, increasing markedly  the
quantity and quality of blood in  the  system.  The best preparations  for children
are, I think, the vinum ferri and the iodide.   In older  persons the  tincture of
the sesquichloride, and some of the forms of the citrate of iron, appear to be most
serviceable; in other cases again, the natural chalybeate waters will be found to
agree best.
  Iodine is especially  valuable  in promoting  the absorption of  effused  plastic
matters, and  in lessening  the morbid hypertrophies which so commonly take
place in scrofula.   The preparation usually employed is the iodide of potassium.
In order that this should produce its full effects, it should be given as freely as 
406
SCROFULA,  OR STRUMA.
the patient  will bear it, continued for a considerable length of time, and espe-
cially administered in combination with other preparations of potassa.  W ith the
view of preventing its irritating the stomach, it should be given in a consider-
able quantity of some  bland fluid.   Its  combination with the other  alkalies
renders it more efficacious  in  removing strumous enlargements and deposits of
aplastic and tuberculous  matter.   For this purpose I have found the following
form extremely useful for adults, the dose being  proportionately diminished  in
the case of children :—
                             B Potassii io'didi,
                                PotasssB chloratae aa 5TJ.
                                Potassse bicarbonatis giij.

Divide into twelve powders, of  which one is to be taken night and  morning  in
half a pint of warm milk.
   In other  cases again, the liquor potassae, Brandish's alkaline solution, or lime
water given freely in  milk, are  serviceable, but I prefer the above prescription.
Cod-liver oil is of essential utility in improving the nutrition of the  body,  in
cachectic  and emaciated states of the system, more particularly in growing chil-
dren, or  in individuals who are suffering  from the  wasting effects  of strumous
suppuration; it not only fattens  but strengthens the system, increasing decidedly
the muscular power and  the quantity of red corpuscles  in the blood.   It may
often  very advantageously be administered in  combination with the iodides of
potassium or of iron.   Of the other  tonic remedies which may be employed  in
this affection, such as the preparations of bark and  of sarsaparilla, I  need say
nothing beyond  that they may  often be usefully administered in fulfilling ordi-
nary therapeutic indications.
   The local treatment of scrofula consists  in  a great measure in  the  ordinary
local management of chronic inflammation, modified according  to  the seat  and
particular nature of the affection.  Much of the local treatment, however, espe-
cially in the more advanced stages, consists  in removing the effects of the disease
in the shape of aplastic deposits, false hypertrophies, and general enlargement
and thickening of parts.   This  may usually be done  by the application of lotions
containing  the iodide or the  carbonate  of potassa, applied by means of  lint
covered with oiled  silk;  3j. of each of the salts, with an ounce of spirits of wine
to eleven  ounces of water  makes an excellent application, that appears to dissolve
away the  fibrinous and plastic  deposits so common  in this disease.  In many
cases frictions with the iodide of lead ointment, or pressure by means of strap-
ping and bandages, will be found the most serviceable means that  the  surgeon
can adopt.   When matter forms, it  should be let out, in accordance with the
rules laid clown in treating of the more chronic forms of abscess.   In these cases
the injection of the sac of the  abscess with a solution of iodine will be found
very useful.
   In cases of scrofulous disease of the soft parts, the bones, or the joints, the
question  of the propriety of operating, whether  this be for the excision of a
tumor, the resection of a joint  or bone, or  the amputation of a  limb, has-often
to be discussed.   In these cases operations should not, I think, be undertaken
too hastily,  too early in  the disease,  or especially in  very  young  subjects.  The
affection  being a constitutional one, it will often be found  as the general health
of the patient improves  by proper treatment, that local mischief which at first
appeared of a very intractable character, gradually assumes  a more circumscribed
and healthy form, and, in fact, to a great extent undergoes spontaneous cure by
the restoration of the healthy action in the parts.  This  we especially find to be
the case  in young children, in whom very extensive disease of the bones and
joints may often be recovered from without the necessity of any surgical inter-
ference.  Should any operation be undertaken it is desirable not to have recourse 
SYPHILIS.
407
to it whilst the disease is actively spreading.  Under these circumstances, it  is
not only probable that suppurative inflammation of an unhealthy kind may be
set up in  the wound itself, but that disease of the soft parts or bones may very
likely recur in the cicatrix of the original wound, or that  the corresponding parts
on the opposite side of the body may become similarly affected in very chronic
cases of scrofulous disease of bones and joints.   I have  several times seen after
excision,  or partial removal  of these  structures, that the morbid  action  has
returned in the contiguous soft parts to such an extent as to render a second
operation  necessary, the tissues in  the  neighborhood of the cicatrix becoming
swollen, spongy, and infiltrated  with a quantity of gelatinous semi-transparent
plastic matter, running into unhealthy suppuration, with fistulous tracts leading
through it that could not be brought to heal.   In a case lately under my care,
in which I amputated a boy's foot at the ankle-joint for very old-standing
strumous disease of the tarsus, this condition occurred in the soft structures of
the stump without any return of disease in the bones, ultimately compelling me
to amputate below the knee.   In some cases of simple strumous disease of the
integuments of the  arm,  leg,  or foot, attended with great  and irregular deposi-
tion of plastic matter, and chronic and intractable ulceration, amputation of the
limb is the only course left to the surgeon; when strumous suppuration leads to
hectic, the patient will speedily sink unless the diseased  structures be removed.
                         CHAPTER  XXXI.

                               SYPHILIS.

  By the " venereal disease" is meant any affection that arises from sexual inter-
course.   It  is  usually considered to include  two distinct  specific diseases—■
Syphilis and Gonorrhoea, which were supposed by Hunter and his followers, to
originate from one and the same poison.  But this doctrine is erroneous, for not
only are the local appearances and constitutional conditions induced  by these
affections widely different, but Ricord has shown in the most conclusive manner,
that the gonorrhceal discharge, when inoculated on the skin or  mucous membrane,
never under  any circumstances  produces a chancre; and that on the other hand
chancrous pus can never be  made  to give rise to a gonorrhoea; but that in fact
each disease  propagates itself, and no other.  The two  diseases may,  however,
co-exist, and those  cases in  which, after connexion with  the same woman,  dif-
ferent men  have  contracted  different forms of the disease, or even  both affec-
tions,  are in  all probability to be explained by the fact that Ricord has pointed
out, that a woman may be affected by gonorrhoea and deep-seated chancres on
the uterus, so that although  only supposed to be laboring under one, she might
easily communicate both  or either of  these diseases;  the true  nature of  her
ailments being only ascertainable by the speculum.
  Syphilis2 is a specific disease, arising from sexual intercourse, and transmissi-
ble  by the contact of  its  own specific  pus with a tender surface, by  inoculation
into the system  through  the medium of the secretions,  or  by hereditary taint
under certain special conditions.  It presents two distinct orders  of, symptoms,
the local and the constitutional.   The local or primary symptoms, occurring only
on the part to  which the virus  is immediately applied, and being  transmissible
solely by direct contact or inoculation ; the constitutional or secondary symptoms,
dependent upon the absorption of  the poison into the economy, affecting conse-
» Gonorrhoea will be treated of in the chapters on Diseases of the Urinary Organs. 
403
SYPHILIS.
quently most of the tissues and many of the organs, and  being capable of here-
ditary propagation, and occasionally of transmission through the secretions.
  It would be  altogether foreign to the scope of this work were I to enter into
the general question as to the origin of syphilis, a  subject that admits of much
dispute, and that has been keenly argued.   After  an attentive  examination of
it, I believe we cannot fail  to  come to the conclusion  that  syphilis was either
introduced into Europe, or originated there, towards the end of the fifteenth
century; or if it be allowed to have  previously existed  in the old world, in a
mild or modified form, that about this  time it suddenly assumed great intensity,
all its symptoms being aggravated in a remarkable  and fearful manner, present-
ing characters  that have  certainly not accompanied it  in modern times, if- we
except the forms that were observed in the British armies during the Peninsular
war, and, according to Larrey,  among the French troops  during Napoleon's
German campaigns.

                           PRIMARY SYPHILIS.
  Primary or  local syphilis is characterized by the presence of specific sores of
special forms and appearance, characteristic of the nature of the disease.   These
may occur  on the cutaneous,  the muco-cutaneous, and mucous surfaces, most
commonly on the latter, on account partly of their greater  exposure to contagion,
but chiefly from their  being less perfectly protected by epidermis.   These local,
specific ulcers or chancres present much variety as to their appearance and the
course they pursue; so great indeed are  these varieties, that  they have been
looked upon by some  surgeons as affording evidence of their being distinct dis-
eases, proceeding from different poisons. This doctrine, however, has been shown
by Hunter, and more  recently by Ricord, to be entirely  erroneous, the  variety
in their appearance depending on seat, constitution, and other accidental cir-
cumstances.  A chancre then  is a specific  venereal sore or ulcer, originating
invariably from contagion, and capable of  propagation to other  parts of the same
or different individuals by inoculation.   Like all other ulcers, a chancre presents
two distinct periods; the first, in which it is either spreading or stationary, in
which  alone it  is specific, and which may be of almost indefinite duration;  and
the second, in which it has commenced to granulate, and a  process of repair to
be set up in it.
  Ricord has made the important observation, that if the pus from a chancre
during its first  period,  be inoculated into any part of the  surface of the body, it
will invariably  produce another  specific syphilitic  sore or chancre, and that no
pus  that is  not chancrous can, under  any circumstances,  occasion  the specific
venereal ulcer.   In this way it is always easy to test whether a suspected sore is
syphilitic or not.  Ricord has further shown that syphilis is  always in the first
instance a local disease, being confined to  the specific sore; and that the consti-
tutional symptoms are only produced by  the absorption of the poison from the
chancre, which is indeed a truly poisonous ulcer, from  which  the virus may be
absorbed into and  disseminated through the whole system.
  Chancres almost invariably result from connexion with a person laboring under
primary syphilitic disease, and hence  are commonly met with on the  genital
organs; in the male on the  glans, the inside of the prepuce, or even the body
or root of the penis;  in the female, on the external organs of  generation or the
uterus.  They  may of course occur in other situations, as, for instance, the
fingers of  a medical man may be accidentally inoculated  by contact with chan-
crous pus, and  they may form on  other parts where they have  been accidentally
or purposely inoculated.   Thus I saw some years ago, in  Ricord's wards, a man
laboring under eczema of the legs, in whom the cutaneous disease had been con-
verted into a series of immense chancres by accidental inoculation from a sore on
the penis. 
             INOCULATION--VARIETIES OF CHANCRE.         409

  When chancres are caught in connexion, they usually commence with a small
excoriation,  which appears to have been directly inoculated with the specific
poison.   In  other cases, again, though more rarely, they may be seen at first in
the shape of a small pointed pustule, which speedily breaks,  leaving an ulcer of
a specific  character in its site.   Very  generally, however, this pustule escapes
observation,  and the  disease is presented in  the first instance as  an ulcer.  The
chancrous ulcer, whatever form  it assumes, seldom makes its appearance until a
few days,  five or six, after connexion.   In some cases, however, I have observed
it, evidently from the infection of a fissure or crack, on the day following impure
intercourse,  and occasionally, in rare instances, it does not occur until a much
later period than that which has been mentioned.
  Whatever be the appearances  presented by a chancre, there can no longer be
any doubt that the disease arises from  one kind of  virus only, the modifications
in the sore depending on its  situation, the constitution of the patient, and occa-
sionally on that of the individual who communicates the infection.  That this is
so, is evident from the fact that every chancre, when  inoculated, reverts to one
typical  form, and  that however much chancres may ultimately differ, they all
present  the same characters during their early stages.   The progress of a chancre
that has been  artificially inoculated on any part of the cutaneous surface is as
follows, and its study will serve to elucidate what  takes place under other cir-
cumstances.   During the first twenty-four  hours after the  introduction of the
specific  pus into the skin on the point of a lancet, we find  that some inflamma-
tion is set up around the puncture, which becomes  hot, red,  and  itchy.  About
the third or fourth day, a pointed pustule is produced, which is at first deep-set,
but becomes on  the following day more superficial, with some depression  in the
centre, resembling pretty closely a small-pox pustule;  on close examination, this
will be found not to be a true pustule,  but rather a mass of epithelial scales and
pus not included in a distinct wall.  On the fifth day it has  become hard at the
base, apparently from the infiltration of plastic matter, and  on  the  sixth it has
usually  dried, forming a small round scab, and leaving an  ulcer which presents
the typical  characters of a time chancre, being circular  and depressed, with a
foul grayish surface which cannot be cleansed,  sharp-cut edges, a hard base, and
an angry-looking red areola around it.   This is  the  typical  chancre, and these
are the  appearances that  every true syphilitic sore on the skin will present about
the fifth or  sixth day after inoculation ;  from this time it may diverge more or
less  completely from these  characters, but will  yet, if inoculated at any time
during the poisonous stage, produce an ulcer that will  run the specific course up
to the same  period, after which it may in its turn again deviate into one or other
of the special forms that chancres occasionally assume.   When inoculated on a
mucous surface, chancres do  not so early assume an indurated character around
their base.
  The varieties presented by chancres have been described under various de-
nominations by  the  numerous writers  on syphilis.  The following classification
will, I think, include  them all :—the  simple chancre or chancrous excoriation,
as it is  termed ; the indurated or Hunterian ; the phagedsenic, and the slough-
ing chancre.
  The simple chancre or chancrous  excoriation, is certainly that form of the
disease which is most commonly met with in London at present.  It consists of
one or more small  sores,  of a very shallow character; resembling  rather an abra-
sion, with sharp-cut edges, somewhat  circular in shape, and having a tawny-
grayish  or yellowish surface, with a narrow red  areola around  the  edge; in many
cases attended with much heat and itching.  These sores  are usually seated on
the cleft under the corona glandis, or about  the glans, the whole of which may
be studded  by them.  In other cases, they invade the fraenum,  which may be 
410
SYPHILIS.
perforated, or  they occupy the mucous surface of the  prepuce; in no cases are
they indurated in their early stages.
  These excoriated chancres not unfrequently present somewhat varying appear-
ances.   In some cases their surface becomes covered with large fungous granu-
lations, hence  termed fungating sores.   In other instances, again, they are truly
irritable, becoming exceedingly sensitive, with a tendency to spread, and having
an areola of a dusky-red hue around them.   It very frequently happens  that
these chancres are attended by much  general inflammation of the penis, the
organ beinjr  swollen,  red,  and  semi-transparent, from subcutaneous  oedema;
usually in a state of  phymosis, with a good deal of purulent secretion between
the prepuce and glans.
  The indurated^or true Hunterian chancre, as it is termed, is not by any means
so frequently met with as the last-described variety;  it may,  however, be looked
upon as the typical form  of chancre, resembling in every respect the inoculated
form of the disease.   The great  characteristic of this form of chancre is the
induration of  its edges and base, and this character is met with from  the very
first.  Any chancre,  but  more especially the chancrous  excoriation, may during
its progress become indurated from undue  stimulation,  or from  being otherwise
improperly inflamed, but  the Hunterian chancre is indurated from the very first,
and  continues so  throughout.  This induration of the base is the result of a
peculiar  plastic effusion,  which, though it  resemble microscopically and chemi-
cally ordinary healthy lymph, yet very distinctly  differs  from it  in  its  vital
characters, just as the pus of a chancre may differ in this respect from  that
which  is  secreted  by a healthy ulcer.  The great peculiarity of the plastic base
of the Hunterian chancre is certainly that it in some way serves as a source for
the continued  production of the virus and  the consequent impregnation of the
system with it.  Besides the presence of this induration, the Hunterian chancre
is characterized by its circular shape, its elevation above the surrounding parts,
and  the very adherent gray slough that covers its surface.   It is usually seated
on the glans, but not unfrequently on the skin of the prepuce or of the root of
the penis.
  The phagedaenic  chancre is characterized  by  a  tendency  to erosion,  with
much destruction of the  parts that it invades.  It may assume the phagedaonic
character from the very first, or this may be set up in  one of the other varieties
of chancre at  some period of their course.   The progress of this phagedaenic or
eroding chancre  is usually somewhat slow, but continuous;  it commonly affects
the  glans, more especially in the  neighborhood of the fraenum  or  urethra, de-
stroying a considerable portion of the organ in this situation.  Mr. Wallace has
divided this form of  chancre into three varieties, that  without slough, that with
white slough,  and  that with the black slough.  Each  of these varieties, again,
may be  of a  simple, an inflamed, or an irritable character.   This classification
appears to me to be a useful and practical one, and I accordingly adopt it.
  The phagedaenic chancre, without slough, is a truly eroding ulcer, spreading
with sharp-cut edges, attended by some slight inflammatory action and with much
activity of progress;  it is commonly observed  about  the framum and under part
of the  glans,  and  _ very frequently  hollows out  and destroys the organ in this
situation to a  considerable extent.
  In the phagedenic chancre, with white slough, we find an irregular  eroding
ulcer, with a  thin margin  of white slough situated  at the junction  of  the  dead
and  living structures;  that which covers the surface of the sore having usually
become darkened by exposure to air, to dressings, and to secretions.
  The phagedaenic chancre, with black slough, differs but  little from  the last,
except in the  color of the slough, which may be in  a  great  measure accidental,
its  tendency to induration, and  to somewhat rapid extension ; it must not be
confounded with the next form of chancre, which presents  many points of dif- 
SEAT  AND  DIAGNOSIS  OF  CHANCRES.
411
ference.  All these varieties of phagedaenic chancre may be inflamed, being at-
tended by much heat, redness, and swelling, increase of discharge and rapidity
of action ;  or they may be irritable, when they are  accompanied by much pain,
and  usually a good deal of constitutional disturbance of a nervous and irritative

  The sloughing chancre, or gangrenousphagedsena, is a combination of rapidly
spreading and destructive gangrene with the syphilitic poison.   It may be looked
upon as a gangrenous inflammation of a  syphilitic character, and usually affects
the prepuce and glans; the parts becoming immensely swollen,  red, and some-
what brawny, and the prepuce being  in  a state of complete and  permanent
phimosis; a dusky black-looking spot soon  makes its appearance on one side of
the organ; this rapidly extends, giving rise to thick, black, soft, and pultaceous
sloughs, destroying perhaps the whole  of the prepuce, and exposing and impli-
cating the glans to  a great  extent, and accompanied  perhaps  by hemorrhage
from the dorsal artery of the penis on the  separation of the sloughs, and by
denudation of the corpora cavernosa.   In other cases again the prepuce sloughs
on one side only, a round aperture forming in it,  through which the glans  pro-
jects, giving the organ a very remarkable, and at first sight, somewhat  puzzling
appearance.
   Chancres may be situated on any part of  the male genital organs, their charac-
ters  varying somewhat, however, according to the situation in which they occur.
They are by far most commonly seated in the angle formed between the glans
and  the prepuce; they then appear most frequently at the orifice  or on the inner
surface  of  the  prepuce, next on the fraenum, then  on  the glans, and  lastly, at
the orifice of  the urethra, or on the skin of the body of the penis.   The situa-
tions that specially modify the character of chancres, are the  fraenum  and the
orifice of the urethra.  Those about the fraenum are often sloughy and  irritable,
have a great tendency to perforate or destroy this fold of mucous membrane, and
are more frequently followed by hemorrhage  or bubo than any of the other varieties
of the disease.
   Urethral chancres are usually situated just within the orifice of the canal, and
may be seen on pressing open its lips, in the form of a small sloughy sore, which
occasionally creeps out upon the glans.    Sometimes they are more deeply seated,
so as to be  out of sight; when this is the case, a thick, tenacious, sloughy, and
bloody discharge appears in small quantities from the urethra;  at a little distance
up the canal there will usually be felt,  on grasping  the  organ  between the fin-
gers, a circumscribed indurated spot, which is somewhat painful  on pressure and
after micturition.  These chancres have been found by Ricord to extend along
the whole of  the urethra even to the bladder,, and  it is their presence in this
canal that formerly led to the supposition of the identity of syphilis and gonor-
rhoea, an error the nature of which has been cleared up by the test of inocula-
tion ; the discharge from urethral chancres producing the typical sore, that from
gonorrhoea giving no result when introduced under the skin.
  In women,  chancres are usually situated  on the external organs of generation,
most usually just inside the fourchette or labia minora, very rarely indeed on the
lining membrane of the vagina, but sometimes on the cervix or os  uteri; hence
it is  impossible ever to pronounce a woman free from  syphilis without examin-
ing  these parts by means of the speculum.  When situated upon the external
organs, they are not unfrequently concealed between the rugae, or in nooks and
corners of the mucous membrane.  In these cases their presence may sometimes
be detected by the labia being swollen and  cedematous from the irritation of the
chancres.
  The diagnosis of chancres is usually sufficiently easy, the peculiar characters
of the sore enabling the surgeon to recognise  it in  all  its forms.  In  other in-
stances, however, it  is by no  means easy to say positively whether an  ulcer on 
412
SYPHILIS.
the penis is or is not of a chancrous character.  It is especially difficult to dis-
tinguish some forms of excoriated chancre from herpes or aphthae on the prepuce
or glans, or from those slight excoriations that many men habitually contract
after a somewhat impure connexion ; so also  the wound  resulting  from a rup-
tured fraenum often presents a suspicious appearance.  In these cases, however,
the absence of any specific character about  the sore, its immediate occurrence
after  connexion, the general known tendency of the patient to these affections,
and the effect of the inguinal glands not being indurated and enlarged, as they
are in cases of true chancre, will enable the  surgeon to make  the diagnosis.
When the prepuce  is in a state of inflammatory phimosis, it is always extremely
difficult  to  determine by mere examination whether there are chancres  under
it or not, though their indurated  bases  may sometimes be felt  through it.  In
the case  of the indurated,  the phagedaenic, or the sloughy chancres, there can
be little  difficulty in establishing  the true nature of the affection.  In those cases
in which a  comparison of the characters of the sore with one or  other of the
different recognised  varieties of chancre failed in enabling the surgeon to deter-
mine the true nature of the affection, it was  thought at one time  that the influ-
ence exercised by mercury upon  the sore would determine whether the disease
was syphilitic or  not; the true chancres  being supposed to be  curable  in no
other way than by the  internal administration of mercury: but although there
can be no  doubt that the  influence exercised by treatment assists the surgeon
considerably in the  diagnosis  of  obscure cases, yet it  cannot be relied  upon as
a test of the nature of the disease, many syphilitic affections being readily cur-
able by very simple  means without mercury.   The only sure and  unerring test
that we possess of the nature of a suspicious  sore, is the result of the inoculation
of its pus into some  part of the surface of the body.  If this be done with the
point of  a lancet into the  inside  of the thigh, the typical chancre will be pro-
duced if the suspected sore  be syphilitic, and  no  effect will result if it be  not
so.   It must be borne in  mind,  however, that if the ulcer from which the pus
is taken  has got into a granulating state, no effect may be produced, whatever
its previous condition has  been; and  that if the sore,  though of venereal origin,
be not a  primary syphilitic one, its pus will not be inoculable.  Though inocu-
lation is  a sure and  valuable test of primary syphilis, it should  not be too freely
had recourse to, as  it not  uncommonly happens, as I have  several times seen,
that the sore produced by it is far more  troublesome in healing than the original
chancre.

                    TREATMENT  OF PRIMARY SYPHILIS.

  The treatment of  syphilis is a subject that has engaged the anxious attention
of the most eminent surgeons, and one on which so much difference of opinion
and practice still prevails, that I shall not endeavor to discuss the  subject gene-
rally,  but rather confine my remarks upon it  to the consideration of that form of
treatment which has met with the sanction of the best surgeons in this country,
and which a tolerably extensive experience in hospital and private practice has
led me to consider as the most safe and effectual.*
  The treatment of chancre is of a local  and a constitutional character, the local
treatment having  for its object either to destroy the poisonous character of the
sore or to modify it  so as to bring it into the state of a healthy ulcer; the con-
stitutional treatment is not only intended to facilitate this, but to prevent if pos-
sible constitutional infection.
  The local treatment, then,  has for its object either the  destruction  or  the
modification of the  specific character of  the  sore.   The  complete destruction of
the local virus should always, if possible, be effected; and if this can be done
 a To those who wish to pursue the subject farther I would recommend the perusal of Mr. Acton's very
complete treatise on the Venereal Disease. 
TREATMENT  OF  PRIMARY SYPHILIS.            413
  in the early  stage of the disease, according to Ricord before the fifth day after
* inoculation, there will not have been time for any constitutional infection to have
  taken place from the absorption of the poison into the system.  But even though
  this time have been considerably passed before a surgeon sees the sore, it is well
  to destroy the ulcerating and poisonous surface, from which continued absorption
  must  necessarily  be going  on.   This should  be effected by the application of
  caustics in a sufficiently concentrated form to destroy radically and at once the
  specific character of the sore, so as not only to save the  pain, but to prevent the
  irritation attendant upon frequent applications.  The nitrate of  silver which is
  commonly used for this purpose is too weak to secure the effect it is intended to
  accomplish, being  apt  to  irritate and inflame,  and not to destroy the chancrous
  surface, thus  necessitating repeated and  painful applications.   I consequently
  prefer to this the  strong nitric acid, one application of which will very commonly
  suffice to annihilate the specific character of the sore, and  which, though  more
  energetic in action, is not more painful than the nitrate of  silver.   It should be
  applied by means of a small dossil of lint wrapped round the  end of a silver
  probe;  with this the sore may be freely mopped, and then a stream of cold water
  having been poured over it to wash away any superfluous acid, a  light poultice or
  a piece of water-dressing should be laid on;  after the small slough produced  by
  the caustic has separated, a healthy granulating surface will  be left.   The caustic
  may be applied at any time  during the continuance of the specific condition of
  the sore; but when once this  has been destroyed, it should  not be reapplied.
  The potassa fusa and the potassa cum calce, though occasionally used, are far less
  manageable and not more efficacious applications than  the nitric  acid.
     These are  the means  that are generally most useful in simple and indurated
  chancres.  In some cases,  however, caustic  cannot be  used at  once;  this is
  especially the case if the sore be inflamed, or if it be concealed by a phimosis.
  If there be much inflammation  about the sore and prepuce, this must first be
  subdued by the application of cold poultices, or of lead and  spirit lotion.  When
  removed, if the sore has  not lost  its specific character, the caustic  should  be
  applied as usual.   When there is much phimosis present, the prepuce should be
  slit up, and the surface of the sore immediately freely touched with nitric  acid,
  so as if possible to prevent inoculation of the freshly-cut surfaces; should this
  take place, they must also be freely sponged with the caustic.  After the slough pro-
  duced by the caustic has separated, the surface may begin to granulate healthily
  at once, requiring but simple dressings ; but in the majority of cases it will con-
  tinue in a somewhat unhealthy condition, requiring special topical applications to
  get it cicatrize soundly.   If it be weak and fungating, an astringent lotion, such
  as the following, will be found most useful:—
                              R. Tannin ^j.
                                Tinct. lavandulae comp. gij.
                                Vini rubri 3iv.
                                    Ft. lotio.

  Or a solution of sulphate of copper may be applied, and the sore touched from
  time to time with the nitrate of silver.  If there be induration  at its base,  the
  black or yellow wash will perhaps be found the best applications that can be used.
     In  the phagedaenic chancres a different management is  required;  if there is
  much irritability about the sore, the nitric acid cannot be borne, and here the best
  application is an opiate  lotion, conjoined perhaps with  small quantities of  the
  chloride  of soda.   If the part require more stimulation, a few drops  of  the
  dilute nitric acid may advantageously be added insteaaof the chloride.  In these
  cases, however, the application of the strong nitric acid may often be required at
  a later period of the affection, on the removal of the local irritation by the topical
  employment of sedatives.
     In sloughing chancres, emollient and antiseptic applications will generally be 
414
SYPHILIS.
found  to agree best;  carrot, opiate, charcoal, or chlorinated poultices should  he
employed, the sloughs removed, and any parts that are partially destroyed by the*
gangrenous action, as portions of the prepuce, slit up, so as to remove tension and
lessen inflammation.  In cases of inflammatory sloughing of the penis, the hemor-
rhage that occasionally results, from some of the bloodvessels of the organ being
opened by this action, may be looked upon as highly beneficial, inasmuch as it is
often followed by an arrest of the morbid process.   When once  the chancre  is
healthily  granulating it must be  dressed in the same way as any  common  ulcer.
In using  lotions to any form of chancre,  care should always be taken to keep a
piece of lint soaked in the fluid constantly applied between the prepuce  and the
glans, and, in  women, between  the opposite labia; for unless  this  be  done, the
contact of the diseased and inflamed mucous surfaces with one another will tend
to keep up irritation and morbid action.
  The constitutional treatment of primary syphilis is of the first importance, not
so much with  a view of getting the local sore to cicatrize, as to prevent,  if possi-
ble,  constitutional  infection.   As it is  impossible to  say when the absorption of
the poison into the system takes place,  though it is probable, as Ricord supposes,
that it does  not occur before the fifth day, constitutional treatment should be had
recourse to from the very commencement  of the disease.
  The  constitutional  treatment  of primary syphilis  has undergone  various
changes according to the prevailing doctrine of the  day.   It had been  decided
by the surgeons of the last and of the early part of this  century, that  mercury
acted as a specific against the  syphilitic  poison.  This doctrine was  so firmly
established,  that Hunter, and many of the great surgeons of  his school, looked
upon the curability of a sore without mercury as a proof that it was not syphilitic.
About the commencement of this century, however, it was found by the observa-
tion  of the  army  surgeons,  amongst whom Mr. Rose took a principal share in
this  inquiry, that  the different forms of primary syphilis were curable  without
the necessity of administering mercury, or indeed to have recourse to any specific
treatment whatever.  These observations, which appear to have been founded on
what was  witnessed in Spain and Portugal during the Peninsular War, led to the
introduction "of an important modification in the treatment of syphilis, viz., the
non-mercurial or simple plan, as  it is termed :  a mode of practice that obtained
great favor,  and has been extensively tried.   Of late years, however, a reaction
has again, I think, taken place in the minds of most professional men, and mer-
cury is again employed in the treatment of this disease, but more moderately and
scientifically, and consequently more successfully than before.
  The arguments  in favor, of  the non-mercurial plan  of treatment are briefly
these; that by this system of treatment the constitution of the patient is saved
the introduction of a mineral which in many cases  acts injuriously, and which,
as the  disease can be cured without  it, may at all events be  looked upon as
unnecessary.   Then, again, it is stated by the  advocates of the simple treatment,
that  secondary affections less  frequently follow this plan than they do  the ad-
ministration of mercury; and, lastly, that those distressing cases of constitutional
syphilis,  which are common  after mercurial courses,  and which are  said to
depend upon a peculiar combination of the syphilitic poison and the mineral in
the system, are never met with in persons who have  undergone the  simple treat-
ment.  These arguments, however, on closer examination and further experience,
have not been proved to be  quite so conclusive as the supporters of the simple
treatment  appear  to believe.   That a great number,  perhaps the  majority, of
cases of chancre can be healed  without the administration of mercury is undoubt-
edly the fact;  but  in many instances it is equally true that the primary sore will
not cicatrize properly unless the mineral be  administered, or  if it do close, that
it heals in an  imperfect manner, readily breaking out again.   But it is a most
serious error to confound  the healing of the sore with  the cure  of the  disease. 
SIMPLE  AND  MERCURIAL  TREATMENT.            415
The cicatrization of the ulcer and the prevention or neutralization of the consti-
tutional infection, are two distinct things;  and the test of the relative value of
these two plans of treatment must depend rather on the relative frequency with
which they are followed by constitutional symptoms,  and on the character that
these assume under one or other of these methods, than on the  mere skinning
over of the ulcer.  I cannot agree with the statement that secondary symptoms
are less frequent after the simple than after the mercurial treatment of syphilis.
I have seen the  non-mercurial plan of treatment very extensively employed at
the University College Hospital.; indeed it was formerly almost invariably prac-
tised there, more particularly in the syphilitic cases  occurring among the out-
patients under the late Mr. Morton, who strongly advocated it; and I have had
repeated occasion to observe the  frequency with which it was followed by secon-
dary symptoms.   In private practice also I have had  considerable opportunities
of comparing the two methods, and I can safely say that I have seen the simple
treatment more frequently followed by secondary symptoms than  the  mercurial
plan has been when properly and judiciously employed.  The supporters of the
non-mercurial treatment, when obliged to admit the great frequency with which
it is followed by secondary symptoms, argue, that if more frequent, they are less
severe after  the  simple than the mercurial plan;  and they state somewhat dog-
matically, and it appears to me without much evidence to support this statement,
that mercury and syphilis together form a sort of poisonous compound  in  the
system which produces the worst and most destructive forms of constitutional
syphilis.  I  deny, however, entirely that we have any proof of the existence of
such a combination as that which  is supposed to be produced  by syphilis and
mercury ; no evidence  that I am acquainted with has  ever been adduced in sup-
port of the formation of such a poison in the system.   It is doubtless true that
after an  ill-regulated mercurial  course constitutional  syphilis  of a very severe
character may occcasionally appear;  but this seems to me to be rather owing to
mercury having been improperly administered in constitutions that will not bear
it, and in which, by the induction of a cachectic  and  depraved condition of the
system, it favors the  occurrence  of some  of the more  severe forms of secondary
syphilis,  in the same way that any other lowering plan of treatment,  or  simple
debility might occasion them, but without the exercise of any specifically inju-
rious influence.  Some of the worst forms of constitutional syphilis that  I have
of late seen,  occurred  in patients to whom no mercury had been administered,
but  in whom the syphilitic virus had been  allowed  to  exercise its  influence
unchecked save by the so-called simple treatment.   I have seen the body covered
by immense ecthymatous crusts and sores  in one case, rupial ulcers with destruc-
tion of the nose and palate in another, and the worst kind of syphilitic cachexy
with the tuberculo-pustular syphiloid in a third; in none of which had any mer-
cury been administered.  But though I cannot admit that the supporters of the
simple treatment of syphilis have brought forward any proof of  its superiority
over the mercurial plan, and though my own  experience  has taught me  that
secondary symptoms occur after it with equal severity and  with far greater fre-
quency than they do when mercury is carefully and judiciously administered, yet
I am quite ready to allow that there are certain forms of primary sore,  especially
those of a phagedaenic or sloughing kind, in which the simple treatment alone
is admissible, the state of the constitution or the disease being such that mercury
cannot be given  in any form.  In these  cases the patient  must be kept in  bed,
his bowels properly regulated, and such a treatment adopted, in accordance with
ordinary medical principles, as will tend  to subdue local action and improve his
general  condition.   It is, indeed, especially in  individuals of an unhealthy or
strumous habit of body, or in those who are  suffering from local visceral disease
of some kind, that this plan of treatment should  be adopted.   So also in those
who, from the nature of their occupations, are subjected to much exposure to wet 
416
SYPniLIS.
and cold, a mercurial course cannot be properly or safely administered, and the
simple treatment is the only plan that should be adopted.   In all other cases I
am certainly of opinion  that mercury ought to be exhibited, and this opinion
appears to be  entertained by the  most experienced surgeons of the day in this
country and in France.
   The first  question in connexion with the employment of mercury in syphilis,
has reference to the principle on which this  remedy is administered.   Whether
mercury exercises a specific action over the venereal poison or not, has been much
discussed, and is difficult of proof.   I am certainly of opinion that it does act as
a specific in cases of primary syphilis, but that this specific action is much influ-
enced by the condition of the system, the habits of the patient, and the mode of
administration of the remedy; these conditions under certain circumstances tend-
ing to counteract or otherwise to interfere with its operation.  As has already
been stated, I do not for  a moment doubt that most primary sores  may be readily
got to cicatrize without administering a grain of mercury to the patient, but I
believe that in these cases, and my belief is founded on tolerably extensive expe-
rience at the Hospital to which I am attached, secondary symptoms will  be almost
certain to occur, and indeed will appear pretty soon after the cicatrization of the
local sore;  the disease in fact appearing to contaminate the system unchecked.
That  mercury in many cases is antagonistic to the syphilitic poison, appears
evident from the fact that in some instances chancres will not heal unless it be
given internally,—from its influence on infantile syphilis,—and that when pro-
perly administered in healthy constitutions it may almost to a certainty be looked
upon as a preventive to the occurrence of constitutional syphilis.   When it fails,
as it doubtless does in many cases to prevent, or to eradicate  the constitutional
infection, the cause of the non-success may usually be traced either to want of
care in its administration, or to the existence  of an impaired state of the patient's
health.
   In  connexion  with the  administration  of mercury  in  syphilis, therefore,
various questions present themselves, the proper determination of which is of the
first importance; these have reference to the state of the constitution, the con-
dition of the sore, and the mode of the administration  of the remedy.
   The state of the patient's constitution influences materially the propriety of
the administration of mercury.  In ordinarily healthy constitutions it may always
be safely employed; but if the  powers of  the system  be broken  by excesses of
any kind, if the patient be of a  strumous habit of body, if he be irritable, fever-
ish, or excited, it must be exhibited with  great caution, or should be  withheld
until these  states of  the system are modified or removed.  It is especially by
administering mercury  to  strumous  and cachectic patients, or to those whose
powers have been broken by  habitual dissipation, that  so much mischief results;
and that it occasionally gives  rise, by acting  as a depressing agent, to local
sloughing, or to some of the low forms of secondary syphilis.
   The condition of the sore in which mercury should be given, is  equally impor-
tant as that of the health.  It should not be  administered during  the early stage
of an inflamed or irritable ulcer.   So long, indeed,  as such a condition  keeps up
in the sore mercury will often act injuriously, by exciting a sloughing  tendency
in it, more especially in debilitated or broken constitutions;  hence it is well to
subdue  the  inflammation  or local irritable  condition  before  the  mineral  is
employed.
   The particular preparation of mercury to be given, the length of time that it
should be continued, and the rules to be observed during the  mercurial course,
are all matters that influence greatly the result of the treatment.
   Mercury may be  administered by the mouth, by inunction, or by fumigation.
When it is to be  given by the mouth in primary syphilis, and when it is desir-
able to  produce but a moderate effect upon the system, I prefer the iodide of 
MERCURY IN SYPHILIS.
417
 mercury, in doses of one grain three times a day; or the Plummer's pill in five-
 grain closes twice or three  times a day, will be found extremely useful when the
 constitution is somewhat  irritable.   If it be desirable to produce a rapid effect
 upon the system, five grains of blue pill may be given night and morning.  The
 other preparations of mercury are not, I think,  required  in the primary form of
 the disease.   When it is  required  to produce a moderate effect, especially in
 somewhat delicate persons, without  irritatingrthe system or inducing much sali-
 vation, the iodide is certainly to be preferred to all other preparations.
.   In some cases the bowels are so irritable that the administration of mercury
 by the mouth invariably  purges the patient; under  these  circumstances  the
 mercurial inunction may be conveniently practised.  This is best done by rub-
 bing a drachm of the strong ointment into  the  inside of each thigh for ten
 minutes every night and morning; or  by putting a similar quantity upon a piece
 of lint and letting the  patient wear it during the day and night in either axilla.
   The  duration of the mercurial course  must depend upon the effect produced
 upon the sore;_ it need not be continued until  this has cicatrized, but it should
 be persevered in until all specific action in it has ceased, and it  has got into a
 healthy and healing state.   This impression is seldom  produced upon the sore
 without a slight effect upon the mouth having previously been  induced, the
 gums becoming spongy, red, and swollen, and an increased flow of saliva taking
 place.  It is never necessary to continue the mercury so long, or to give it to so
 great an extent, as to produce very profuse salivation.  It was in attempting to
 do this, and by administering the remedy in too large a quantity and too rapidly,
 that  the older surgeons produced such injurious consequences.  The effect pro-
 duced upon the sore, rather than that upon the gums, should be our guide as to
 the proper time for discontinuing the mercurial.
   The  rules to be  observed during a course of mercury  exercise considerable
 influence upon the effects produced by it.  The  system  should always be pre-
 pared for its  administration  by a free  purge.  Whilst  it is being given,  the
 patient should, if possible, be kept  in bed, or  at all events be confined to  the
 house, taking  as  much rest  as possible;  the diet should  be  moderate and  un-
 stimulating, and the dress  be as warm as the season  will admit.  If the mercury
 be given by the mouth, and gripe, it will be  found useful to combine it with
 capsicum.  If it purge, small doses of opium may advantageously be exhibited in
 conjunction  with  it.   After it  has been  carried  to  the full extent deemed
 advisable, it  should not be suddenly left  off,  but gradually discontinued by
 diminishing the quantity daily during  a week or ten days.  If  administered in
 accordance with these  rules, and in proper constitutions, we shall seldom find
 any of those injurious effects produced that were formerly described as resulting
 from the exhibition of this mineral; those severe and extensive forms of ulcera-
 tion of  the mouth leading  to necrosis of the jaws, and  the mercurial erythema,
 or erythismus, described by the older surgeons,  are now happily almost matters
 of history, being but seldom if ever met with.
   These are the general principles upon which primary syphilis requires  to be
 treated : now for a few  words as to the special management of the different forms
 of chancre.
   The simple ox excoriated chancre should be cauterized with nitric acid, dressed
 with water-dressing for  two or three days until  the  slough separates, and  then
with the black wash, or the sulphate of copper, or tannin and wine lotion if the
sore be weak  and  fungating; in  which condition  also it will require the  occa-
sional application of the nitrate of silver.  At the same time the patient should
be put upon a  mild course of the iodide of mercury.
  In the indurated or  Hunterian chancre, the nitric acid may be freely applied
in the early stages, so  as  to  destroy the surface  of the sore, but  no  attempt
should be made to burn away the  indurated base with caustics, as they will prove
                                     27 
418
CONSECUTIVE SYPHILIS.
 unsuccessful  in  this, the indurated  condition  always extending  beyond  the
 influence of the caustic.   In  these cases the best local application  is generally
 the black wash.   It is in this form of sore  that mercury is especially useful, and
 is  most imperatively  required;  a full and  continued course should  be adminis-
 tered, and the influence of the mineral kept  up until all hardness has disappeared;
 unless this  be done, the  patient will almost to a certainty suffer  early and
 severely from secondary symptoms.
   In the phagedaenic chancres the line of practice is not so clear, as much must
 depend upon the  particular form of the sore, and the state of  the patient's con-
 stitution.  If there be much inflammation  or irritation about  the chancre, this
 must always be subdued in the first instance, by the employment of mild local
 antiphlogistic means and the application of opiate lotions.  In  many cases, how-
 ever, the local inflammatory action is  best  removed by the application  of the
 concentrated nitric acid, this being followed by opiate lotions or emollient poul-
 tices, the caustic being reapplied so often as there is a tendency to the extension
 of  the disease.   The constitutional treatment in  these phagedaenic chancres
 must usually be of the non-mercurial kind; indeed it is  the indiscriminate use of
 mercury in these  cases that has,  I  believe,  brought so much  discredit upon this
 remedy in syphilis.   The constitutional treatment of phagedaenic chancre must
 be directed by general medical principles; rest in bed, a mild diet, the adminis-
 tration of salines and opiates, in  those cases in which there is inflammation and
 irritation conjoined; whilst in those in which there is a debilitated  or cachectic
 condition, tonics,  such as bark or iron, with  good food and  stimulants, may  be
 required, together with opiates  to allay pain and to procure  rest.   Although
 mercury is not generally admissible  in these cases, yet in that form of phage-
 daenic chancre that is characterized by a white slough, it has been found useful
 by Mr. Wallace, and the utility of this practice I can confirm, having found it
 of service in some of the more rebellious varieties of this  disease;  the mineral
 must, however, be very cautiously administered, and in but small  doses.
  In the gangrenous or sloughing chancre,  if there be much local inflammatory
 action and general constitutional disturbance, the patient  should be treated  on
 an actively antiphlogistic plan; he must be bled freely in the arm if young and
 robust, but, at all  events, be well purged, have salines, and in some cases anti-
 mony, kept on a low diet, and have  local antiphlogistic treatment.  Free incisions
 should  be  made  through the sloughing textures, and as the powers  of the sys-
 tem give way, or, from the first, if there be much debility, the mineral acids, with
 bark, good nourishment and stimulants will be required; at the same  time that
 chlorinated charcoal or yeast poultices are applied locally until  the sloughs have
 separated, when the sore must be dressed on ordinary principles.   If there  be
 free hemorrhage from any arterial branch, this may require ligature  or touching
 with the actual cautery.
  After a  chancre has been healed in one  or other of these  ways, we must en-
 deavor to prevent the manifestation of constitutional  syphilis, by the general
 improvement of the patient's health.   This is usually best  done by putting him
 on a course of sarsaparilla  with the mineral acids, and  by scrupulous attention
 for some months to his habits  of life.   The syphilitic poison may linger for a
 great length of time in the system, not declaring itself  by any overt manifesta-
 tions so long as the health  continues good,  but if the patient fall into a debili-
 tated state, even though some years have  elapsed, the disease will show itself at
 once by some  of its local effects.

                        CONSECUTIVE SYMPTOMS.
  The  primary symptoms of syphilis are not unfrequently followed  by a series
of affections which may be termed consecutive, depending  as they do upon the
primary disease, but yet being local in their character, and presenting  no evidence 
BUBO.
419
of constitutional infection.   These consecutive symptoms are, an induration of
the chancrous cicatrix, bubo, and warts.
   Indurated Cicatrices.— 3lost excoriated chancres are  healed without  any
cicatrix or other trace of them being left, but in the indurated, the pb.ageda.niic,
and the sloughing chancres, there is always loss of substance, often to a consider-
able  extent, and consequently  a depressed scar.   In some  cases, however, of
excoriated  and Hunterian  chancre, but  most  frequently,  I think, in the exco-
riated chancre,  an  imperfect cicatrization takes place over the  surface of the
sore, the specific character of which has not been destroyed; the consequence of
which is that the tissue of the cicatrix gradually increases in size, becomes in-
durated, and is  capable of infecting the system.   These indurated cicatrices are
especially apt to follow slight syphilitic excoriations, which may skin over spon-
taneously, even without  the  patient having been aware of  their existence, or
which have cicatrized  under simple  treatment.   Under these circumstances a
patient  laboring under constitutional syphilis will apply to  a surgeon, and  on
being questioned, may deny having had any primary disease; but on examina-
tion an  indurated cicatrix will be found, evidently the result of a chancre, that
has not been properly attended to.
   These indurations vary in size  from a  pea to a chestnut; they are usually
situated on the  mucous surface of the prepuce or glans, and sometimes on  the
framum, and are commonly accompanied by an enlarged and indurated condition
of the inguinal  glands.   This indurated cicatrix is a condition of importance, as
it shows the persistence of the syphilitic poison in the site  of the chancre, where
it exists as  a continued  source  of infection  to the system,  which it may poison
as effectually and as quickly as an open chancre, a kind of zymotic action being
continued in it, generating  and  transmitting the syphilitic ferment into the  blood.
These indurations  must  be looked upon  as infallibly leading to constitutional
syphilis, unless speedily removed.  If left to themselves, they readily break into
secondary ulcerations,  forming excavated and  sloughy sores.   On examining
their structure, it is found  to be composed simply of plastic matter, consisting of
the ordinary filaments of this, with spindle-shaped and elongated cells, undergoing
transformation into fibro-cellular tissue.  It is a remarkable fact, that the indu-
rated  cicatrix  not  only always comes on slowly after the sore has apparently
healed,  but very frequently does not  make  its appearance until after a lapse of
some weeks or months, without inflammation, pain, or local inconvenience of any
kiad, the surgeon often discovering it without its having attracted the patient's
attention.
   The treatment of this induration must be conducted in  the same  way as that
of a Hunterian chancre, by means of a full  and steady course of mercury, until
it has wholly disappeared.  Unless this be done, there is  no safety for the patient
from constitutional syphilis.  Caustics should never be  applied to these indura-
tions as they occasion troublesome  ulcers, and the only local treatment that is
likely to be of any service, is the application of a piece of lint soaked in black
wash, so as to prevent excoriation.
   Bubo.—Every enlargement of the  inguinal glands that occurs in a case of
syphilis must not be considered a  bubo.   The glands may be irritated by con-
comitant inflammatory action about the penis, as when balanitis  or  phimosis are
present, or they may be enlarged from the simple excitement of the parts, espe-
cially in strumous or debilitated subjects.  In these cases the affection must be
considered as a  simple irritation of the inguinal glands, which will speedily sub-
side under proper antiphlogistic treatment of a mild kind.  Indeed, it scarcely
ever  happens that  a chancre has existed for some  days without the lymphatic
glands in the groin becoming enlarged and somewhat indurated, especially those
that lie  parallel to Poupart's ligaments, their enlargement being attended with
a degree of  stiffness and dragging pain.   Under these  circumstances, true spe- 
420
CONSECUTIVE SYPHILIS.
 cific bubo is very apt to  occur if the patient  continue  to walk about, or if the
 poisonous matter  from the chancre becomes absorbed.  „When once  the glands
 in the groin have become specifically irritated  it is extremely difficult to prevent
 suppuration taking place.  Most usually only one  or two glands  suppurate,
 although several may be enlarged, and very commonly the disease  is confined to
 one groin only, though both may be affected, more particularly if the chancre is
 situated upon  the fraenum ; the suppuration may be limited to the gland imme-
 diately affected, or it may extend into the surrounding cellular tissue, or even be
 chiefly confined to this.
   The syphilitic bubo is  essentially produced  by the  absorption and  deposit of
 the venereal virus in the substance  of the gland, the tissue of which becomes
 poisoned, so that  we may consider with Ricord, that a  bubo is, properly speak-
 ing, a chancre  of an absorbent  gland, differing  only in seat from that which is
 situated upon the surface of the body.   Ricord has observed, and I have often
 had an opportunity of testing the correctness of this observation, that the pus of
 a syphilitic bubo  is as readily inocukble  as that of an  ordinary chancre.   The
 ordinary syphilitic bubo, then, may be considered as a specific abscess of the ab-
 sorbent glands  and surrounding  cellular tissue.   It runs the ordinary course of
 an acute abscess, often undermines the skin to a considerable extent, with much
 red or purple discoloration, and   when it has burst or been opened, presents a
 ragged or sloughy-looking cavity,  having an  unhealthy appearance;  it most
 usually occurs about the second  or third week  after the  first  appearance,  of the
 chancre, but may happen at an earlier or later  period.
   The French  surgeons  have  described  a form  of bubo that they call bubon
 d'emblee, or primary bubo; this  is said to occur from the direct absorption of the
 syphilitic poison, without the previous formation of  a  chancre.   It  is seldom
 that satisfactory proof can be  given of  the  existence of such a bubo.   It
 doubtless frequently happens that small  excoriated chancres heal in a few days,
 before which time,  however, the inguinal  glands have become irritated  and
 enlarged, and as the enlargement of the  glands goes on after the healing of the
 chancre, a bubo may be formed when all trace  of its primary source has entirely
 disappeared.
   Bubon d'emblee, or primary  bubo, has  only fallen  under  my observation in
 one case, and, until  that  occurred, I doubted its existence.   In  the case re-
 ferred to, a young man applied to me  with  rather  a large abscess in the  groin,
 for which I sent him into the hospital.   On being questioned, he  denied  ever
 having had any syphilitic disease, though  he admitted  having had intercourse
 with a woman of the town.  On examining  the penis no chancre, abrasion, or
 cicatrix could be discerned.  The abscess was opened,  and two ounces of rather
 bloody and very thick  pus let out;  no enlarged  glands  could be seen.  As the
 pus looked suspicious, it was inoculated  into the left thigh, when  two distinct
 and well-marked chancrous pustules were produced.1                           '
   In some cases the bubo, as has been well shown by Mr. Solly, assumes a ten-
 dency to creep  or spread  over the  neighboring  integument, extending in  this
 way to a considerable distance down the  thigh, upon  the abdomen, or over the
 ilium; this creeping bubo is characterized by the peculiar semicircular  or horse-
 shoe shape that the sore assumes, and by its tendency to  cicatrize by one margin,
 whilst it slowly extends by the other, the  cicatrix always being  thin, blue, and
 weak, closely resembling that of a burn.
   After a bubo has disappeared, a good  deal of induration may be left in the
 glands of the^ groin, together perhaps with matting of the surrounding cellular
 tissue, and this induration may continue for years, or even for the remainder of life.
   The treatment of bubo  consists in the first  instance of an endeavor to prevent

Swhite!v. and XXV^LT * larVa'ed'  UrClhral Cha"Cre haVe existed?-Vid<= Ricord, Lettra ««r to 
BUBO.
421
the occurrence of suppuration, and should  this take place, to let out the matter
and  close the wound which results.
   The preventive treatment of bubo is of considerable moment; for if suppura-
tion  take place, a tedious result will  often be  entailed on  the patient.   It con-
sists essentially in perfect rest of the part, the application of leeches, and of cold
lead poultices;  at the same time  the  free  internal  administration  of  mer-
cury as for a chancre should be persevered in; for not only has this a tendency
to promote the resolution of the swelling,  but also to prevent the infection of
the constitution, which readily takes place when  once the poison has entered
the absorbent system.   The employment of antimonials in nauseating doses has
been strongly recommended by Mr. Milton, and deserves, I think, the attention
of the profession.
   If there be  not much  inflammatory action about the  bubo, but  if this be
indolent and  chronic, the application of blisters, of discutient plasters, or of the
tincture of iodine, is occasionally useful.  A plan of discutient treatment recom-
mended by a French army surgeon,  M. Malplaquet, I have found very service-
able in several  cases.   It  consists in applying a blister about as large as half-a-
crown over the  surface of the inflamed gland, and  dressing the raw surface
produced by it with a piece of lint soaked in a saturated solution of the bichloride
of mercury for  a  couple of hours, when the white eschar will have formed;  a
cold poultice  should then be  applied, and continued until all excited action has
gone down.
   If, notwithstanding our endeavors to prevent suppuration, matter forms within
or around  the  gland, as evinced by the swelling becoming soft, boggy, and
inflamed, it should be freely opened, either by a horizontal or vertical incision,
whichever will give the readiest outlet to the  pus.   If the integuments be much
thinned, undermined, and of a bluish color, I prefer  making  the opening with
potassa fusa,  as it destroys those unhealthy  tissues which would otherwise inter-
fere with the  cicatrization of the wound.  The cavity that is  now exposed presents
a cancerous appearance, being irregular and  sloughy, with elevated and  angry
red edges.  This should be dressed with the aromatic wine and tannin lotion, at
the same time that the system is kept under  the  influence of the mercury.  If
we find  that the character of  the sore does  not improve,  the potassa fusa should
be freely applied to its  surface and edges,  and after the sloughs have separated
the  granulations may be dusted with  red  precipitate powder; the cicatrization
will  in many  cases be much facilitated by the application of a  compress, with a
spica bandage, and by keeping the patient at  rest.  Not unfrequently the heal-
ing of the sore is interfered with by overlapping of the undermined edges; these
may occasionally be made to  retract by being freely rubbed  with the nitrate of
silver.   If this  do  not  succeed it may be necessary to pare  them  off with a
knife or scissors, or to destroy them with potassa fusa;  the sore  should then be
dressed from  the bottom, and treated on general principles.   Sometimes slough-
ing  action is set up in the  open bubo, and  then extensive  destruction of  tissue
may ensue, and even fatal hemorrhage from  the femoral artery has been known
to occur.
   Venereal Warts.—Various  forms of warts occur as the result of primary disease,
independently of any constitutional  affection, arising from simple irritation of
the muco-cutaneous surfaces;  besides these, warts or verrucas of  a truly specific
and contagious character are  met with.  These commonly occur on the prepuce
or glans, and  are especially apt to be  situated  in the angle between these parts;
they are of a bright-red color, very  vascular, and  if left without interference,
may  increase  immensely in  size and number, distending the prepuce, and giving
a clubbed appearance to the  penis;  there  is  always  phimosis attending  them,
and then tension of the  prepuce may be such, that  ulceration occasionally takes 
422        CONSTITUTIONAL,  OR  SECONDARY  SYPHILIS.

pkce in it, giving rise to  a protrusion of these  growths through  an  aperture in
its side.   These warts are occasionally met  with in the  vagina, forming large,
irregular, cauliflower-looking  masses.   The  treatment consists  in snipping, and
paring them off with scissors, and afterwards touching the part from  which they
sprint with nitrate of  silver, to  prevent their recurrence.  In  order to do  this
effectually, it is necessary to lay open the prepuce in all those  cases in which the
glans cannot be freely exposed by drawing this back.

               CONSTITUTIONAL  OR  SECONDARY SYPHILIS.
  By constitutional syphilis is meant the general infection of the system by the.
venereal poison absorbed  from  a chancre, by which it  is always preceded: in
many cases, but  not  necessarily, a bubo has also  been  one  of the antecedent
symptoms.  This  form of syphilis  is commonly called secondary, in contradis-
tinction to the primary or local disease.   It manifests itself not so much by the
occurrence of any special  disease, as by the tendency it occasions to the develop-
ment of inflammation in various  tissues and organs, and by the peculiar impress
that it communicates to the form  and  course of the  inflammatory affection it
induces.
  Constitutional  syphilis  is not contagious.   This point, which I look upon as
one of the fundamental doctrines in syphilis, has in my opinion been incontest-
ably proved by the observations of Hunter, and more recently by Ricord, who
has shown that the pus from secondary sores is never inoculable;  observations
that are fully carried out by what may often be observed in  practice.   It is,
however, hereditarily transmissible, under certain circumstances, from parent to
offspring.
  The period at which constitutional syphilis declares itself usually varies  from
six weeks to six months after the occurrence of the local disease.  Occasionally
it shows itself earlier, about the second or third week, when it may be coincident
with the existence of primary syphilis ; in other cases again it does not manifest
itself for years after the primary  disease.  Most  commonly its S3rmptoms are pro-
gressive, the  milder,  such as the affections of the skin  and mucous  membrane,
occurring first; the more severe, as those of the bones and organs,  afterwards;
but in other cases this progression is not observed, symptoms of great intensity
setting in early, without being preceded by those of a  slighter kind.
  When once syphilis has become  constitutional, it is extremely difficult to say
when it can be eradicated from the system ; and indeed it is  a question whether
it may not impress the constitution in a peculiar way, modifying  certain actions
during the rest of life, as we know is the case in other specific diseases, such as
cow-pox or scarlet fever.  Certain it is that if neglected or improperly treated, it
will affect the system for an indefinite time, declaring its existence by exciting and
modifying various local inflammations years  after the  original absorption of the
poison.  Ricord inclines to the belief that a person who has once had secondary
symptoms, and gets  well of the constitutional affection, cannot  have them a
second time, though he contract  a fresh chancre;  and Mr. E. Wilson attributes
many of the  ordinary non-specific  cutaneous  diseases to the  latent influence of
constitutional syphilis.   Without perhaps admitting to their full extent the doc-
trines of these surgeons, I certainly think that daily  experience  tends to show
that in many constitutions syphilis cannot be eradicated, and that in most others,
when  once it  has occurred, it  is apt, even  when apparently cured, to  modify
certain cutaneous and other affections in a  remarkable  manner, after a lapse of
many years; showing clearly that if the poison no longer exist in the system, the
constiution has received a peculiar impress from it. which it is long in losing.
These remote effects of syphilis have by Ricord been called  " tertiary. "   This
term is convenient as indicating  a peculiar stage of the constitutional manifesta- 
           CONSTITUTIONAL,  OR  SECONDARY  SYPHILIS.        423

tions, in which the tissues  are more deeply affected than in the secondary form
of the disease.
   Although the disease may continue to modify the system for years, or even for
life, yet it seldom proves fatal.  In some cases, however, death may occur, either
by the cachexy that is induced,  by the supervention of phthisis, or by caries of
the skull, and consequent disease  of the brain;  fatal and  specific  syphilitic
diseases of the lungs and brain have been spoken of,  but I do not think we pos-
sess positive evidence of the existence of such affections.
   It is especially  when  the disease has got into the tertiary stage that it runs so
protracted and  tedious a course.   When  the syphilitic manifestations are con-
fined  to affections of the cutaneous and mucous surfaces, the disease may, and
does occasionally,  wear itself out, the materies morbi being apparently carried off
by the secretions  of these tissues; and it is only in this way, I believe, that  the
affection can be eradicated from the system.
   That constitutional syphilis is dependent  on the  absorption of the  syphilitic
poison into the blood, and its  consequent general diffusion through  the system,
there can be little doubt.   Xot only is this rendered evident by the great variety
of tissues and organs  in which it manifests itself locally, but also in the induc-
tion of the peculiar syphilitic cachexy.   Constitutional syphilis may  affect  the
following tissues and organs, and usually does so in the order  in which they are
mentioned—viz.,  the skin, mucous membranes, periosteum, and bones; the throat,
tonsils, palate, eyes, nose, larynx, tongue,  and testes.
   The first occurrence of  constitutional syphilis is  often ushered in  by febrile
symptoms, resembling those of ordinary inflammatory fever, but of rather a  low
type.   In proportion to the severity of these is usually the rapidity of the pro-
gress  and the extent of the local manifestations.
   In  other cases  again the patient gradually falls into a feeble  and  emaciated
 condition, becoming sallow and  earthy-looking, with a loss of hair, and depres-
sion of mental  and  bodily  vigor.  In  this condition  not only are the  nutritive
functions impaired, as is evidenced by his  becoming weak and  thin, but the repa-
rative actions are  lessened, wounds do not heal kindly, and fractures are slow in
uniting.
   The syphilitic  affections occurring on  the skin and mucous membranes  are
usually of a secondary character,  though some belong to the tertiary group;
whilst those of the bones and different organs, as the  larynx and testes, are com-
monly tertiary.  Although the integumental structures are usually first affected,
yet it sometimes happens that the disease  manifests itself upon the deeper and
more  important tissues,  without having previously implicated any others.
   Constitutional  syphilis is not by any means a necessary consequence of  the
primary  disease;  many of those affected with chancre  escape all  after-conse-
quences ; in this respect much will depend upon the duration  and nature of  the
primary sore, its treatment, and  the state of the patient's health.
   That the duration of the local disease influences materially the occurrence of
constitutional syphilis, cannot I  think be doubted.   Ricord states that there is
no instance  of secondary syphilis occurring if the chancre be destroyed before
the fifth day after the inoculation of the poison.   This may be so, but the state-
ment  appears to me to be scarcely  capable of proof, as it is certainly of very rare
occurrence for a  chancre to  be detected and  completely destroyed so as to be
converted into a simple granulating sore by the fifth day after the infection.   It
is seldom that it is observed much before  this period, and even if it be, no sur-
geon could be sure of its complete  destruction at so early a period after its occur-
rence.  Ricord also  appears  to  incline to the  belief that the  quantity of  pus
absorbed from these primary sores destroyed before the fifth day does not influ-
ence the nature  or severity  of  the secondary symptoms, and in fact that  the
patient runs no greater risk from one than from a dozen of them.  In this doc- 
 424        CONSTITUTIONAL,  OR  SECONDARY  SYPHILIS.

 trine I cannot agree, for I can see no reason for placing syphilis in a different
 category to any other animal or vegetable poison, in all of which the constitu-
 tional effects are  certainly proportioned to the extent of the local infection; at
 the same time I fully admit that the treatment of the sore and the state of the
 patient's health influence the severity of the constitutional phenomena to a very
 considerable extent, and probably, indeed, to  a greater degree than  any other
 cause.   That the treatment  of the primary sore exercises considerable influence,
 cannot be doubted.   The liability to constitutional  syphilis  is, I  believe, mate-
 rially lessened by a mercurial course, and  the severity of the secondary symp-
 toms is not in any way increased if that course  be properly conducted.   The
 state of the patient's health also greatly influences the probability of the occur-
 rence of constitutional  syphilis.   If, after the cure of the primary disease, his
 health  continue  good,  no infection of  the system  will manifest itself; but if
 broken or cachectic, then secondary syphilis will occur contemporaneously with,
 or at a very early period  after the primary disease;  and indeed I generally look
 upon the chance of the speedy supervention of secondary syphilis as more imme-
 diately dependent on this than on any other cause.   It is remarkable for how long
 a time the syphilitic poison will continue dormant in the constitution without pro-
 ducing any  local  manifestation of its existence  until this is developed under the
 influence of a broken state of  health.  I have at present under my care an ex-
 tremely severe case of constitutional syphilis, in which twelve years have elapsed
 since the occurrence of the primary disease, during  the whole of which time no
 secondary affection occurred until the patient's health gave way from other causes.
 And  I have had lately an officer under my care in whom constitutional syphilis
 in a very severe form occurred, for the first time,  after salivation for hepatic dis-
 ease,  five years after the primary sore had been contracted;  no  constitutional
 manifestation declaring  itself in the meanwhile.   Not  only does  a state  of ill
 health hasten the  occurrence of secondary syphilis, but cachexy, neglect, or indif-
 ference to its existence, may keep it up indefinitely.
   But not only are the  constitutional symptoms influenced by the causes  that
 have just been discussed, they are  likewise modified to a considerable extent by
 the character of the primary sore.   Secondary  syphilis certainly occurs with far
 greater frequency and severity after the Hunterian and the phagedaenic chancres,
 than  after  other  forms of the disease.    The  question  as to  there being any
 connexion between the nature of the sore  and that of the  consecutive constitu-
 tional affection, has been  much discussed, and though I cannot agree  with the
 doctrine of the plurality of venereal poisons, yet I hold with Carmichael that the
 different forms of primary sore will, if left to themselves, be followed each by
 its own peculiar train of constitutional symptoms.   In fact I am fully convinced,
 as the result of much and close observation on this point, that there is a general
 correspondence between  the kind of ulcer and the constitutional  syphilis that
 follows it;  both in fact being chiefly dependent upon the state of the patient's
 health.   The same  condition  of  system, for instance, that will give  rise to a
 phagedaenic or sloughing chancre, will occasion rupia or ecthyma with  necrosis
 or caries of  the bones, as the constitutional manifestations; whereas that which
 occasions the indurated  chancre will equally modify the secondary disease, so
 that it assumes a squamous form, accompanied perhaps by iritis and osseous dis-
 ease ;  and the excoriated chancre will generally be followed by papular or roseo-
 lar  eruptions,  with mucous tubercle of  the tongue  or  throat.   That these
 sequences are of very frequent occurrence, I cannot doubt,  having so frequently
observed them; and that they are not of constant occurrence is, I believe, owing
 to the character of the  constitutional affection being often modified by the state
of the patient's health having  undergone  a change  subsequent to the cure of
the primary sore.   Thus a patient having  Hunterian chancre, will usually get
psoriasis as the secondary cutaneous disease, but let  him fall  into a cachectic 
               TREATMENT  OF  SECONDARY  SYPHILIS.            425

state of health between the healing of the  chancre and the occurrence of the
constitutional  affection, and rupia will manifest itself.
   In the treatment of constitutional syphilis, our object is not so much to  re-
lieve or to remove any local morbid condition as to eradicate a  poison  from the
system; and,  indeed, the various local manifestations, more especially those that
appear upon the  cutaneous and mucous surfaces, may rather be looked upon as
efforts of nature  for the elimination of the virus from the system through the
medium of the great excretory and emunctory organs; and it is often apparently
by aiding this natural action by the administration  of those remedies that act
upon these tissues that the poison is most effectually eradicated.
   During the  continuance  of the pyrexia, which often ushers  in the secondary
symptoms, little can be done in the way of specific means for the removal of the
disease from the system; rest and mild antiphlogistic treatment being all that
can be accomplished during this stage of invasion and of constitutional reaction.
At a  later period, when the  cachexy  which  is attendant on the disease has
declared itself, attention  to the  hygienic and dietetic management  of the patient
is of the utmost importance ; a light nourishing diet, often accompanied by the
moderate use  of wine or  beer, and in some of the lower forms of secondary
syphilis occurring as the result of phagedaanic  chancres  in broken constitutions,
a general tonic plan of treatment, such as the administration of bark, quinine, or
iron, and more especially of cod-liver oil, with the mineral  acids and sarsaparilla,
is required, in combination with the  more specific means  that we possess, for the
eradication of  the disease from the system.   These remedies must  be adminis-
tered in accordance with general medical principles, and no special instructions
need consequently be laid down for their use here.
   The great remedies that we possess for the eradication of the poison from the
system are mercury and  the iodide of potassium.   Of the  value  of mercury in
constitutional  syphilis, every surgeon of  experience must  have  had abundant
proof.   It  may admit of  doubt whether mercury can  be  justly  considered as
exercising a specific action in constitutional syphilis, as there are  some cases of
the disease that it certainly does  not appear to influence in  a beneficial manner, and
others, the severity of which is certainly increased by the administration of this
remedy; but  it appears  to me that in these cases it is rather the patient's con-
stitution which does not  bear the remedy well than the disease that is at fault.
We know that in many states of the system, and in  many individuals unaffected
by syphilis, mercury acts injuriously, more especially when anything like cachexy
is present;  and we cannot but suppose  that the same injurious influence  on a
particular  habit of body must continue, though it be  contaminated with the
poison of syphilis.  The best proof that we possess of the  influence of mercury
over constitutional syphilis, an influence, indeed, that almost approaches  to the
nature of a specific action,  is in the case of infantile  syphilis ; here mercury will
not only cure  the disease, but will eradicate the virus from the system in a way
that no other remedy can accomplish.
   In the treatment of constitutional syphilis with mercury everything depends
on the proper  administration of the remedy at a suitable period of the case, and
in a fitting  condition of  the constitution.   The question as to the propriety of
the administration of mercury in constitutional syphilis, the particular prepara-
tion to be used, and the period  of the disease in which it should be given, must
be determined in  a great measure by the previous treatment of the primary dis-
ease, by the condition of the patient's general health, and by the duration of the
secondary symptoms.  If mercury have been freely  given,  perhaps in repeated,
irregular, and  ill-conducted courses, for  the cure of the primary affection; if the
patient have fallen into a cachectic  state, having lost flesh, color, appetite, and
spirits;  if the constitutional affection have assumed the  tertiary form, and have
deeply implicated the bones, mercury should not be given at all; or, at all events, 
42G        CONSTITUTIONAL,  OR  SECONDARY  SYPHILIS.

not without proper  previous  preparation.  Under these circumstances  I thiirk
we should  endeavor, if possible,  to remove the constitutional  affection  without
mercury.   It is true that in many cases we shall not succeed in doing so, but at
least we  improve the  health, check  the disease,  and bring the  patient into a
proper condition to support a mercurial  course, should it  be thought necessary
eventually to put him upon one.  It is in these conditions of the system that the
nitro-muriatic acid and  sarsaparilla are of so much service.^  From twenty to
thirty minims of the dilute acid with half an ounce of the fluid extract of sarsa-
parilla in four ounces of water, may be administered three times a  day.   To this,
the iodide of potassium, in five-grain doses, may often be advantageously added;
or, this salt may be given alone in some  bitter infusion, as of cascarilk,  quassia,
or bark;  or, if the patient be  in a very cachectic and emaciated state, in cod-liver
oil.  It  is  in these cases, likewise, that  the preparations of iron  may be given
with so much advantage.  When there is great  emaciation, I have  found the
combination of the iodides of potassium and of iron with cod-liver oil to be espe-
cially beneficial.  But useful as  these remedies, especially the iodide of potas-
sium and the dilute mineral acids, unquestionably are, more especially when admi-
nistered  in the compound decoction of sarsaparilla, I do not  believe that they
exercise  any specific influence on the disease, or that they do  more than relieve
or remove local manifestations, often of a troublesome and disfiguring character,
failing altogether to cure the constitutional  affections and to eradicate the virus
from the system, for  the removal of which  mercury will at  last be required.
Their great utility appears to consist in  removing cachexy, and in restoring the
vigor of  the nutritive  and reparative actions, which' are in abeyance;  and, by
improving the general tone of the system, in enabling it to resist more  effectually
the advance of the disease, and, in some  cases, perhaps, to allow this to wear
itself out.  That great advantage results  from maintaining the tone of the system
in syphilis is undoubted; we always find that the intensity of the ravages of the
venereal  poison are in direct  proportion to  the debility and  want of resisting
power in the constitution of the patient.   Besides being useful in this way, these
remedies are often  of service in  removing local affections, and in repairing the
injury inflicted upon tissues and organs by  the low and  specific inflammation
that is set  up  in them.   In this respect,  indeed, nothing can exceed the value of
these remedies in constitutional  syphilis.   I  do not, however, believe that the
disease can be eradicated from the system by these means, or that any of these
remedies, even the iodide of potassium, can take the place of mercury in the treat-
ment of  constitutional syphilis;  indeed I cannot call  to mind a single case in
which this form of the affection has been radically and permanently cured with-
out the administration of mercury.  Those cases in which  they exercise  most
beneficial influence, are certainly instances  in which mercury has been injudi-
ciously administered, either for the primary or the secondary disease, and in which
the powers of the constitution have in this  way been sapped.   Under these cir-
cumstances, a course  of the  iodide of potassium or the mineral  acids, in sarsa-
parilla, should always be administered, with the view of improving the patient's
general  health.
   Looking, therefore, upon  mercury as the only remedy we possess  that influ-
ences directly and permanently the venereal poison, I think that it should always
be administered in a full course during some period of the treatment of constitu-
tional syphilis.  The time at which it should be  given is  of considerable impor-
tance ; thus, it must not be administered until the initiatory pyrexia has subsided
under the use of ordinary antiphlogistic treatment; nor should it be given if there
is very  marked  cachexy.   After  this  has  been removed, however, by other
means, the exhibition  of mercury may be proceeded with.
   In administering this remedy for constitutional syphilis, we must  not give it
largely,  so as to affect the system rapidly, but as a mild course for some weeks so 
SYPHILITIC  DISEASES  OF  TnE  SKIN.
427
as to act freely upon the  secretory and excretory organs, and thus to eliminate
the poison from the system.   The most useful preparations are the bichloride, in
doses from the twelfth to the eighth  of a grain;  or the iodide, in one-grain doses
three times a day.  These should be given with sarsaparilla, which keeps up the
power of the system and acts freely upon the kidneys and the skin.  The mercury
should be continued for  at least from three to six weeks until a decided improve-
ment has taken place in  the constitutional symptoms.  I do not think it desirable
to produce salivation; all the good effects of mercury can be obtained far  short
of this; and indeed  if  the  remedy be pushed to such a point as to  affect the
mouth or gums, it will  commonly act  injuriously, by depressing the powers of
the system too much.   I  therefore think it well to suspend its administration
whenever an impression has been made upon the disease, and before this  effect
has been produced.  The cautions necessary during the mercurial course,  when
administered for  constitutional syphilis, are precisely similar to those that we
have described as necessary  during the primary  treatment of the disease.
   In  some cases of constitutional syphilis, affecting the skin and more superficial
structures,  mercury may conveniently be administered by fumigation.   This plan
of treatment, which has been especially recommended by Mr. Langston Parker,
consists of a combination of vapor bathing and of mercurial fumigation; and this
gentleman  speaks in the highest terms of the value of this remedy in syphilis,
as shortening the  duration  of ordinary treatment,  and permanently curing the
disease  without the constitution of the patient being in any way injured by its
employment.   The baths may also be  associated with appropriate internal  treat-
ment.   During the use -of the fumigations, the patient should be dieted, and be
put on a full course of sarsaparilla.  The bath may be administered every second
day, and should consist  of about 3j of cinnabar slowly volatilized by means of a
spirit-lamp, at the same time that steam is  disengaged from  boiling water.  In
this way I  have for some time past used them at the hospital and in private, and
with very great success, in cases of syphilitic cachexy with extensive  cutaneous
diseases of an ecchymatous or rupial character, in constitutions in which mercury
could not be borne in any more active  form.
   Whatever plan of treatment be adopted, it should be carried out for a  suffi-
cient  length of time ; great evil often resulting by intercepting it too  suddenly,
and contenting oneself with  the removal of the local mischief, whilst the disease
is left firmly seated in the constitution.
   Local Secondary Affections.—We shall next  proceed to consider the charac-
ter and treatment of the  different local forms  in which  constitutional syphilis
manifests itself.   These may be considered as they affect different tissues and
organs,  and require  separate consideration, according to  the  part that  is in-
fluenced by them.  We shall consider them as affecting the  skin, the mucous
membranes, the mouth,  nose, tongue, palate, larynx, testes, and the bones.
   The syphilitic  affections of the skin,  syphilo-dermafa, or syphilides, present
various modifications of  appearance, corresponding pretty closely to the different
groups of idiopathic cutaneous diseases;  thus we find  exanthematous, papular,
squamous,  vesicular, pustular, and tubercular syphilitic affections  of  the  skin,
with various ulcers and growths.  These differ from the corresponding simple
cutaneous diseases in their redness being  more dusky or coppery, in leaving
stains of a brownish or purplish hue, in their outline being circular, and in their
crusts or scabs being dark,  blackish, thick, and rugged-looking.  Besides this,
syphilis modifies  materially the general  character of the cuticle, causing  it to
assume  a yellow or earthy tint.   The worst forms of these affections are com-
monly met  with on the face and more exposed parts of the body.
  Syphilitic diseases of  the skin  arrange  themselves under the  following
groups :—
  1st. The roseolar  consists of blotches of a  reddish-brown  or coppery  tint, 
428        CONSTITUTIONAL,  OR  SECONDARY SYPHILIS.

which becomes  more  distinct  as  the  redness  declines;  they vary in  size from
small circular spots  to large and diffused  patches.  These are usually first ob-
served about the abdomen, and commonly occur early in the disease, often before
the primary sore is healed.   Syphilitic roseola usually follows the  chancrous ex-
coriation, and is very  frequently accompanied  by an erythematous condition of
the throat.
   The squamous  syphilide occurs in  small patches of an  irregular shape, of a
red and  somewhat coppery color,  which are commonly covered with thin filmy
scales.  In many instances the patches are, however, quite  smooth, so as to have
a  glazed and almost shining look.  They are  usually situated on  the inside of
the arms  and thighs,  often on  the scrotum and  penis,  even occurring on the
glans.   They also  frequently appear on the palms and soles, where deep fissures
and cracks are met with.   About  the lips, the squamous syphilide gives rise to
deep and troublesome fissures.   It is often associated with a deep and excavated
ulcer of the tonsils, with  inflammation of the iris, and not  uncommonly with
disease of the periosteum and bones, and almost invariably  follows the indurated
chancre.   Associated with this condition  are  large brown patches or  maculae,
which occur  on  various parts of the body.
   The vesicular syphilide is of very rare  occurrence.   In one case which fell
under my observation,  it appeared in the form of clusters of  small pointed vesi-
cles, which, on drying, left gray or brownish crusts and coppery marks.
   Syphilitic  pustules,  on the contrary, commonly occur; beginning as small
hard papulai of  a  coppery hue,  slowly softening in the centre  into a small deep-
seated pustule, having a  large  brown  or coppery areola, and forming  speedily
large,  circular,  dark-brown,  or  even black scabs; usually flat  and irregularly
crusted, at other times conical.   When flat, they constitute syphilitic ecthyma;
when conical, the rupial form of the disease.  After their separation troublesome
ulcers, of a  circular shape, and with rather a foul surface, are commonly left.
This disease first appears upon the face, but speedily shows  itself on various parts
of the body,  more  especially on  the extremities ;  it commonly occurs as an early
sequence of  the phagedaenic chancre, and  is always indicative of constitutional
cachexy;  when  following other forms of chancre, it is,  I believe,  owing to the
system having in the mean time fallen  into a low and broken state.
   Syphilitic  tubercles commonly occur as an advanced  or tertiary symptom : they
appear as hard,  smooth, flat,  and elevated bodies, of a reddish-brown or  purplish
color, seated  on  the face, the  tongue, the limbs, the penis, and the uterus. They
may be resolved by proper treatment, but have a great tendency to ulcerate and
to destroy the parts on which they are situated, giving rise to large, deep, foul,
and serpiginous  sores.
   Syphilitic  boils of an indolent character, but painful, and discharging a thin
ichorous pus, with a core of  shreddy cellular tissue, and leaving deep, irregular
and foul ulcers,  are not uncommonly met with.
   Syphilitic  ulcers may result from pustules, tubercles, or boils, or commence
as tertiary sores : they frequently occur  where  the  integuments are  thin, or
where they are  moistened by the  natural secretions of the  part;  they are circu-
lar with elevated edges, tend to spread in  circles, with  a foul, grayish  surface;
often creeping along slowly, and destroying deeply the parts they affect;  leaving
cicatrices of  a bluish or brown color, thin  and smooth, which are apt  to break
open again on the application of any slight irritation.
   The hair and  nails are commonly affected in advanced constitutional  syphilis;
baldness, constituting syphilitic  edopecia, occurring either generally or in patches,
without any apparent disease of the skin.  Disease of the nails, syphilitic onychia,
occurs in two forms, either as  a foul ulceration between the toes, or else as a
chronic inflammation,  with fetid discharge in the matrix of the  nail; which be- 
              SYPHILITIC  WARTS  AND CONDYLOMATA.          429

comes black, more or less bent, and scales off, with the formation of a dirty ulcer
under its detached edge.
  The treatment of cutaneous syphilis must be conducted in accordance with the
general principles already laid down, and with special reference to the  characters
of the concomitant constitutional condition, or of the other local  manifestations
accompanying it.   In the  early stages, when ushered in by febrile disturbance,
a mild antiphlogistic treatment is required: when the pyrexia has  been subdued,
more specific  measures must be had recourse  to.   In  the  roseolar  forms  the
treatment of the  secondary affection should  be  guided by the  previous manage-
ment of the primary  sore.  If mercury have  been given for this, we  should
content ourselves with the  iodide of potassium in infusion of quassia,  or what is
better, in full quantities of the decoct, sarsae.  co.   Should mercury not have
been given in the primary sore, it must be had recourse to  in the secondary
affection.   In the squamous  syphilide, mercury, I think, is always  necessary,
and here I give  the preference to the  iodide over the  other preparations.  In
the pustular forms, syphilitic rupia and  ecthyma, the constitution being com-
monly shattered,  a tonic plan  of treatment is required in the first  instance, after
which the bichloride of mercury in tincture  of  bark or decoction  of sarsaparilla
should be steadily administered.  In these cases also much benefit will be de-
rived by the mercurial fume-bath.  In  the tubercular syphilide much the same
treatment is required as in the last variety ; in these cases, however, I have often
found Donovan's  Solution of  the  greatest possible value, the disease rapidly dis-
appearing under its use ; the same  plan is required in the management of syphi-
litic boils.   In the treatment of secondary syphilitic ulcers we shall find it neces-
sary to use caustic freely, with the view of setting up a  new and more  healthy
action in the part.  For this  purpose nitric acid, or the acid nitrate of mercury,
is especially serviceable; on the separation of the slough thus produced the sore
may be dressed with red precipitate powder, or ointment, or the black wash, to
which,  if there be irritation,  opium may be   added, the same constitutional
treatment, especially Donovan's Solution, being  had recourse  to.   In syphilitic
alopecia, the internal administration of the bichloride of mercury with  bark or
iron, and the external use of a strong stimulant, such as the nitrate of mercury
ointment or the  tincture of lytta, will be found  most serviceable;  and in syphi-
litic onychia, the free application of nitrate of silver, followed by the black wash,
and the bichloride or Donovan's Solution internally,  is the proper  treatment.
   Warts, excrescences, and vegetations are commonly met  with in constitutional
syphilis, especially in  the  neighborhood of the mucous  canals,  being usually
situated in the neighborhood of the anus, the perineum,  or scrotum;  and in the
female, upon and within the labia.  They are  also very frequently  met with
about the tongue,  on the  tonsils,  palate, and  lips.  When occurring  in  the
neighborhood of  the organs of generation, they are  usually large, flat, soft, and
uniform in structure and appearance, with a good deal of mucous exudation, and
a sort of perspirable moisture of the neighboring  skin.   When  seated  in  the
mouth or throat they are usually small,  and not  so distinctly elevated or circum-
scribed, but look rather like a thickened and opaque condition of the  mucous
membrane  in  these situations.  These  secondary warts,  condylomata  or mucous
tubercles, as they are often termed, differ essentially from the primary vegetations,
not only in their appearance and general uniform character, but in being depen-
dent on the constitutional condition of the disease, and not on local causes solely,
such as the irritation of discharges  and  the want of cleanliness.   They are also
certainly contagious; and  I  have  known instances  in  which they  have been
distinctly  transmitted  in this way.  Their treatment  must be constitutional as
well as  local;  the constitutional means should  consist in the administration of
the bichloride of mercury with sarsaparilla;  and the best local treatment that I
am acquainted with is to rub  them freely with the nitrate of silver, dressing the 
430        CONSTITUTIONAL,  OR  SECONDARY  SYPHILIS.

parts between whiles with chlorinated lotions.  Not being pendulous or distinctly
protuberant, they do not, like the primary excrescences, require excision.
  The mucous membranes of the mouth, nose, pharynx, and penis are commonly
affected with secondary syphilitic  eruptions; these assume the form  of mucous
tubercles, or of the exanthematous, tubercular, and  ulcerative syphilides.  The
exanthematous affection corresponding to the roseolar form of cutaneous syphilis,
and arising from the same cause and in the same constitution,  principally affects
the palate and throat.  The tubercular variety corresponds  to the squamous cuta-
neous eruptions, and is chiefly met with as flat, hard, and elevated tubercles in
the interior of the mouth,  nose,  and throat.   The  ulcerative affection of  the
mucous  membranes assumes a variety of forms, which  will immediately be
described, and occurs principally in the throat  and nose.   The exanthematous
affection of the mucous membrane is usually  an early sign of constitutional
syphilis, frequently showing itself a few weeks  after the primary occurrence of
the disease.  The other  varieties belong  to  the more advanced secondary or
tertiary periods.
  The syphilitic affections of the  mucous  membranes so readily extend to, and
are so commonly associated with, corresponding  disease of the deeper structures,
that we shall more conveniently consider their different forms  according as they
affect distinct organs or parts of the body.
  The  lips  are  commonly affected  in  persons  laboring  under  the squamous
syphilide, with  fissures or cracks usually somewhat indurated,  and very painful
in the movements of these parts.  The application of a pointed piece of nitrate
of silver to  the bottom of the crack will  give  the most  effectual relief.  The
inside  of the cheeks  are not unfrequently affected  in  a similar manner, or
become the seat of mucous tubercles, which must be treated as has already been
stated-
  The tongue may be affected with syphilis in various forms; when severely, its
disease usually constitutes one of the tertiary varieties of the affection. In many
cases the mucous membrane becomes thickened, but preserves a peculiar glossy,
semi-transparent, almost gelatinous appearance,  and, being irregularly fissured,
gives  the organ a thick  and misshapen look.   In other instances, again,  the
epithelium is diy, white, and opaque in patches; the surface of the tongue look-
ing as if it had been dyed white here and there.   Occasionally ulcers form upon
its surface or sides; these are usually irregular in shape, with a foul surface and
a good deal of surrounding induration, and, unless care be  taken, may readily be
confounded  with schirrus or epithelial cancer of the organ.   The diagnosis of
these  affections we  shall consider when  speaking of diseases of the tongue
generally.  Occasionally a hard, elevated, circumscribed tumor of a dark-red or
purplish color slowly forms towards the centre of  this organ;  it increases with-
out pain and in a gradual manner, and principally occasions inconvenience by its
bulk and the impediment it occasions in the movements of the tongue.   These
various  diseases indicate a deeply-seated constitutional affection, and require  the
administration of mercury either in the form of  iodide or bichloride.  Donovan's
Solution is  extremely useful in many  of these  cases.  The  ulcers should be
touched from time to time with the nitrate of silver.
  The syphilitic diseases of the throat are amongst the most common manifesta-
tions of constitutional syphilis, and frequently occur  early.  They present several
distinct forms,  corresponding to  analogous  primary  and secondary  cutaneous
affections.  One of the earliest conditions is a deep-red exanthematous efflo-
rescence of the soft palate and the  pillars of the fauces, either without ulceration,
or with  but superficial abrasion, but with much cachexy and depression of power,
and perhaps with considerable pyrexia.  It often occurs about the period of  the
invasion of  the roseolar or rupial  syphilide, and requires the same treatment as
is necessary in these affections,  together with the local application of a strong 
        SYPHILITIC  DISEASES OF  THE THROAT  AND NOSE.    431

 solution of the nitrate of silver.   A deep excavated ulcer, with a hard base and
 foul grayish surface, of circular or oval  form, is not unfrequently  met with on
 one or other tonsil; it corresponds to  that  class of secondary phenomena that
 follows the indurated chancre, and  requires mercury in some form for its  cure;
 in  this and many other cases the mineral may most conveniently be applied  to
 the throat by  means of fumigation.   A sloughing ulcer  is occasionally seen on
 the side of the throat or palate, with much swelling,  a foul gray surface, and
 rapid  destruction of parts, giving rise  very  commonly to perforation  of ,the soft
 palate, and thus, by partially destroying the curtain between the mouth and the
 nose, occasioning serious inconvenience to the patient during deglutition and in
 speech.   This form of ulcer is connected with the rupial or ecthymatous syphi-
 lides,  and requires the same constitutional treatment as these.  The  best local
 plan is free  sponging with strong nitric acid, and gargling with solutions of the
 chlorides.  More rarely a form of the serpiginous ulceration is met with, produ-
 cing considerable contraction and inconvenient consolidation of tissues after its
 cure.   It is,  I think, best treated by the local application  of nitric acid, and the
 internal administration of the bichloride.
   The mucous membrane of the  larynx is not unfrequently affected in advanced
 syphilis.  In these cases, chronic inflammation, with thickening and ulceration,
 takes  place  about  the  rima glottidis,  with  the  general and local symptoms of
 chronic  laryngitis; such as  huskiness of voice, cough,  and  expectoration of
 tenacious or  offensive  mucus;  a  difficulty  in deglutition, and a tendency to
 choking on swallowing liquids, with tenderness on pressure about the throat, also
 come on. These cases are usually accompanied by much constitutional cachexy,
 and not unfrequently eventually terminate fatally by the sudden supervention of
 oedema glottidis.   The constitutional treatment must depend upon the concomi-
 tant symptoms and the general state of the patient; most commonly tonics will be
 required. The local means consist in the free application  of the solution of the
 nitrate of silver to the rima glottidis, and the occasional employment of counter-
 irritation.  In  many cases  it may become necessary to open the windpipe, in
 order to prevent the patient dying of asphyxia; this must be done in  accordance
 with the rules that will be laid down when treating of chronic laryngitis.
   The nose is commonly affected  in constitutional syphilis, and often destructively
 so,  especially in  individuals much  exposed to changes of temperature, and who
 are unable to pay proper attention to  their  treatment.   The mucous membrane
 becomes chronically thickened, with discharge of  blood  and pus, coryza, and
 habitual snuffling.   In other cases, ulceration takes place, with a very foetid odor
 of the breath, and the formation  of thick ecthymatous  crusts on the septum, or
 between this and  the alae.   This ulceration  is of a very persistent  and trouble-
 some character, and requires usually a mercurial treatment, with the local appli-
 cation  of strong nitric  acid,  or  of the acid nitrate of mercury, to  arrest  its
 progress.  In many  cases ulceration  will rapidly proceed to destruction and
 perforation of the septum,  or necrosis of the spongy  bones,  the vomer,  and
 ethmoid; sometimes excavating  the whole of the interior of the nose, scooping
 and  cleaning it out into one vast chasm.   When this happens, the nasal bones
 are usually implicated, being flattened, broken down and destroyed;  the alae and
 columna ulcerating away, and producing vast disfigurement.   Occasionally the
 disease extends to the bones of the base of the skull, and  in this way may occasion
 amaurosis, epilepsy, or death.   The  treatment of these nasal  affections must be
 conducted in accordance  with general principles.  In many cases mercurial fumi-
 gation  is extremely useful; in others, where  the  disease is of an ulcerative cha-
 racter,  the strong  acid and  caustic  applications already mentioned, with chlori-
 nated solutions occasionally sniffed up,  will do much to  stop the progress of the
disease.  As necrosis occurs, the  dead bone must be removed.
  Diseases of the periosteum and bones are amongst the  more remote and severe 
432        CONSTITUTIONAL,  OR  SECONDARY  SYPHILIS.

effects of constitutional syphilis, when it has  reached the tertiary stage.  They
are especially apt  to  occur in cases in which  mercury has  been  improperly
administered, and after the patient has  passed through the whole course of the
less severe syphilitic affections, such as those of the skin, mucous membrane, and
throat.   These affections, however, especially of the  periosteum, are not neces-
sarily preceded by the minor constitutional effects, but may in some cases declare
themselves  at the  same time that the affections of  the skin and mucous mem-
branes do.   They more  commonly occur amongst the  poorer  classes, especially
those who are  exposed to atmospheric  vicissitudes,  and especially in strumous
constitutions.
   Venereal periostitis  or nodes may occur in almost any of the bones, but is most
commonly met with on the tibia, the clavicle, or the bones of the forearm. Some
joints are also not unfrequently affected  by it; the sterno-ckvicular articulation
and knee-joint are especially often the seats of this disease.
   ATodes are indolent,  elongated, Uniform, and hard swellings, sometimes tender
on  pressure, and generally but little painful during  the day, but  at night the
aggravation of pain is peculiarly marked, and constitutes perhaps the most dis-
tressing symptom in these cases.   They consist of a thickened state of the perios-
teum,  with  some  plastic  effusion within  and  underneath it,  and occasional
thickening of the subjacent bone; they may continue permanently, or may termi-
nate by resolution; it  is seldom that they suppurate, unless there  be disease of
the subjacent bone.  The treatment consists, if there is much tenderness, in the
application  of leeches; if there be  no  great  sensibility on pressure, but con-
siderable  nocturnal pain, blisters should be applied.   When in a chronic state,
the tincture of  iodine is a useful application.   They  sometimes become soft  and
prominent, and feel semi-fluctuating, especially when seated on the cranium, so
as almost to  tempt  the surgeon  to make an opening  into them; this, however,
should never be  done, as the swelling, however great, will subside under proper
treatment.  For  the ultimate  removal of the  tumor, and the relief of the noc-
turnal pains, we possess an excellent and sure remedy in the iodide of potassium.
   The venereal affections are principally met with in those bones that are  flat and
compact, as the cranial, nasal, and maxillary bones.   In these, various forms of
disease occur.  One of the most common is perhaps chronic osteitis, with hyper-
trophy and  condensation of the  osseous tissues,  often to a very marked extent.
This affection may  occur in the bones of the skull, but  is also met with  in some
of the long bones, as  the  tibia and the ulna; it is characterized by very severe
pain, especially of a nocturnal  character, accompanying the enlarged  and thick-
ened state of the  bone.
   Syphilitic necrosis chiefly occurs in the bones of the skull and  jaws, the  alveolar
processes of which  may exfoliate; the palatine process of the superior maxillary
bone, the spongy and the nasal bones, are also commonly destroyed by this morbid
action; but it is a remarkable fact that the palate bones are rarely, if ever, affected.
In consequence of this destruction of bony tissue, the  interior of the nose becomes
chronically diseased, the organ may fall  in, or a communication be established
between the nose and the mouth through the hard  palate.
   Syphilitic caries, or ulceration of bone, presents  different forms, which, accord-
ing to Mr.  Stanley, correspond to analogous  ulcers  and eruptions of the skin.
Thus, there may be the simple ulcer of the bone, showing a  rough, irregular,
porous., and depressed  surface;  the worm-eaten caries consisting of small pits or
excavations, studding the surface; and the serpiginous or creeping ulcer,  marked
by imperfect attempts at repair, and the deposition of new bone in nodules or
masses.  The cranial  bones are those that are most  commonly affected  in  this
way, and their disease  may sometimes prove fatal by the irritation set up  by it in
the brain or its  membranes.   The bones of  the  extremities,  however,  are not
unfrequently similarly  affected. 
SYPHILITIC  DISEASES  OF  EYES  AND TESTES.        433
  The treatment of these conditions varies somewhat, according to the form the
disease assumes, and  the previous management of the patient.  In osteitis, the
principal reliance should be placed upon the conjoined influence of calomel and
opium, provided the patient have not previously been fully mercurialized.  If so,
our chief reliance must be upon the iodide of potassium. In syphilitic necrosis the
constitutional  cachexy demands  the principal  share of attention;  the necrosed
bone should be separated as it becomes loose, the  local irritation depending on its
presence then  subsiding.  When the bone has fallen into a carious state, the
iodide of potassium in combination with iron, cod-liver oil, or sarsaparilla, with the
mineral acids, will improve the tone of the system, and stay the progress of the
disease.  The ulcerated and  exposed bone requires to be dressed with strong
stimulants; the red oxide of mercury, in  ointment or  powder, is  perhaps  the
best; in some cases, touching the  part  freely with the  acid nitrate of mercury
will establish a more healthy action.
   Syphilitic iritis  commonly follows the indurated chancre, being  associated
with some  of the more advanced secondary sequelae  of that form of the disease.
It  usually  occurs after exposure to cold, and often in people that  are otherwise
strong and healthy.    The ordinary symptoms of iritis,  somewhat modified,
characterize the affection.  The  patient  complains of dimness of  sight, pain in
the eye, and often very severe circumorbital or hemicranial pains.   On examining
the eye, the conjunctiva will be found slightly injected, and a zone of pink ves-
sels to be  seated  on the sclerotic, close to the cornea;  the aqueous humor  has
lost its transparency,  giving a muddy look to the eye, and the color of  the  iris
is altered.   The pupil  is  irregular in shape, usually angular towards the nasal
side, and small  yellowish  or  brownish nodules  of  lymph  may be seen to  be
deposited on the surface of the  iris.  If the case be left to itself, or be impro-
perly treated, it will  advance to disorganization or to permanent  opacity of the
eye.  The  treatment of these cases consists in local depletion by  means of cup-
ping  and leeches to the temples, and the  administration of calomel and opium
internally,  at the same time that a drop of the solution of  atropine is put into
the eye.   Most  commonly, as the mouth becomes affected by the  mercurial, the
eye will clear, the lymph becoming absorbed, and the pupil  regaining its normal
shape  and  color.  In some cases,  however, a  chronic inflammation continues;
under these circumstances, the best effects result from the administration of small
doses of  the bichloride, with repeated blistering to the  temples,  and in a  later
stage soda and bark may be advantageously given.
   Syphilitic disease of the testicle is one of the more advanced conditions of the
constitutional affection.   It commonly occurs as the result of that train of symp-
toms that follows the Hunterian chancre; viz., squamous affections of the skin,
the excavated ulcer of the throat,  iritis and nodes, but usually does not appear
until these different manifestations of constitutional syphilis have  each in their
turn  passed away; the  patient,  indeed, appearing  to have recovered from all
disease, and being otherwise in  good health.  The testis will then be observed
gradually to  enlarge, until it attains the size of a turkey's egg, or even larger,
being ovoid in shape, heavy, and smooth, not painful except by its  weight, which
causes dragging and  uneasy sensations in the cord  and loins.  This disease  is
very commonly accompanied by a small hydrocele, constituting, indeed, a hydro-
sarcocele.  Most frequently only one testis is affected; it is but very rarely that
both are diseased.   The affection continues to increase, giving rise to  uneasiness
from its size and weight, but is  not followed by suppuration or other inconvenience.
   Mr. Hamilton of Dublin has lately described another form of syphilitic sarcocele,
under the term  "tubercular syphilitic sarcocele."  In this  the testis is enlarged
to three  or four times  its natural bulk, of an  irregular shape,  presenting an
uneven, hard, and knotty mass ;  it is neither painful nor tender, but inconvenient
from  its  weight, causing pains  in  the  loins and cord.   Both testes are usually
                                     28 
 434        CONSTITUTIONAL,  OR SECONDARY  SYPHILIS.

 affected, but one is worse than the other, and when the disorganization is great,
 Mr. Hamilton  states  that all sexual desire is lost, and that neither erections nor
 emissions take  place;  both,  however, returning  as  the treatment  effects the
 restoration of the organ to its normal condition.   In these cases suppuration not
 unfrequently takes place, followed by the discharge of thin pus, the formation of
 fistulous openings, and occasionally the protrusion of a  fungus.   This form of
 sarcocele occurs in persons of a broken and cachectic constitution, who are suffer-
 ing severely from the more advanced and inveterate forms of tertiary syphilis,
 especially of the bones and throat.
   In the simple syphilitic sarcocele the enlargement of the testes is principally
 due to the deposit of" semi-transparent white or yellow lymph, in a uniform man-
 ner throughout the substance of the organ external to the tubuli.   In the tuber-
 cular syphilitic  sarcocele, Mr. Hamilton states that tubercles of  a yellow color,
 and varying in size from a split pea to a chestnut, or  even larger, are found in
 the  substance of the organ; these, softening, give rise  to suppuration in and
 around them, and thus to the ultimate disorganization of the testis, which becomes
 converted into a hard, irregular, fibro-cellular mass, in which cretaceous matter is
 occasionally deposited.
   In the  treatment of the simple form of sarcocele, a full mercurial course is
 generally  necessary;  the  bichloride, in doses of the  sixth or  eighth of a grain
 three times a day, is the best preparation.   This  should be continued for at least
 six or eight weeks, or until hardness disappears.   Any hydrocele that exists should
 be tapped, and the fluid drawn off by means of a  small trochar and canula before
 the  treatment  is  commenced.   After the mercury has  been  discontinued, the
 remaining swelling of the testis may be got rid of by the internal administration
 of the iodide of potassium, in five-grain doses, twice or thrice daily, with frictions
 with  the iodide of lead ointment.   In these cases, care  should be taken not to
 irritate the scrotum with very stimulating applications, as the skin is  tender, and
 readily becomes excoriated; ordinary strapping is of very little use, but in some
 cases I  have found  strapping with the emplastrum  ammoniaci  cum  hydrarg.,
 diluted  with equal parts of emplast. belladonnas, of service.   If suppuration
 occur, and a fungus protrude, the  same treatment must be  adopted as will be
 described  when we come to speak of the strumous testicle.
   Besides  these  various constitutional manifestations of syphilis, tumors  of the
muscles  and tendons, depending on this disease, have  been described by  Mons.
Bouisson. _ These appear to consist of a limited hypertrophy of the tissue of the
muscle,  with an effusion of plastic matter in its  interior.  When affecting the
tendons, these  tumors are elongated, and  resemble nodes upon them.   Their
presence is attended  with some pain during the contraction of the muscle; they
are usually somewhat globular, and vary  in  size from a nut to a pigeon's egg,
being accompanied by nocturnal pains.   They are best treated by the  iodide of
potassium.

                           INFANTILE  SYPHILIS.
   The existence of a primary sore on the labia  of the mother may possibly in-
fect the child at birth with  primary syphilis, just as it might inoculate the hand
 of the accoucheur; but syphilis  thus  contracted by the infant is not the form
 of the disease that is described as " infantile syphilis."   This is  a truly heredi-
 tary affection, transmitted to the infant at the time of its conception, or commu-
 nicated  to it through the medium of the  mother  during intra-uterine life, and
 existing as a constitutional  affection at the time of its birth.   Though we may
 believe that syphilis is not easily eradicated from a system into which it has once
 been received, and that under certain conditions it may readily be transmitted to
 the  offspring;  yet, I think  we  are still  ignorant of the amount  and nature
 of the constitutional  affection  of the  parents that is necessary for the develop- 
SYPHILIS IN INFANTS.
435
ment of syphilis  in  their children, and that we are certainly not warranted in
concluding that a parent who has been, or even who is actually affected  by con-
stitutional syphilis, must necessarily have syphilitic, or even a feeble  and stru-
mous family ; although the probability undoubtedly is that such will be the case.
I have at present under my observation a gentleman whom I had attended for
secondary syphilis, and who, contrary to my advice, married a few years ago, and
though he  has since  then suffered from psoriasis of the hands, mucous  tubercles,
fissures on  the lips and  tongue, and venereal sarcocele, yet his  wife has borne a
perfectly healthy family, not  only without any syphilitic taint, but without any
apparent constitutional debility.
   Syphilis, when transmitted by the parents, appears to lessen the vitality of the
ovum to such a degree, that it either cannot reach its development, or if it do so,
that the child  that  is born is not only tainted, but enfeebled in constitution.
When the  ovum  is infected with syphilis, several morbid states may result, ac-
cording to the intensity of the  infection.   It may be so blighted that it never
reaches the maturity of infra-uterine  life, but becomes early aborted;  in this
way many consecutive  miscarriages may happen in consequence of one or both
of the parents  having constitutional syphilis, but  if  they be put under proper
treatment by a mercurial  course, and  the disease be  thus eradicated  from the
system, the ovum will at the next pregnancy probably reach its full development.
The embryo may go  its full time, and the foetus be borne with syphilitic cachexy
and  local  manifestations of the disease fully  developed  upon it.   More fre-
quently, however, it  happens that the  child, although cachectic and sickly-look-
ing,  is brought  into the world without  any syphilitic affection, but in the course
of a few weeks, usually from the third to the eighth, these declare  themselves.
In other cases again, it is not  impossible that the syphilitic taint may manifest
itself in a different  way than in that  which has just been alluded to;  that no
local manifestation may occur, but that an impaired and depraved state  of con-
stitution and of  nutritive activity may be inherited, which, in after life, gives
rise  to some of  the various forms of scrofula, or of other constitutional  disease,
dependent  upon an enfeebled state of system, or a diminution,  as it were, of the
general vitality.
   The mode of  communication of  syphilis to  the ovum, or to the intra-uterine
foetus, is an investigation that has much occupied the attention of surgeons, and
is of considerable practical interest.  It appears certain that the poison may be
communicated to the embryo in at least four ways.   Thus, the father  may have
a constitutional taint of which he has been imperfectly cured, and without com-
municating any syphilitic  disease to his wife, may be  the parent of an offspring
that exhibits indications of being infected; or, the mother, having a similar con-
stitutional  disease, may in like  manner taint her own offspring;  or, again, the
diseased child  may be  born  of parents both of whom are  constitutionally in-
fected ; and, lastly,  the mother may become pregnant with a healthy embryo,
but  afterwards  contracting syphilis, may  transmit it to  her offspring.   These
points appear to be generally agreed upon by surgeons of  experience.
  There are several other questions,  however, in  connexion with  the trans-
mission of  syphilis to and from infants, which are of an intricate character, and
have not as yet been cleared up to the satisfaction of all  surgeons.   Thus, for
instance, it has become a question whether a mother  pregnant with a syphilitic
foetus, the offspring of a father laboring under constitutional  disease, can be in-
fected through it without she herself having had primary syphilis ?   Ricord
states that a woman may be so infected; I agree, however,  with Acton, that this
is doubtful; but I do not think  that the profession is  at present in possession of
sufficient evidence to prove this point satisfactorily either way.  Then, again,
the question has arisen whether a wet-nurse laboring under constitutional syphilis
can infect the child that she suckles, the infant being  contaminated through the 
436        CONSTITUTIONAL,  OR  SECONDARY  SYPHILIS.

medium of the milk.   Ricord admits this, but Acton states decidedly that the
disease  cannot be so transmitted.  My own opinion is that it can, though rarely,
be so transmitted;  and, indeed, there are a  number of cases on record in proof
of this, references to which will be found  in " Ranking's Retrospect," vol. iv.
The converse of this is also  a matter of dispute, whether a syphilitic child  can
infect a healthy nurse.  This question is one of very great importance, inasmuch
as actions for damages have been brought by women who have stated that they
have  become diseased from the child that they have nursed.  Ricord and Acton
deny the possibility of this mode of the transmission  of  syphilis, but there are
cases recorded that prove the contrary, and on such a question as this, one posi-
tive fact must necessarily outweigh any amount of negative evidence.  Not only
have  Hunter and Lawrence related cases in which an infected child communicated
the disease to several nurses in succession; in Hunter's case  three wet-nurses
were successively infected, two  of whom gave the disease again to their own
children, but a considerable mass of evidence upon this point is to be found in
" Ranking's Retrospect" {Loc. cit.)  The disease is especially apt to be commu-
nicated in this way if the nurse have any crack or abrasion  upon her nipple, and
the infant sores upon the mouth.  Dr. Colles, however, who  had great experience
in syphilis, states that the disease may be communicated to the nurse from an
infected child by mere contact, without excoriation.
   The  symptoms of infantile syphilis are sufficiently well marked:  consisting
principally of cachexy, with disease of the  mucous and cutaneous surfaces.  The
first indication is usually the cachectic appearance of the child; this invariably
shows itself at birth, syphilitic children being always described as being small,
shrivelled, wan, and wasted when born; the  face especially has an aged look, the
features being pinched, and the flesh soft and flabby; the complexion generally
has a yellowish or earthy tinge, and  these characters  continue until the disease
is  eradicated  from  the  system of the child.   The first local sign that declares
itself is usually a congested condition  of the mucous membrane of the  nose,
giving rise to the secretion of offensive mucus, and causing the child to make a
peculiar snuffling noise in breathing, as if it had a chronic catarrh; this snuffling
may exist from the  time of birth, but generally comes on very shortly afterwards.
   The disease manifests itself upon the  cutaneous and mucous surfaces,  some-
times before  or at  birth, in other  cases not  until several  weeks  have  elapsed.
The most common period for the occurrence of these signs is the third or fourth
week.  The cutaneous  eruption usually makes its appearance  on the nates, the
scrotum, the soles of the feet, and around the mouth;  hence, on examining a
syphilitic child, these parts should always be looked at first.   It presents itself
in three different forms: most frequently as flat tubercles, varying in size from
a split pea to a four-penny piece, smooth, slightly elevated, and of a coppery or
reddish-brown color.   These tubercles  are  often  accompanied by  cracks  and
fissures about the mouth  and anus.  Though commonly  called squamous,  they
are not in reality scaly, but are always smooth  and flat.   Intermixed with these
are brownish maculae or spots, differing in size, and  variously figured.
   The vesicular or  bullous eruption is  not  so common as  those just described,
but yet I have frequently seen it in syphilitic  children.   It appears in the form
of vesicles, about the size of a split pea, with a dusky coppery areola and base;
drying into brown scales or scabs, and commonly conjoined with  the tubercular
affection.   These bullae are most frequently seen on the soles of the feet.
   The treatment  of infantile syphilis is of a  preventive and  curative character.
Its occurrence in the infant  may be prevented by putting the infected mother
on a mercurial course so soon as her pregnancy is ascertained; this indeed  may
be necessary in order to prevent miscarriage, but should  be done cautiously and
by inunction  rather than by mercury administered by the mouth.  Should re-
peated miscarriages have occurred, as the consequence of constitutional syphilis, 
SURGICAL  DISEASES  OF  THE  SKIN.
437
one or other, or both the parents, if at  fault, should be  put upon a  mercurial
course, and thus the recurrence of this accident prevented.
  The curative treatment as regards the child is extremely simple.   It should
be brought up  by hand, lest  it infect  the  nurse or continue to receive  fresh
accession of poison from the diseased milk of its mother.   It must then be put
under the influence of mercury, which in these  cases acts  almost as  a specific;
and indeed the ready manner in which all  disease may be eradicated from the
system of a syphilitic child by this mineral, is perhaps one of the strongest proofs
that can  be adduced of the specific character of its action on the venereal poison.
The mercury may be given by the  mouth in the  form of small doses of hydrarg.
cum creta; but as it often purges the  child when administered in this way, Sir
B. Brodie  has recommended  its introduction into the system by inunction, in
which way I invariably employ it, and  have found it a most successful mode of
treating  the disease.   The most  convenient plan is, as recommended by Sir
Benjamin, to spread 3L of mercurial ointment on the under part of a flannel
roller stitched  round the thigh just above the knee, and to renew this every day.
This treatment should be continued for two or  three weeks  until all rash and
snuffling  have  disappeared, when the mercury having been discontinued, the cure
may be perfected by the administration of small  doses of the iodide of potassium
in milk or cod-liver oil.   Occasionally the cutaneous manifestations of infantile
syphilis are complicated with, and  obscured by some of the common diseases of
the skin incident to early childhood; more particularly with eczema impetiginodes
of the  head, face, and body.   Under these circumstances the diagnosis may not
be easy, though the history of the  case, the concomitant appearance of two  forms
of the disease,  and the  existence of snuffling and  cachexy, tend to establish it.
The eczema, also, under these circumstances, is browner, and more squamous than
usual.  In cases such  as these, the best plan is  to treat  the syphilitic affection
first with the mercurial inunction, and  then to put the child under a mild course
of Donovan's Solution, two or three minims for a dose, and keeping it at the
same time on a good nourishing diet.
                  DISEASES  OF  TISSUES.


                        CHAPTER XXXII.

SURGICAL AFFECTIONS OF  THE SKIN  AND ITS APPENDAGES.

  The various  specific cutaneous affections, such as eczema, scabies, impetigo,
acne, lepra, psoriasis, &c, properly fall within the province of the surgeon,  and
are  commonly treated  by him in practice;  but  as the  consideration  of these
diseases would necessarily lead into the whole subject of Dermatology, the limits
of this  work would not enable me to discuss so extensive and special a branch
of surgery, and  I must therefore content myself with the consideration of some
of those affections of the skin, which, as requiring manual assistance, may perhaps
be more looked upon as within the scope of the present Treatise.   These diseases
may be considered under the several heads of diseases of the appendages of the
skin, as of the cuticle and nails; the non-malignant ulcers of the skin, and the
malignant ulcers and tumors of this tissue.
  Warts and corns are affections of  the cuticle, with which the surgeon may
often have to  interfere.   Warts consists of elongated papillae, with strata of 
438
SURGICAL  DISEASES OF  THE  SKIN.
thickened and hardened cuticle, usually situated about the hands and face, and
chiefly affecting  young people;  they appear in many cases to be  simple over-
growths  of  the  cutaneous structures, coming and going without any evident
cause.   In other cases again they are of a more permanent character, becoming
hardened, and dark  in color, and continuing  perhaps through life.  The treat-
ment of  these affections is usually sufficiently simple.   As  their vitality is low,
they may be readily destroyed  by the application  of caustics or astringents;
amono-st the more useful of these I have found the concentrated acetic acid and
the tincture of the sesquichloride of iron.  Brodie recommends the solution of
3i. of  arsenious acid in half an ounce of nitric acid.  In some cases they may
be ligatured or snipped off with advantage.
   Corns usually consist of small thickened masses of epidermis accumulated on
those points on which  undue friction or pressure has been exercised,  in order to
guard the subjacent cutis from injury.  These  epidermic masses are usually hard,
dry, and scaly;  at other times they are soft and  spongy, owing to their being
situated in places where the secretions of the skin accumulate, thus keeping them
moist.   Under old and very  thickened corns, it is stated by Brodie that a small
bursa is  occasionally found.  Corns are at all  times sufficiently painful, but be-
come especially so if inflammation or  suppuration take place underneath them,
the accumulation of a small drop of pus under the thickened cuticle,  which pre-
vents its escape, giving rise  to very intense agony.   There is  a special form of
corn that I  have only seen in the sole of the foot, and which may become the
source of the greatest possible pain and inconvenience to the patient,  preventing
his walking,  and in fact  completely crippling  him.   This corn  is  usually of
small size  and round  in shape,  the  neighboring cuticle being always greatly
thickened and hardened.  It is extremely sensitive to the touch, the patient
shrinking when it is pressed upon, as if an exposed nerve  had been injured. On
slicing it down with a scalpel, it will  be found to be composed of soft,  tough,
and white  epidermis, arranged in tufts or small columns, in the centre of each
of which a  minute black dot is  perceptible.   Each tuft  appears to be an elon-
gated and thickened papilla, and the black speck is a small point of coagulated
blood which has been  effused into it.   Around the depression in which each of
these corns  is seated, the hardened cuticle forms a kind of wall.
   The treatment of ordinary corns consists in shaving or rasping them down so
as to prevent the  deeper layers of cuticle retained by the indurated superficial
ones, giving rise  to  pain by  pressure  on the  papillae of the cutis.   Relief may
also be afforded by removing all pressure  from bearing upon the  corn, by atten-
tion to the shape of the shoe, and by wearing a piece of soft leather or  of amadou,
having a hole cut in the centre into which the corn projects.  It is well to avoid
the application of caustics  to ordinary  corns, injurious consequences being often
produced by these agents,  especially in elderly people, in  whom fatal gangrenous
inflammation, as I have seen in one case, may be excited  by their action.  If the
corn suppurate it must be poulticed and shaved down, and the  drop of  pus let
out by puncture with a lancet.   In the painful papilkted corn of the sole of the
foot 1 have  found the application of potassa fusa,  so as to destroy it thoroughly,
to be the best and the speediest remedy; and  as this corn always occurs in young
people, no  danger attends its use.

                         DISEASES OF THE NAILS.
   The  nails may become diseased, either by undergoing structural changes, by
having their matrix inflamed, or by growing into the soft tissues of the toe.
   In some broken  states  of health, and  especially in  persons suffering from
squamous disease of the skin, the nails occasionally become  blackish or dark-brown
in color, are rugged, dry, and cracked, scaling off as it were, without any apparent
affection of the matrix.  This condition, of which I have seen several instances, 
ONYCHIA.
439
is  best cured by a course of alteratives and  sarsaparilla, the disease yielding as
the general health becomes improved.
   Onychia is a disease of the nails dependent on inflammation of the matrix;
it occurs under two forms, the simple and the specific.  In simple onychia, there
is redness, heat, and swelling set up, usually on one side of the nail, in the angle of
the tissue in which it is  implanted; there is a  discharge of pus, and the  nail
gradually loosens, becomes dark-colored, somewhat shrivelled, and may eventually
be thrown off, a  new nail making its appearance below, which commonly assumes
a somewhat thickened and  rugged shape.   This disease usually  results  from
slight degrees of violence, as the running of thorns and splinters into the finger.
The treatment consists in subduing inflammation by local antiphlogistics, poul-
ticing, &c, and watching  the growth of the new nail, which may be sometimes
usefully directed by the application of a layer of wax.
   The specific  or malignant  onychia is  a  more serious affection, and is often
dependent on injuries inflicted on the finger in a  syphilitic or cachectic condition
of the system.   In it a dusky red or livid inflammation takes place at the sides
or root of the nail, ulceration is set up, accompanied by the  discharge of sanious
and very fetid pus, and large loose granulations  spring up at its root and sides,
so that the end of the toe or finger that is affected, and this is  most commonly
either  the  great toe, the  thumb,  or the  index  finger,         Fig. 134.
becomes greatly enlarged and bulbous in shape.  The
nail then shrivels, becomes  brown or black, and peels
off in strips (Fig. 134); after its separation, thick  epi-
dermic masses, forming aborted attempts at the produc-
tion of a new nail, are deposited at the base and sides.
In the treatment of this form of onychia, both local
and constitutional means  are required.  The first  and
most essential point  is to remove the nail,  either in
whole or part, as it acts as a foreign body, and prevents
the healing of the surface from which it springs;  the
ulcer  should then be well rubbed with  the nitrate of
silver, and dressed with black wash. Colles recommends
fumigating it with a mercurial candle made by melting
3i. of cinnabar  and gij. of white wTax together.  The
constitutional treatment consists of means calculated to
improve the general  health; with this view  Sir A. Cooper recommends calomel
and opium.   I  have generally found the bichloride with sarsaparilla the most
useful remedy.
  The ingrowing of the nail is  an extremely painful and troublesome  affection,
principally occurring in the  great toe, and  brought about  by wearing pointed
shoes, by which  the sides of the soft parts of the toe are pressed upon, and made
to overlap the  edge of the nail.   An ulcer  here forms, the  liability to which  is
greatly increased by  the nail being cut  square, so that the flesh presses  against
a sharp and projecting corner of it.  This ulcer secretes a fetid sanious discharge,
and large granulations are thrown up by it.   The consequence of this condition
is lameness and inability to walk or stand with comfort.  Various plans of treat-
ment have been  devised with a view of raising the edge of the nail and pressing
aside the soft structures.   I have never, however, seen much permanent benefit
result from any of these means,  and the only method that is, I think, really ser-
viceable to the patient is the removal of the whole nail.   As this operation is an
excessively painful one, chloroform should always be administered.  It is  per-
formed in the following way: the surgeon holds the  diseased toe in his left hand,
and then running one blade of a strong sharp-pointed pair of scissors under the
nail up to  its  very root, he cuts through its whole  length, and removing the
scissors, seizes first one-half and then the other with a pair of dissecting forceps,
 
440
SURGICAL  DISEASES OF THE  SKIN.
and twists them away from their attachments.   The raw surface left is covered
with water-dressing, and speedily throws out granulations that form the rudiments
of a new nail.
                   TUMORS AND ULCERS OF  THE SKIN.
  We have already considered  the  ordinary non-malignant ulcers  of the skin
(Chap. .22), as well as some of the simple tumors that occur in connexion with
this tissue;  we shall  now proceed to the  consideration of the more malignant
diseases of this structure, such as the  cheloid and fibro-vascular tumors, lupus,
and cancer.
   Cheloid and fibro-vascular tumors  of the skin  are semi-malignant  growths
situated on the trunk and  extremities, usually flat and expanded, oval, round,
or irregular in  shape, slightly elevated above the surface of the  skin, and com-
monly occurring in otherwise healthy individuals.   They may remain stationary
for years, but not uncommonly have a  tendency eventually to ulcerate, to bleed,
and to assume a sort of malignant action; at other times they extend slowly, with-
out ulceration, moving forwards  as it  were upon the skin,  the part over which
they have passed assuming much the appearance of the cicatrix of a burn, being
red, contracted, drawn in towards the  centre, and  wrinkled.   Closely  allied to
these  are those  fibro-plastic growths  that have a tendency to sprout up in scars,
constituting the "warty tumor of cicatrices," described by Mr. Hawkins.   This
morbid condition appears to be simply an abnormal increase in  the activity of
the development of the  cicatricial tissue which springs up with great luxuriance.
These various forms of tumor should always be extirpated early by the knife, as
they do not appear to be amenable to  any constitutional or  local treatment, and
have  certainly a disposition to malignant degeneration.  As  there is a great ten-
dency to local recurrence of the  disease after removal,  it should be widely
excised, but even then it is likely enough  to return, requiring  perhaps repeated
operations before the  patient can be  freed  from this affection.

                                   LUPUS.
   Under the term lupus, various semi-malignant and malignant affections of the
skin,  of very different kinds, are commonly included;  indeed,  the distinctions
between lupus and the  different forms  of  epithelial cancer have not as yet been
well made out.   There  are three forms, at least, in which the diseases included
under the term lupus may make their appearance.   1st, As a superficial affection
of the skin, not attended by ulceration, but  accompanied by important and de-
structive changes in its  tissue, this is the lupus non-exedens  of some writers; 2d,
as a slowly ulcerating form of the disease, giving  rise to the  different varieties
of lupoid ulcer; and 3d, the  lupus  exedens, a disease  of a rapidly destructive
character, not only eroding superficially, but destroying the  tissue deeply. These
various forms of lupus are most  commonly seated on the face or neck, but are
occasionally met with on other parts of the body, as upon the limbs or trunk.
   Lupus non-exedens appears in  the shape of a red patch on the skin, covered
by fine, branny, epidermic desquamation; it may remain stationary for years, or
slowly spread over  a  great extent of surface, producing contraction  of the skin,
with wrinkling and drawing in of the features, and much stiffness in their move-
ments.   The integument  affected by  it  maybe in  one of two states; it may
either continue red, irritable, and branny, having the appearance of a thin cica-
tricial tissue, and in this way the greater  part or the whole of the face may be
affected;  or it may leave a firm, white, smooth, and  depressed cicatrix, exactly
resembling  that produced by a burn,  along the anterior margin of which the
disease slowly spreads, in the form of an elevated ridge composed of soft bluish-
white or reddish tubercles.
   The lupoid ulcer usually occurs about the face or neck, but sometimes on the 
LUPUS.
441
 extremities of elderly people, or of those in  broken health.   It may commence
 as the last-described variety, which after a time breaks into an ulcer; or a small
 crack forms in the first instance, which scabs over, and as this scab separates the
 characteristic sore  appears.   It  is in the first case a round or  oval flat ulcer,
 without granulations  on its  surface and without action in it, with somewhat
 elevated edges, often stationary, at other times slowly  extending; in this way it
 may continue for months upoivthe cheeks or neck.   In other instances again it
 spreads more rapidly, attaining a large size, and presenting a somewhat fungat-
 ing surface, from  which  some purulent discharge is thrown off.  This form of
 sore I have most commonly seen about the ears and occiput in elderly persons.
' In  other cases again  it spreads with great  rapidity,  giving  rise to  extensive
 ravages.  Thus, I  have seen it extend down the  whole side of the neck, from
 the ear to the clavicle, cleanly dissecting away the skin and  exposing the struc-
 tures immediately subjacent, as the  acromial and  clavicular  branches of the
 cervical plexus of nerves, and destroying the patient by exhaustion.
   The lupus exedens, or the more deeply ulcerating  form  of the disease, may
 begin in two ways, with or without the existence of a tubercle on the skin.   It
 is most commonly seated on the nose, beginning by ulceration of the mucous or
 muco-cutaneous surface, without any precursory tubercle, surrounded by redness
 of a violet or dusky hue, and  attended by, much inflammation, swelling, pain,
 and coryza.  The ulcer is at first covered by a thick scab;  as this separates the
 sore extends, and  often  rapidly destroys  one or both alas, the  tip and columna;
 after this the destructive action usually ceases for a time, the sore crusting over
 with grayish, hard, and adherent scabs, but if not, it may go on eroding one-half
 the face, producing a frightful, rugged-looking cavity,  and exposing and destroy-
 ing the bones and large cavities of the face.   I believe, however, that these two
 forms of disease,  that which  is limited to the nose, and that  which extends
 widely over and through the face, essentially differ  from one another; the first
 being generally of a scrofulous character, in fact consisting  of strumous ulcera-
 tion in one of the extreme parts of the body, the vitality of which is  below its
 normal  standard, and usually occurring in young persons, especially in women
 from eighteen to twenty-five years  of  age.   The other form of this destructive
 ulceration  is an extensive, deeply-eroding, and fatal disease, affecting the whole
 of the soft  tissues and bones of the face, being distinctly of a cancerous character,
 and ought not, consequently, to be described as one of the varieties of  lupus.
   The strumous form of lupus exedens, that which destroys merely the extremity
 of the nose, is commonly rapid in its progress, the part appearing to melt down
 under the  disease, so  that  in the course of a few weeks the whole of the organ
 is destroyed.  In other cases again  it  is very slow,  occupying perhaps  many
 years, and partaking somewhat of the red and branny form of lupus non-exedens.
 In other cases again it  is evidently associated with  and dependent  upon the
 syphilitic  taint, and ought then to be considered  rather as a  variety of  local
 syphilis in a strumous constitution than as a distinct affection.
   It is not often that we have an opportunity of examining microscopically the
 structure ofdupus.   Some time ago, however, I removed by  excision a patch of
 lupus non-exedens, which had existed for fourteen years  under the chin of a
 woman aged thirty, who was otherwise in good health.  On examination it was
 found to be composed  of large cells having clear and very distinct cell-walls, many
 times larger than  blood disks, and well-marked refracting nuclei.  There  were
 some cells clear and globular, without nuclei; others were fusiform  and elon-
 gated with nuclei, evidently  undergoing fibro-plastic transformation  (Fig.  135).
 Molecular movement was very distinct in one of these  globular cells.   The mass
 of skin  appeared  to  be converted into granular  matter, intermixed with these
 cells.
   The diagnosis of lupus is  not always easy, the  disease being specially apt to 
442              SURGICAL DISEASES  OF  THE  SKIN.
be confounded with some forms of impetigo, with syphilitic tubercles and sores,
and  with cancer.   From impetigo  it may be distinguished by the absence of
                 Firr 135                   pustules,  and of  the thick gummy
                                         crusts characteristic of this affection,
                                         as well as by the less extent of sur-
                                         face  implicated, and  the  deeper and
                                         more eroding  form of the lupoid ul-
                                         ceration.  From  syphilitic disease of
                                         the skin the  diagnosis is not always
                                         practicable,  inasmuch as  true lupus
                                         may  occur as  the result of constitu-
                                         tional syphilis.   In  other cases the
                                         history of the  affection, the limitation
                                         of  the  disease,  and  the  absence of
                                         intervening secondary manifestations,
                                         make it easy to distinguish one from
                                         the other.  From  epithelial  cancer
                                         lupus cannot in some  cases be distin-
guished, the two affections indeed  being  closely blended  together,  and  being
scarcely recognisable as distinct diseases.
  The treatment of lupus depends in a great measure upon the variety of the
disease with which we have to do, and the constitutional condition attending it,
and calls for the employment not only of local but  of general remedies.
  In lupus  non-exedens we may, if  the disease  be limited, excise the patch and
heal the sore that results, by granulation.   Not unfrequently, however, the cica-
trix is apt to undergo fibro-vascular degeneration.  If excision be not had recourse
to, on account of the extent and superficial character of the disease, it is useless
to attempt to destroy it by caustics.   In every case in which I  have seen these
means tried, they have failed in effecting a cure.   In  some instances, however,
the application of a strong solution of the nitrate of silver to the morbid  surface
will induce  a healthier action ; though in the  majority of instances local applica-
tions of a soothing kind  can alone be borne.   Lotions containing glycerine are
especially useful, as they  prevent the surface becoming dry and harsh.   If the
disease be situated on the face, care should be taken  to avoid exposure to cold
winds, dust, &c.  In the  constitutional treatment,  the avoidance of stimulants of
all kinds, the use of a bland diet, and the employment of  some of the  prepara-
tions of arsenic, will  be  found  to  be the most likely means to effect a cure.
Indeed, arsenic may be considered the great remedy in this disease; the liquor
arsenicalis, or the  iodide  in combination  with  small doses of the biniodide of
mercury, will be found extremely useful;  so also Donovan's Solution is  most
beneficial in many  instances.
  In the treatment of the lupoid ulcer, the same constitutional  remedies should
be employed as have just been described, and a healthy action induced in the
sore by the  application of the chloride of  zinc paste to the whole of its surface.
The best mode of applying this is to keep the chloride prepared  for use by being
mixed with  two or  three parts of flour.   When  wanted, a sufficient quantity of
this powder should be made into a stiff paste, by the addition of a little water,
and then spread over the  surface to be attacked  by it, in a layer about the thick-
ness of a wafer.  This should be left on for two or three  hours, and then removed;
the  sore being covered with  a piece of water-dressing until the grayish slough
that has been produced  has separated, when the caustic  may  be reapplied as
often as necessary.   Besides the chloride of zinc, various other  caustics  may be
had recourse to, each of which possesses some peculiar advantages.   The nitric
acid is useful, if the action to be produced is not required to be very deep, for as
it hardens and  coagulates the tissues to  which it is applied, it does not conse- 
CANCER OF  THE  SKIN.
443
quently extend so far as the chloride.  The acid nitrate of mercury presents the
same advantage as the nitric acid and other fluid caustics,—that it can be applied
into the fissures and  hollows of the part into which the more solid caustics do
not penetrate, and is certainly useful in  inducing a healthy action in  the part,
especially if there be a syphilitic taint.  The potassa fusa and Vienna paste are
useful, so far  as their destructive properties are concerned, but are somewhat
uncontrollable, and apt to spread.  The most convenient mode of applying them
iSPto cut a hole in a piece of plaster the exact  size and shape of the  ulcer, to
apply this around its borders,  then to cover the sore with a layer of potassa cum
calce, one line in thickness, and over this to lay on another piece of plaster.   In
this way a considerable amount of caustic action may be induced, which will  be
limited to the exact surface to which it has been applied.   Of all these caustic
applications, however, I give the preference to the chloride of zinc;  its action is
more continuous, and appears to give a healthier stimulus to the part  than any
of the  other agents.
   The treatment of lupus exedens must have reference to the constitutional con-
dition in which it occurs;  if this be of a strumous character, the administration
of cod-liver oil and the iodide of potassium with a nourishing diet, will be most
serviceable; if in a syphilitic constitution, the remedies that are applicable to the
cure of tertiary syphilis,  such as the bichloride of mercury and Donovan's Solu-
tion, are especially useful.  Tn  many cases also in which there can be  no  suspi-
cion of a syphilitic taint, these preparations of mercury, as well as the iodides of
the same metal, may be administered empirically with great advantage.   The
combination of arsenic, iodine, and  mercury that exists in Donovan's  Solution,
or that is contained  in  a pill composed of & gr. iodide of arsenic and y^ gr. of
biniodide of mercury, as recommended by  Dr. A. T. Thomson,  has appeared to
me to  be extremely beneficial, and  in many cases certainly exercises a marked
influence in arresting the disease.   Whilst  the patient is undergoing a course of
these remedies, much attention requires to be  paid  to  diet, clothing, and his
general hygienic conditions.
   In the local treatment the first thing that requires to be done  is to subdue in-
flammatory  action and irritation, by leeches, emollient  lotions, and  opiate or
henbane poultices.   As this subsides, the progress of the disease will usually be
arrested, for a time at least, and then by the application of the chloride of zinc,
or the  acid nitrate of mercury to the surface, a more healthy action  may  be  set
up, and the sore be got to cicatrize.   Great mischief, however, will result  if the
caustics be applied too early, as  the  destructive action of the disease will then be
augmented.  The inflammatory redness and  branny  desquamation  resembling
lupus non-exedens that  surrounds the ulcer may usually most readily be got to
disappear by the repeated applications of a strong solution of the  nitrate of silver,
which  should be applied  every second day by means of a camel-hair brush. The
cicatrix that forms  in this disease is thin, and breaks readily, giving way on
exposure to  cold,  or on the occurrence of constitutional  derangement.   The
patient should, therefore, for  some length of time after recovery, he careful not
to expose himself to any such  influences.   In the more rapidly spreading and
worst forms of lupus exedens, that horrible disease termed by the older surgeons
Noli-me-tangere, nothing can  be done beyond the relief that is  afforded by the
administration of opiates, and a  general sedative plan of treatment.

                          CANCER OF THE SKIN.
   Cancer may occur in  the  skin as a  true scirrhous or  encephaloid deposit;
most commonly, however,  those affections of the skin termed cancerous consist
of the epithelial form of the disease, and are usually seated about the lips, face,
and scrotum, or at the orifices of the mucous canals; these we have already con-
sidered generally, and shall have to  revert to them more fully, when treating of 
444              SURGICAL  DISEASES  OF THE  SKIN.
 the special affections of these parts.   Some forms of lupus, also, may be of a
 cancroid character, but they do not exhibit  the true evidence of malignancy by
 infecting the  system,  and giving rise  to  secondary deposits  in  the different
 viscera.
   True cancer of the skin may occur in three forms: as the indurated  wart of
 a scirrhous character, specially described by Scarpa; as scirrhous or encephaloid
 infiltration and fungus;  or  as ulcers which, primarily originating from some
 local irritation of_a simple kind, may by the persistence of this assume a tniy
 cancerous  character; thus, I have seen the scrotum and the neighborhood of the
 apertures of fistulae  in perineo, in a case of  old-standing disease, become con-
 verted into a truly cancerous  mass.
   The scirrhous wart is usually of the natural color of the skin, but sometimes
 of a reddish or dark-grayish hue, hard, and  somewhat irregular in shape; it may
 remain  for a  long  time  stationary, but at last ulcerates and  spreads  rapidly,
 giving rise to vast destruction of parts;  the ulcers formed by it presenting the
 characters of cancer, with a hard base, everted edges, and foul surface.
   The infiltrated cancer of the skin occurs in  the  form of a flat  dark induration,
 which scabs over with dark, rugged, grayish-brown incrustations, having shooting
 pains in and  around it, and  after  remaining stationary perhaps for years, runs
 into ulceration and rapidly destroys the parts it affects; after ulceration has been
 set  up, the patient's life, according to Dr. Walshe, is seldom prolonged beyond
 two years.   Encephaloid cancer of the skin is of rare occurrence, but occasion-
 ally forms  large fungating masses sprouting from, and solely connected with, this
 tissue.  The  cancerous ulcers  of  the skin  may occur from  the  irritation and
 contact of secretions, as of the urine,  or an unhealthy and specific action may be
 set up in an old ulcer, as of the leg, and cause  it to assume a cancerous character
 (Fig. 136).   These  cancerous ulcers may indeed  occur upon almost any part of
v the body:  I have seen them on the  back, breast, fingers, hand, thigh, and sole

                                    Fig. 136.
of the foot.  They are flat, gray, or sloughy-looking, often with  warty granu-
lations, a good deal of induration about them, and but little discharge.
  The treatment of cutaneous cancer consists  in the excision or amputation of
the part affected.  Its removal by excision, whether in the form of wart, crust,
or ulcer, should be effected so soon  as its true characters have  declared  them-
selves; provided it  be of such a size, and so situated, that it can be  freely
removed with a sufficient stratum of subjacent healthy parts, and a wide border
of surrounding  skin.  Should it be  so situated that its excision through sur-
rounding healthy tissue  is not practicable, amputation of the limb must be had
recourse to, as was done  in the case above depicted.  Under such circumstances
as these, the limb may be removed at no great distance above the disease, it not
being necessary, as in other cases of  cancer of the extremities where the bones
are affected, to allow a joint to intervene between the seat of operation and the
malignant growth. 
INFLAMMATION OF  THE LYMPHATICS.
445
                        CHAPTER  XXXIII.


     DISEASES OF  THE  LYMPHATICS AND THEIR GLANDS.

   Inflammation of the lymphatics, lymphatitis, angeioleucitis, is a diffuse, or
erysipeloid inflammation of these vessels.  In it, according to Tessier, the lymph
coagulates, forming  a rosy clot which obstructs the  interior of the  vessel, the
walls of which,  at  the same  time, become thickened, softened, opaque,  and
surrounded by a quantity of infiltrated cellular tissue.
   This disease may  be  idiopathic;  when it is closely  associated with  erysipelas;
but more commonly it  is set  up from the irritation  induced  by an abrasion or
wound.  During the progress of an ordinary injury, the patient is seized with
rigors, followed by febrile reaction, and  attended, perhaps, by vomiting or diar-
rhoea.   These symptoms often precede  by twelve or fourteen  hours the local
signs of the disease, but more commonly accompany  them.   On examining the
part it will,  if superficial, be seen to be covered by a multitude of fine red
streaks, at first scattered, but gradually approximating to one another, so as to
form a distinct band, about an inch in breadth, running from the  part affected
along the inside of the  limb to the  neighboring lymphatic glands, which maybe
felt to  be enlarged and tender.   The  band itself feels somewhat doughy and
thickened.   There  is usually more or  less oedema of the limb from the impli-
cation  of the deeper layers of vessels and their obstruction by the inflammation.
Along the course of the inflamed  absorbents erysipektous-looking patches not
unfrequently make  their appearance, which coalesce until they assume a con-
siderable size, and constitute a distinct variety as it were of erysipelas.  In some
cases  the glands are affected before any other local  signs manifest  themselves,
owing  probably to the  deeper-seated lymphatics having been first  implicated;
and not uncommonly throughout the  disease inflammation  continues to be con-
fined principally to  this set of vessels, giving rise to  great and brawny swelling
of the limb, but without  much, if any, superficial redness.  The constitutional
disturbance  at first  of  the active inflammatory type  may gradually subside into
the asthenic form.
   The disease usually  terminates in resolution at the end of eight or ten days,
not uncommonly it  runs on to erysipelas, and in other cases again, limited sup-
puration may take  place,  or a chain of abscesses form along  the* course of the
inflamed absorbents and in the glands to which they lead.  In some instances
after the disappearance of the disease, a state of chronic and rather solid oedema
of the  part  may be  left, giving rise indeed to a species of false hypertrophy of
it, and constituting a troublesome after-consequence;  more rarely, death results
either  from  erysipelas,  by the supervention of pyemia, or by the occurrence of
secondary abscesses.  This is chiefly in broken constitutions, in which the disease
has made extensive  ravages, and becomes associated with low cellulitis.
  The  diagnosis  of inflammation  of the  absorbents is easily made; the only
affections with which it can be confounded being erysipelas and phlebitis.  From
the first it may be distinguished by the streaked character and limited extent of
the redness;  though as the two affections so  commonly occur  together the  dis-
tinction is of little moment.   From phlebitis, the disease we are now considering
may  be recognised  by its superficial redness, the inflammation of  contiguous
glands, and the absence of the knotted corded state, characteristic of an inflamed
vein.
  The  causes of inflammation of the absorbents closely resemble those of erysi-
pelas, the disease being especially disposed to by atmospheric vicissitudes, by par- 
446          DISEASES  OF  LYMPHATICS AND GLANDS.

ticular seasons of the year, more especially the early spring, and by the epidemic
constitution at  the time tending to disease of a low type.  So also  the broken
health of the patient and the neglect of hygienic precautions  tend to induce it.
Amongst the most direct causes are wounds of all kinds, but  especially such as
are poisoned by the introduction of putrid animal matters or  other  irritants, or
that of recent origin.   It is very rarely indeed, that inflammation of the absor-
bents occurs without some such  cause, but yet I think we are  warranted in con-
sidering it as of idiopathic origin in  some instances.  I have at least seen cases
in which  careful examination has failed in detecting any breach of surface, or
evidence of poisonous absorption.
   The treatment consists in the  employment of antiphlogistic  remedies, such as
the application  of a series of leeches  along the course of the inflamed absorbents,
followed by assiduous poppy fomentations; the limb at the same time being kept
elevated.   The bowels  should be freely opened, and  if there  be much pyrexia
present, salines  with antimony may be administered.  If the fever assume rather
a  low form, the liquor ammoniae  acetatis may be given in camphor mixture;
support being administered, or withheld,  in accordance with the  principles laid
down when speaking of the  treatment of inflammation  generally.  If chronic
induration  and oedema occur, the. application of blisters will  be  found to be of
use in taking down the  swelling and hardness; bandaging so as to compress the
limb  methodically, may be of service  in  the later stages.   If abscesses form,
these should be opened early, and treated  on  ordinary principles.
   [In the treatment of angeioleucitis, the early employment of a blister sufficiently
large to extend  completely around  the  circumference of the  limb,  has  been
strongly recommended  by Dr. Physick.  He  directed  the application to be made
at a point some distance  above that portion of the lymphatic tract, which was
immediately involved.—Ed.]
   Inflammation of the lymphatic glands or adenitis, may occur either by the
extension of inflammation along the course of the lymphatics, by the irritation
induced by acrid or poisonous substances  conveyed along these vessels, and not
inflaming them, but inducing diseased action in the glands through  which they
are carried;  or, as a consequence of strains  resulting from over-exertion, as is
often seen in the glands of the groin from walking too much.   In whatever way
occurring, inflammation of the absorbent glands is always attended by a stasis of
the lymph, by  coagulation of it, and, if the  whole or greater  part of the glands
of a limb are affected,  the course of the fluid through the absorbent vessels may
be so seriously interfered with, that oedema, often of a solid character, occurs in
the lower parts from which the lymph ought  to have been conveyed.
   Adenitis  may  be acute, subacute, or  chronic.  In  the  acute form of  the
disease, which almost invariably occurs as a consequence of angeioleucitis, there
is pain, swelling,  tenderness,  and stiffness about the affected glands,  with a dull
heavy sensation in them, followed by all  the signs of acute abscess, the glands
gradually softening in the centre, and the suppurative  inflammation extending
to the contiguous cellular membrane, through which it becomes somewhat diffused.
In the subacute  inflammation, which is of common occurrence as the result of
injuries or  strains, the glands  become swollen, enlarged, and tender, and are
marted "together by the inflammatory and plastic consolidation of the  neighbor-
ing tissues.   If abscess form, it commonly commences in the first instance in the
structures around the   glands, and these are  perhaps  eventually  exposed at the
bottom of the cavity that results.  This is especially apt to happen in cachectic
and strumous persons from slight sources of irritation.   Very  commonly in such
subjects  as  these, the   inflammation of  the  glands runs into a  chronic state;
which, indeed, may at last terminate in their permanent  enlargement and indura-
tion, or tuberculous degeneration.  When the glands become chronically inflamed 
           ENLARGEMENT  OF THE LYMPHATIC GLANDS.       447

from the first, they will be found to be enlarged and hardened, with tenderness
and pain about them; after a time suppuration takes place  within them,  or per-
haps it  may occur in the cellular tissue around  them, which breaking down,
leaves them in the form  of reddish-gray or fleshy masses,  that protrude in  the
midst of the suppurating cavity; as the inflammation subsides, the skin becomes
of a reddish-blue or  purple hue, is thinned, and firmly incorporated  with  the
subjacent tissues.
   But the glands not uncommonly enlarge chronically without any inflammation,
simply as the result  of strumous disease or of chronic  irritation of some kind.
They may remain  permanently enlarged, or after continuing so for months or
years, may slowly break down into unhealthy suppuration, leaving the skin thin,
blue, and undermined, with weak, often protuberant cicatrices.  The pus dis-
charged from these strumous glands is of a curdy ill-conditioned character.  In
all probability the peculiar enlargement and tendency to unhealthy suppuration
arise from the deposit of  tuberculous matter  within the gland.  These changes
principally occur in  the  neck, especially in the  submaxillary glands, and  the
glandulae concatenatae, sometimes in  the axillary or inguinal glands, forming
large indurated and nodulated tumors, matted together, and  suppurating in  the
interstices of the cellular tissue, or in the substance of the glands  themselves.
This strumous enlargement of the  glands occurs chiefly in children and in young
people, in whom indeed it is commonly looked upon as one  of the most frequent
accompaniments of the strumous diathesis.
   The treatment of inflamed absorbent glands varies, of course, greatly, accord-
ing to the stage of the affection.   In the acute stage, leeches and fomentations
are especially  required.  In the  subacute condition,  spirit  lotions containing
the iodide of potassium will subdue the inflammation and take down the swelling;
at the same time the health must be  regulated by aperients,  and a moderate
antiphlogistic plan of treatment.   If  abscess forms, this must be opened with a
knife and the part  well poulticed afterwards; the fistulous openings which  are
often left require to be treated by stimulating applications, especially by rubbing
them with  the nitrate of silver, but  very commonly they will not  heal unless
they are slit up and dressed from the bottom.
   The chronic inflammation or enlargement of  the  lymphatic glands  or  the
induration left as the result of the acute  disease, require to  be treated on  dif-
ferent principles.   If there be any pain and tenderness about them, the applica-
tion of the iodide and spirit-lotion will be required.   If they have  already sup-
purated, and an aperture  exist leading down to an indurated mass, or if there be
surrounding induration of the  soft tissues, it is often  a good  plan to rub  the
ulcerated part freely  with caustic potass, which will dissolve it away by exciting
inflammation around the plastic deposit, and thus causing its dissolution into pus.
When merely chronically enlarged, without being irritated, methodical friction
with the iodide of lead ointment  will produce absorption of the  inflammatory
effusion  constituting  the  bulk  of  the enlargement,  and this  in many instances
may remove the tumor entirely.   In  other cases  again painting the part with
the tincture of iodine, and improvement of the general health, will  cause  the
removal of the diseased structures.  Extirpation of enlarged lymphatic glands is
seldom  necessary,  and if undertaken  may lead to more serious and extensive
dissections than might appear at first  requisite, a chain of diseased  glands often
extending to  a considerable distance,  and after one has been removed others
coming into sight.  As a general rule, these operations should not, I think, be
undertaken,  though  Velpeau,  Sedillot, and others advocate  their  performance.
Cases, however, occasionally occur, in  which such a procedure may be deemed
advisable, the affected gland being large, indurated, and solitary.
  The lymphatic glands occasionally become much enlarged in the neck, axilla,
or groin, without any indications of struma, but attended by much debility, and 
448
DISEASES OF  VEINS.
usually great emaciation ;  under these  circumstances, the best remedies are, the
liquor potassae in full doses, and cod-liver oil.
  Besides these inflammatory and strumous enlargements of the lymphatic glands
various other alterations are frequently observed in  them; thus, they  may un-
dergo cancerous degeneration,  as the result of absorption from a scirrhous, mela-
notic, or encephaloid tumor.  In other cases again, they have been found to have
undergone calcification, as the result of strumous or inflammatory degeneration;
and lastly,  a varicose condition  of  the  absorbent vessels that pass through them
has been observed  by Amussat and Breschet; but these are rather  matters of
pathological than of practical interest.
                        CHAPTER  XXXIV.

                      DISEASES  OF  VEINS.

                                PHLEBITIS.

   Inflammation of the veins, originally studied by Hunter, has of late years
attracted the attention of many distinguished  Continental  and British patholo-
gists, amongst whom may be  especially mentioned Breschet, Velpeau, Cruveil-
hier,  Arnott, Lee, and Tessier.   This disease is commonly excited by the wound
of veins, as in operations, venesection, and  injuries of various kinds;  or it may
result from the application of ligatures to them, and is especially predisposed to
by a previously unhealthy condition of the vessel, and by epidemic  constitution
and season; in fact, by those influences that dispose generally to the diffuse forms
of inflammation.
   When a vein is  inflamed, important changes occur both in the coats of the
vessel and in the contained blood.   The coats  of the vessel  generally become
thickened, the outer one especially being vascular and infiltrated; the inner
coat becomes softened, pulpy, and usually more  or less stained by the  coloring
matter of the blood of a dark-red or purple hue.  The  blood in the inflamed
vessels undergoes coagulation, and adheres  to their sides; this tendency to adhe-
sion and coagulation being increased by the effusion of plastic matter from the
wall of  the vessel.   As a consequence of this, its interior becomes stuffed with
a solid mass of  coagulated blood and lymph.  This coagulation of the blood in
the interior of the inflamed vein is a very remarkable circumstance, and appears
to be  specially induced by the morbid action going on in the coats of the vessel,
though in many cases it is doubtless aided by the blood  becoming entangled in
the plastic matter with which the lining membrane of the vein speedily becomes
coated.   Suppuration often takes place in the interior of the vein, the pus being
produced not by the transformation  of the  contained blood, but by effusion from
the coats of the vessel.  These changes  may  occur in any vein, external or
internal, and we often find them associated ; the same vessel containing a mix-
ture of coagulum, fibrine, and  pus.   The extent of surface  which the inflamma-
tion may occupy varies from that of a small vessel a few  inches in length, to
the trunk and branches of one  of the largest veins in the body.   In accordance
with these pathological conditions, three varieties of phlebitis may be described:
the adhesive, the suppurative, and the diffuse.
   In  the adhesive phlebitis, plastic matter is thrown out by the wall of the vein,
and the blood coagulating upon and in this, a firm plug is formed, by which the
vessel is more or less completely obstructed.   This  obstruction of the vessel, 
VARIETIES OF PHLEBITIS.
449
which is the common result of this  form of the  disease, may continue perma-
nently, the plug becoming incorporated with its  coats, and gradually undergo-
ing cellulo-fibrous degeneration converts it  into an impervious cord.   In other
cases again, a channel eventually forms through the axis of this coagulum, allow-
ing the circulation through the vein to be re-established.
   The suppurative phlebitis is always preceded or accompanied by the adhesive
form of the disease, the adhesive action bounding and limiting the suppuration,
and preventing the pus from becoming mingled with the current of the blood.   If
the plastic plug is insufficient to occlude the vessel, or if it become  absorbed or
metamorphosed into pus, then this fluid may get  access to the general circula-
tion, and produce that serious and fatal train of symptoms constituting pyemia,
and depending on the admixture of  pus  with the  blood.  In  this form  of  the
disease, the pus is usually found between the coats of the vessel and  the  plug,
or in a portion of the vessel unoccupied by coagulum, but confined at either  end
by a mass of plastic matter ;  when thus limited or encysted, it can do  no mis-
chief to the system; but if the plug that bounds it becomes absorbed or degene-
rates, it will mix with the general current of the blood.  Pus has been described
as forming in the centre of the coagulum, but Gulliver has shown that in many
cases the fluid described as pus is merely disintegrated fibrine.
   The diffuse phlebitis is an erysipeloid form of the disease, often running for a
considerable distance along the coat  of  the vein,  which becomes  thickened,
pulpy, and red, without adhesions forming, or the blood coagulating;  indeed,
in these cases  there appears to be a great want of  plasticity in this fluid.  This
form of phlebitis is commonly, though not  always,  fatal; its fatality was sup-
posed by Hunter to be owing to the extension of  the inflammation to  the heart,
and  by Hodgson to the extent of surface affected;  but Arnott has shown that
the inflammation scarcely ever reaches the  heart, and  that the extent  of vein
inflamed is commonly very limited; it  not unfrequently happening that  the
disease proves fatal when  but a few inches are affected, as in  the  vessels of a
stump.   Hence it is probable that death is owing either to the admixture of  pus
with the blood that circulates through the inflamed portion of the vein, or by
such changes induced in the blood by the inflamed surface over which it passes,
as are incompatible with life.
   The essential difference between these  forms  of phlebitis  would therefore
appear to depend on the formation and situation of the plastic matter.   So long
as the inflammation is purely adhesive, or, as the pus formed by it is bounded by
adhesive plugs, it does not differ in its effects from ordinary inflammation ;  but
if the pus get into the circulation by  the breaking down or disintegration of these
limiting plugs, or if  the blood be deeply and seriously altered  in its characters
by changes induced in  its  passage over the inflamed surface, then we  get  these
peculiar phenomena indicative of general blood-poisoning, which have been  de-
scribed as pyemia.   (Chap. 28.)
  The symptoms of phlebitis vary according to the  form it  assumes.  In  the
adhesive  phlebitis the action  is usually localized  and limited; very commonly
arising from traumatic causes, and not unfrequently subacute.   When traumatic,
it  may occur  in  any vein that is  wounded, but when  idiopathic, it commonly
occurs in those situated in the  calf or leg, especially if they are varicose.  The
inflamed  vein  is  hard, swollen, knobbed, and  painful, the knobs constituting
distinct  enlargements opposite  to  the valves; if  superficial, it is  of a reddish-
purple color,  and  is attended  with some degree of stiffness and  inability to
move the limb.   There  may  perhaps be no pain,  but only deep tenderness
over the  course  of the vessel.  There is always some oedema around  the  in-
flamed vein,  and in the  part that supplies it with blood.   This  cedematous
condition of the limb is a most important diagnostic sign in deep-seated phlebitis
when the vein cannot be felt, as in the pelvis, for  instance, and may perhaps  be
                                    29 
450
DISEASES OF VEINS.
the first symptom  observed,  coming on either  suddenly or gradually.   The
oedema may give  rise to a hard, white, and tense condition of the  limb, which
pits on pressure, though in some cases the hardness is too great for this.   Occa-
sionally, in deep  phlebitis, the limb  may suddenly swell to a considerable size,
without there being any subcutaneous oedema.   In a  case of  phlebitis of the
deep veins of  the leg and thigh, lately under  my care,  the calf of the affected
limb suddenly enlarged with great pain and much distension of the subcutaneous
vessels with fluid blood, but without any subcutaneous oedema.   As the inflam-
mation  subsides,  the  swelling of the limb goes  down, the circulation passing
through  its former channels, or  the blood  being carried  off by the  collateral
venous system.  If suppuration occur, no change takes place in the symptoms
so long as the pus is localized or encysted, until  it perforates the coats of the
vein, and passing into the external cellular tissue forms a common  abscess.  If
it break through  its plastic barriers, then, however, a very different result occurs,
and the symptoms of  purulent  infection  come on.  The constitutional disturb-
ance in  these forms of phlebitis is often of a very mild character; in other  cases,
however, symptoms of well-marked pyrexia  manifest themselves, often accom-
panied by rather  a depressed state of system.
  The treatment  of adhesive phlebitis consists in  the free application of leeches
along the course of the inflamed vessel, with rest of the  limb, and fomentations;
at the same time salines and purgatives must be administered, and the ordinary
antiphlogistic means be had recourse to.  If  depression come on, carbonate of
ammonia must be  early given.   The hardness  which is often left  after the
removal  of the inflammation, may usually be got rid of by salt  and nitre poul-
tices, as  recommended by Dr. Basham.   If abscesses form, they must be opened
wherever they occur.   If oedema of the limb continue, the application of blisters,
or the pressure of an elastic roller, will remove this troublesome symptom.
  The diffuse phlebitis is  ushered in by the  ordinary symptoms of pyrexia, at
the same time that pain and tenderness,  with  a  certain amount of oedema and
hardness, may manifest  themselves along the course  of  the  inflamed vessel.
These symptoms,  however,  speedily give way to those that characterize the lowest
forms of ataxic fever, such as a fluttering pulse, a brown tongue, sordes  about
the mouth and teeth, with much anxiety of  countenance, diarrhoea, vomiting,
extreme  prostration, delirium, and death.  These symptoms are, indeed, due to
the formation of pus  in the vein, its admixture with the blood, and  consequent
poisoning of the  system.   The whole danger  and peculiarity of diffuse phlebitis
depend, I believe, upon this circumstance, and I would, therefore,  refer for the
consequences and treatment of this form of the affection  to the chapter on pyemia
(p. 368).
                                  VARIX.
   By varix or varicose veins is meant a  dilated  condition of these vessels with
hypertrophy  of their coats, giving rise  to oedema, tension, weight,  and pain in
the parts they supply, often with a good deal  of numbness, difficulty in motion,
or  loss  of power in  the  affected limb.   In  other cases, their pressure on the
nerves  of  the part, as when occurring in the spermatic cord, may give rise to
very severe suffering.
   In appearance, varicose veins are  tortuous,  dilated, and  sacculated;  they are
serpentine in their course, and feel thick under the finger.   They may be  super-
ficial or deep-seated;  when superficial the disease is often limited to  one of the
larger venous trunks  of a limb, the smaller branches  not being engaged.   This
we commonly see to  be  the case in the internal saphena;  in other cases, the
small cutaneous veins alone may be  affected, appearing as a  close network of  a
purplish-blue color under the skin, with  much discoloration of  parts, and some
oedema of the limb; or both sets of vessels may be implicated.   The deep-seated 
         CAUSES  AND  STRUCTURE  OF VARICOSE  VEINS.      451

varix is not by any means so common as the  superficial, and when it occurs, is
generally the result of the pressure of a tumor, or of some similar cause.   Vari-
cose veins, especially when superficial, are very apt to inflame, with coagulation
of the blood within their sinuses.
   The veins of the skin and mucous membranes  are  those that are most, liable
to this affection.   It is most commonly met with in the legs, and more  parti-
cularly in the  trunk  of the  internal saphena; but any of the superficial veins,
as of the arms, chest, head,  neck, hypogastrium, or thorax may be  affected;  the
veins about the anus are especially liable to varix, constituting some forms of pile;
so, also, the spermatic veins very often become enlarged, constituting varicocele.
As a general rule, superficial varix is infinitely more common  in  the lower than
in the upper part of the body, owing evidently to the tendency to the gravitation
of blood in the more dependent situations.   When occurring  at any point above
the pelvis, it may be looked  upon as arising, in all probability, from the pres-
sure of a tumor of some kind upon  the large venous  trunks.  The deep-seated
veins that are  principally affected are, the internal jugulars, the vena azygos, and
the veins of the prostate.
   The causes of varix are generally  such conditions as induce more or less per-
manent distension of the veins.  Thus, for instance, blows, strains,  and habitual
over-exertion of a part, by driving the blood  into the  subcutaneous veins, may
give rise to their  distension; so, also, certain  occupations may favor gravitation
of blood to the lower part of the body;  then, again, the length  of a vein, as of
the internal saphena, may occasion its dilatation hy the  weight of the long column
of the contained  blood.   Any obstacle to  the return  of the blood from a vein,
as the pressure of a tight  garter below the knee, or of a tumor upon one of the
large venous trunks, may give rise to its permanent  distension,  as well as to
that of all  its branches.  In  other cases, again, the affection, or  the disposition
to it, appears to be hereditary, and, in many instances, it is difficult to recognise
any cause except an enfeebled and relaxed state of the walls of the vessel, such
as is met  with   in  tall, debilitated, and  phlegmatic  people.   Age influences
materially the  occurrence  of the disease, which is rare in the earlier periods of
life, but  gradually increases as the  individual  advances in years.  In  women,
especially, the  affection is common,  in consequence, partly, of natural debility,
but more frequently from the pressure of the enlarged uterus during pregnancy.
   In structure varicose veins are sometimes simply dilated without any thicken-
ing of their coats,  but in other instances  they are truly  hypertrophied, their
cavity being dilated and  walls  thickened, the  vessel  likewise being elongated,
forming curves and bending  back on itself.    Sometimes the enlargements at
particular points  appear to be multilocular, the vein forming a series  of curves
and dilatations together.  The  valves are always insufficient in varicose veins,
being usually bent backwards or ruptured,  and the lining membrane is marked
by longitudinal striae.   The blood in  these vessels has a tendency to coagulate
in large masses, the vein being at times the seat of inflammation, by which this
tendency is materially assisted.   The neighboring and  subjacent parts are much
modified in structure, and there is usually chronic  oedema, with infiltration of the
skin and cellular tissue, which may at  last run  into ulceration, giving rise to
the varicose ulcer which  has already been  described  (p. 339), and  which, if
communicating with a large branch, may yield a copious or even fatal hemorrhage.
  The treatment  of varicose veins  is of a palliative  and curative kind.   The
palliative treatment consists in moderate  compression exercised upon the vessel,
so as to support its weakened and dilated coats, and thus prevent its further dis-
tension and the pain occasioned  by this, as well as the other after-consequences,
such as oedema, disorganization, and ulceration of the skin.   The presssure must
be applied very smoothly and  evenly, lest it irritate  and ulcerate the  skin, or
produce distension of the vein below the part compressed.  For the purposes of 
452
DISEASES  OF  VEINS.
compression, bandages and elastic stockings are commonly employed.   I know of
no better material for this purpose than Churton's elastic bandages, and I have
in many cases used Huxley's stockings, made of an elastic woven material, with
o-reat advantage.   In  some cases an elastic pressure by means of a vulcanized
India rubber band or garter may be applied around  the  limb, so as to stimulate
the action of the valves of the vein;  by compressing this it cuts off the weight of
the column of blood from the  terminal  branches.   In other cases again the ap-
plication of a truss to the upper part of the saphenous vein, as  recommended by
Colles, may be of service.   Palliative treatment  by some or other of these plans
is usually sufficient to keep the disease in check in  ordinary cases of varix;  but
under  certain circumstances, it becomes  necessary to change the palliative  for
a curative plan.   This is especially requisite under the following three condi-
tions :—if the varix be of such large size as to produce  much inconvenience, or
to give rise to severe pain by its  pressure on the  nerves in its neighborhood; or
if a varicose vein  has burst, or is on  the point  of giving way; or, lastly, if an
ulcer dependent on  its existence will not  heal.    Under one or other of these
circumstances it may be necessary to have recourse to curative treatment.  With
this view various  plans have been  recommended,  all of which, however, have
for their object the production of obliteration of the vein at one point by exciting
adhesive inflammation  there, and thus causing it  eventually to degenerate into
a cellulo-fibrous cord.   In this way the trunk of a  varicose vein and  the larger
masses of varix may be occluded.  But  can the disease be  cured by the local
obliteration of the vein ?  To this question I have  no hesitation in answering in
the negative.
   After having observed  a very considerable number of these cases, both in my
own practice and  in that  of Mr. Liston,  I  have  no doubt that though the trunk
be  obliterated, a collateral venous circulation is set up, which is very apt to take
on  a varicose condition, and thus to  cause a return  of the disease some time after
the operation.  But though the cure is not radical, much benefit may often be
effected, by removing varicose knots that occasion pain or inconvenience,  by
enabling an ulcer to  cicatrize, or by occluding  a vein from which hemorrhage
has occurred.  The  principle  of  all curative  treatment  in varix  consists  in
exciting adhesive and localized inflammation in the vein on the cardiac side of
the varix, so as to occlude it, and thus, by directing the blood  into other channels,
to  relieve the distension of the diseased vessels  and the inconvenient results
that follow this.   As the treatment thus  necessarily involves the artificial exci-
tation of phlebitis,  there is always a risk of the inflammation  passing beyond
the adhesive stage into that of suppuration, or diffuse inflammation, and out of
about forty cases, in which I have seen  or  performed  these operations, two
patients have died, one from phlebitis, the other from erysipelas.
   Various plans  for obliterating the veins have been recommended by surgeons.
They  resolve themselves into  four principal heads of treatment.   1st.  The
subcutaneous section of the vein, or the excision of  an inch  or  so of the vessel.
This plan of treatment is severe,  and not unattended by  danger, as we learn
from  Sir B.  Brodie.  2dly.  It has been recommended  by  Mayo,  Seutin,
Bonnet, and others, to excite inflammation in the  vein by producing a series of
deep eschars or issues in  the skin covering it, by the  application of a caustic,
such as the chloride of zinc or potassa fusa.  Mr.  Skey speaks very favorably of
this mode of obliterating varicose veins, as being devoid of danger.   He recom-
mends the eschars to be made  by the application of a powder, composed of three
parts of lime and two of potass, made into a paste with spirits of wine at the
time of application.   The eschars  should not be larger than a split  pea,  and
their number must depend on the extent of the disease.  Others again recom-
mend the obliteration of  the vessel  by introducing needles into it, and transmit-
ting a galvanic  current  along and across them.   Of this  plan of treatment  I 
ARTERITIS.
453
have not had any experience,  nor do  I believe  that it is  ever  employed  by
surgeons in this country.   The  most convenient way of obliterating the vein, in
my opinion, and  that which I always employ, consists in compressing the vessel
at several points, by  passing a hare-lip pin underneath it, laying a piece of wax-
bougie upon the vessel, and then applying the twisted suture around the pin and
over the bougie (Fig. 137 a).   In this way the vessel gradually ulcerates by the
pressure that is exercised upon it, and the presence of the  bougie prevents  the
ligature injuring the skin.  In performing this  operation there are a few points
that require attention;  thus, care must be taken that the vein  be not transfixed,
but that the pin be pushed underneath it; the  ligature should not be too thin,
and must be applied  tightly over the bougie; several pins, as  many as eight or
ten, should be introduced along  the  course of the same vessel, at distances of
about  three-quarters of an inch from  one another; those highest up should  be
put in first, and they should  be left in for at least a week or ten days, by which
time the obliteration of the vessel will have taken place.
  In addition to the application of the  needles in the  usual way, Mr. Lee  has
recommended the subcutaneous  division of that  portion of the  vein  which is
included between them, after coagulation of  the blood has taken place.  This, I
have found to be  a useful addition to the ordinary treatment,  and to insure the
obliteration of the vessel.
  The points of the  pins may be prevented pressing injuriously upon  the  skin
by putting small  pieces  of adhesive  plaster under them.  The powers of  the
constitution should at the same time be improved, and the activity of the circu-
lation kept up by nourishing diet, tonics, and wine.   Whilst the pins are in, the
patient must not be allowed to move about, and after they have been taken out,
the limb should be bandaged for some  time.  In general no ulceration  takes
place about the pinhole apertures, but occasionally, in debilitated constitutions, a
sore forms, which  requires to be treated on ordinary principles.
                         CHAPTER  XXXV.

                       DISEASES OF  ARTERIES.

                                ARTERITIS.

  The causes of inflammation of arteries or of arteritis are extremely obscure;
in many cases it arises from  constitutional  causes, with  the  nature of which we
are as yet unacquainted.   In the  majority of instances, however, it is distinctly
of traumatic origin, occasioned by the wound, rupture, or ligature of an artery. 
454
DISEASES  OF  ARTERIES.
Fig. 139.
  Arteritis occurs under two distinct forms, as the adhesive or limited, or as the
diffused or erysipeloid.   Adhesive arteritis may either be of an acute or chronic
character, and  may be idiopathic or  traumatic in its  origin.  Diffuse arteritis
invariably arises from injury or ligature of the vessel.                 #
  In the adhesive arteritis, both the coats of  the vessel and the contained blood
undergo important alterations.   In the simplest form, arising, for  instance, from
                       the pressure of a tumor upon an  artery,
       Fig. 138.          the coats  are  thickened  and fused^ toge-
                       ther, as  it were, so as to form  an imper-
                       vious cord;  in the more  acute  forms  of
                       the disease, the  sheath and the external <__
                       coat  become  pulpy  and  vascular,  with  "ft
                       effusion  of plastic matter in and  around
                       them.  The middle coat does not undergo
                       any primary change,  but  after  a  time
                       becomes contracted, thickened, and some-
                       what softened.  The internal coat becomes
                       softened, pulpy, and stained by imbibition
                       of the coloring matter of the blood.   In
                       consequence  of  these  changes  in  the
                       coats, the vessel loses its  elasticity  and
                       becomes  brittle.  After the inflammation
                       has existed  for  a short time,  a  plug  is
                       deposited  in  the diseased  part of  the
                       artery;  this plug assumes  two  distinct
                       forms.   It may  be deposited as a mem-
                       branous layer of decolorised fibrine,  oc-
                       cluding the orifices of collateral branches
                       (Fig.  138);  but most frequently  it  is
                       deposited  in  the form of  a  conical plug,
                       which completely blocks up the vessel  at
                       the part inflamed, below which the calibre
of the artery is  somewhat contracted (Fig. 139).  These plugs
are formed of two distinct materials, the middle  and lower part,
being a mass of a yellowish or reddish color,  composed of inflam-
matory  exudation  matter,  intermingled with fibrine  deposited
upon it  by the  circulating blood,  and adhering firmly to the
contiguous walls  of the vessel.   The  upper portion  of the plug
is of a black color, and  consists of simple  coagulum, deposited
upon and tailing on to the decolorised  mass; it is usually long,
narrow, and stringy, and is  not adherent  to the  sides  of the
vessel.   These plugs may continue permanently to block up the
artery, which gradually contracts upon  them so as to be  eventually converted
into a fibro-cellular cord, or, they may be partly absorbed or channelled through
their centre, or lastly,  they may be entirely  removed by absorption, and  the
calibre of the vessel freely restored.
  In diffuse arteritis, the morbid appearances extend  more  widely, spreading
along the coats of the artery to a considerable extent; there is redness of a deep
claret color, injection, and thickening of the coats, a loss of the physiological
properties of the vessel, with an absence of all plastic exudation.
  The secondary effects of arteritis, are of considerable importance.   The plug,
which renders  the vessel  impervious by obliterating  it, may in some cases give
rise  to gangrene of the parts supplied.  This is especially apt to occur if the
arteritis  be acute, if the  patient be  aged, or if the plug be so  situated as to
occlude some of the principal  anastomosing branches, so that there  may not be
Plastic deposits in aorta.
 Plastic pluga
 occluding the
axillary artery. 
ARTERITIS.
455
 time  or opportunity for  the  collateral circulation to establish itself.   In other
 cases, again, plastic  matter may not only be deposited at the part inflamed, but
 may even be carried lower down than the original seat of disease, and thus accu-
 mulate  in the terminal branches  of the  artery.  The vessel will  thus be ob-
 structed at two points, between which a pervious part will  be included.   This
 double occlusion of the vessel, I believe, renders gangrene of the limb inevitable
 at least in all those cases in which I have seen mortification result from arteritis
 this condition has existed.  This plastic matter poured out at the inflamed point,
 may in some cases be carried on through the terminal branches of the vessel into
 the capillaries, and thus entering  the  general circulation, form buff-colored de-
 posits in various organs, more especially in the  spleen.  In other cases,  again,
 it is  carried into the veins, giving rise  there to phlebitis  and to other similar
 conditions.
    Arctation  or even occlusion of the interior of the  artery, not unfrequently
 occurs as a consequence of inflammation of the vessel.   This usually results from
 chronic arteritis, often excited by the pressure of a tumor or of some  other local
 irritant.  As it  is usually a slow process, there is abundant time for the anasto-
 mosing circulation to be set up, so that the vitality of the limb or part supplied
 by the diseased  vessel, is  preserved.   The artery, that  has  been  so narrowed
 and closed, ultimately becomes converted into  a cellulo-fibrous cord, up to  the
 nearest collateral branch, just as if  it had been occluded by the application of a
 ligature.
   The symptoms of arteritis depend not only on the condition of the vessel itself,
 but on that of the parts which it  supplies.   There is  pain, with  some tension
 and stiffness of the affected limb, with a good deal of tenderness, and a cord-like
 feeling along the inflamed vessel, in which also  a jerking and forcible pulsation
 can be felt.   The pain below the part of the artery that is inflamed, is always of
 a very severe character, and  is distinctly  of  two kinds; superficial,  and deep.
 The superficial is seated in the skin, which is excessively sensitive to  the touch,
 so that the patient cannot bear the finger to be laid upon it, just as is the case in
 neuralgia.   This pain is of a  smarting and pricking  character, and is I believe
 always associated with more or less loss of muscular power.   The deep pain is
 of a burning and  lancinating character, and  not only follows  the course of the
 vessels, but strikes through the limb in different directions.  If the inflamed
 part of the vessel be not completely occluded by the plastic plug deposited in it,
 the pulsation in the arteries of the  limb, below the seat of the disease, may con-
 tinue much as usual;  but in the majority of cases the pulsation ceases in all the
 vessels on the distal side of the inflamed spot, the  limb gradually loses its tem-
 perature, becoming of a dark  or livid color,  and cold ; hut yet the inordinate
 sensibility of the  surface continues.   As the gangrene advances, however, this is
 lost; the parts, at the time that they lose  their  sensibility, assuming the ordi-
 nary characters of dry and  shrivelled, or  mummified  gangrene, until all indica-
 tions of vitality cease.   If, however, the veins be inflamed, as well as the arteries,
 the dark  moist variety of mortification will result.  It is in this way  that some
 of the so-called " spontaneous  gangrenes" are occasioned.   The constitutional
 symptoms, which in  the  local limited adhesive arteritis are in  the first instance
 of an inflammatory kind, speedily sink into the  ataxic form as gangrene comes
 on.  In  the diffuse  arteritis,  the  asthenic fever sets in early,  and speedily
 destroys life.
   The  spontaneous gangrene resulting from arteritis may occur in the upper as
 well  as in  the lower extremities, and  is  not  unfrequently met with  in young
 people; at least in most of the cases in which I have seen it, it has occurred in
 individuals under the age  of thirty.  When  the result of pure  arteritis,  inde-
pendent of any other structural affection of the coats of the vessel, the gangrene
I believe  most commonly occurs in the upper extremity.   Arteritis, however, is 
456
DISEASES  OF  ARTERIES.
by no means necessarily followed by mortification ;  the liability to loss of vitality
depends on the seat of" the  inflammation, being greater when it takes place in
the neighborhood of the large collateral trunks of the limb and when it is of an
acute character, so  that the anastomosing circulation has not time to establish
itself.   It  also occurs more frequently when the arteritis is idiopathic than when
it is traumatic, as then  a larger extent of vessel is plugged, and there is  a greater
tendency to the occlusion of those important collateral  branches by which the
vitality of the limb is ultimately to be preserved.   The clogging  of the terminal
branches by the plastic  matter poured  out at the seat of inflammation and washed
down into  the lower part of the limb, is a powerful cause of gangrene.  Those
arteries, the  inflammation of which most commonly terminates in this way, are
the iliac and the axillary; and it is not uninteresting to observe that the cause
of danger in  this disease is the very condition that gives safety in phlebitis, viz.:
the plugging of the vessels with plastic matter.
   The treatment of arteritis  must be conducted on general  principles.   Leeches
should be applied  to the  part and perhaps blood taken from the arm; calomel
and opium may then be administered, but  as  a general rule  I would prefer the
exhibition  of those salines, such as nitre and the acetate of potassa in large doses,
which we know by experience to possess considerable influence in the solution of
fibrinous deposits.    When gangrene has occurred we must wait for the line of
separation  before amputation is had recourse to, as the disease  must be looked
upon as being of constitutional origin.

                   STRUCTURAL DISEASES OF ARTERIES.
  The arteries are  the seat of various structural lesions which  play an impor-
tant part not only  in giving  rise to ulterior diseases in the vessel itself; but in
disposing to various affections of the  organs which it supplies.   If we look on
an artery as a tube composed of tissues that differ largely in their organization
and structure, we must necessarily consider their diseases  to be  equally varied,
and we shall find  that  whilst the changes which take  place in the external or
cellular coat, in which  the whole  of the vital  or nutritive activity of the vessel
resides, are chiefly of a conservative character, those that have their seat in the
internal and middle coats, have a destructive  tendency.  This important  differ-
ence in the character of the diseases of the coats of the vessel, is dependent on
their relative degrees of vascularity and of vitality.  The diseases of the internal
coat are the most interesting  in a pathological point of view, those  of the external
coat in a practical one.
   The  coats of an  artery are liable to the following changes.  1st. Plastic de-
posit on the lining  membrane.   2dly.  Fatty and  plastic deposit under the lining
membrane.   3dly.  Fatty and granular degeneration, and 4thly.  Calcification.
  The plastic deposits on the free surface are of a fibrino-albuminous character,
occurring  in  the  form of  rounded,  semi-transparent,  and  glistening masses,
usually met  with  in the aorta or larger arteries  around  the  mouths  of their
secondary vessels, or, of aneurismal sacs; and not unfrequently agglomerated on
calcareous  spiculae, where they attain  great tuickness.  They are almosVstruc-
tureless, gelatinous, sometimes rosy-looking, and cut with  a hard  cartilaginous
section.  The plastic deposits on the attached surface of the lining membrane
are opaque, semi-transparent, yellowish-white, elastic, but hard masses, composed
essentially  of plastic matter with some oily globules intermixed.
  The fatty  and granular degenerations of the internal coats are of the most
interesting character, and play an important part  in arterial diseases.  They occur
under the different forms of atheroma and steatoma, and are met with  either in
the arterial coats themselves, or in the plastic deposits which occur upon or un-
derneath them.  These atheromatous deposits occur in very different forms, ac- 
          PLASTIC  AND  FATTY  DEPOSITS  IN  ARTERIES.       457

cording to their age, &c.  Their first appearance  is in the shape of fine white
opaque streaks, situated in the  substance of the lining membrane of the artery.
As such, they are most commonly met  with in the upper part of the arch, and
in the neighborhood of the orifices of the large arterial trunks; especially along
that part of the vessel from which  the intercostals arise.   Here they may be
seen at a very early age.   I have met with them in children of three, five, or
seven years old.  As the disease advances, these streaks aggregate together so as
to form a large, white, and opaque  patch; in this condition the middle coat  is
implicated.  This becomes thinned by the pressure of the patch, and, from being
yellow and elastic, is altered into a gray, semi-transparent, and inelastic membrane,
which often becomes  stained by imbibition with blood, and corresponds to the
steatomatous deposits of Scarpa  and Hodgson.   In the third stage the  patch
softens, becoming converted into a  pultaceous or cheesy mass, and  even  some-
times undergoing complete liquefaction into a yellow creamy fluid, which has
often been mistaken  for  true  pus.   These changes will always be found to be
dependent on the abundant formation  of fat globules and scales  of cholesterine
in it.  These softened atheromatous patches will  be found  to be situated in a
kind of pouch or depression  in  the internal or middle coats of the artery, usually
of a  more or less oval  shape.  At the same time that the changes just described
are going on in the  coats of the vessel, an important alteration is  taking place in
the connexions between the internal and middle coats at the edge of the athero-
matous  patch ; here  they become firmly incorporated together, so that  the' one
cannot be peeled away from  the other, and the diffusion  of the softened atheroma
between the two membranes is  arrested.   So also, when the atheroma is washed
away by the current of the circulation, the infiltration of the blood between the
coats and out of the pouch thus formed in the walls of the artery is prevented.
   The changes just described as taking place in the internal and middle coats
of the vessel are of a destructive character, and tend to lead to its rupture; but
coincident with these, conservative  processes take place in  the external coat.
This becomes thickened,  indurated, and strengthened  by the deposit of plastic
matter, until at last it becomes  the sole support of the vessel,  round  the exterior
of which it forms a thick  and somewhat rugged wall.  It is especially  opposite
the deeper and more eroded atheromatous patches that this  consolidation of the
external  coat takes place, thus preventing the perforation of the artery in  this
situation.
   The nature and  seat of these changes will be  understood by what has been

                                                   Fig. 141.
Early stage of atheroma.
already  stated concerning them.   Atheroma  essentially consists, as was  first
pointed out by Mr. Gulliver, in a fatty and granular disintegration of the arterial
coats; the  transformation into fatty and granular matter taking place both in
Fig. 140.
Fatly deposits in internal coat. 
458                     DISEASES  OF  ARTERIES.
Fip-.142.
Atheroma from old patch.
old plastic  deposits, and in the  internal and middle coats of the vessel.   The
                           fatty matter consists of oil-globules and cholesterine
                           in various proportions,  the  plates of  cholesterine
                           being largest  and most  abundant in  those cases in
                           which the atheroma is the softest (Fig. 142).   This
                           fatty transformation is one to which  the fibrous tis-
                           sues  generally are peculiarly subject, and  to which
                           those that enter into the formation of an artery are
                           especially liable.  All those theories are consequently
                           erroneous which  attribute atheroma to previous in-
                           flammation, to suppuration, or to a deposit sui generis
                           in the artery.   The primary seat  of these changes is
                           the lining membrane of the vessel, in the outer layer
                           of which, corresponding to  Henle's fenestrated coat,
they are first met with, as I have often observed after macerating and dissecting
diseased arteries.
   The  most important consequence of these changes in the structure of the
artery is the effect produced  upon the vital  properties of the vessel;  instead of
being an elastic resilient tube,  reacting on  the contained blood  and serving to
regulate its distribution, it becomes inelastic, and consequently, either gradually
dilates  in its calibre  under the  influence of the outward pressure of the blood
contained within it; or, becoming incapable of aiding in  the  distribution of the
vital fluid, tends to impair the due regulation of the supply to the organs to which
it  leads, and thus may indirectly occasion a diminution or even loss of their
vitality, giving rise to softening, disintegration,  or mortification of their tissues.
   Calcification of the arteries comes next in order of frequency to their fatty
disintegration.   This consists in the deposit in  their coats of a quantity of hard
and gritty earthy and  saline matters,  which, though commonly called osseous,
present none of the true characters of bone,  no trace of  bone-corpuscle or of
vascular canal being ever traceable in them.  Microscopical examination shows
them to consist of an  irregular  crystalline granular mass, without  any evidence
of organization, composed, according to Lassaigne, of 50 parts of animal matter,
                            47 £ of  the  phosphate, and  2  of the carbonate of
                             lime,  in  every 100.    The deposit  aJways  takes
                             place in the first instance in minute sabulous grains
                             or granules,  these after a time  coalesce,  assuming
                             different forms  according to the seat of the deposit
                             and the age of the individual.
                               The  laminar form  of the deposit is the most
                             frequent, and is principally met with in the larger
                             arteries, such as the aorta, the iliac, and the caro-
                             tids.   In this variety calcareous masses and plates
                             of  various sizes, from a grain of sand to a shell-
                             like plate an  inch in width, is met with in  these
                             vessels.   The thickness of the  patch varies from
                             that of silver  paper to  two or three lines across.
                             Their shape is elliptic or  triangular, the largest
                             diameter  being  in  the  direction of  the  axis
                             of  the  vessel.   The edge of the plate is ragged,
                             rough,  and uneven, and the  surface  smooth  and
                             incurvated  towards the cavity  of  the artery; if
                             large, it  is usually fissured or cracked,  and  sur-
                             rounded by much  atheroma.   These patches are
situated in the longitudinal fibrous coat, and  are chiefly deposited where this
structure abounds, as at the arch of  the aorta,  the bifurcation of the iliacs, and
Fig. 143.
 
CALCIFICATION  OF  ARTERIES.
459
 in the carotid arteries.  The inner coat is usually thickened  and opaque where
 it covers the patch, and the middle much thinned and wasted.
    The annular calcification principally occurs  in arteries of the third magni-
 tude, such as the popliteal  and the  femoral.  It commences by the deposit of
 granules of calcareous matter (Fig. 143 a), which are arranged in lines running
 transversely to the axis of the vessel; the lines gradually increase in breadth until
 they  coalesce  laterally, the  intervening spaces being filled up, and the vessel
 being converted  into a rigid  tube (Fig. 143 b).   This  form of  calcification
 occurs in the  transverse  fibres of the  middle coat, and  is accompanied by but
 little  atheromatous matter.
    The tubular calcification appears to be an increased  degree  of  the varieties
 just  described, the arteries being converted into  pipes  or tubes of calcareous
 matter, with the  exception of a few shreds and patches,  and some atheroma  de-
 posited in its coats (Fig. 123).  It is especially the tibials and coronary arteries
 that are liable to  this kind of  transformation.  When  an artery has thus been
 converted into a tube of calcareous matter, masses of pale, opaque, waxy-look-
 ing fibrine are deposited in it, and  may block  it  up more or less  completely.
 These masses not uncommonly undergo subsequent atheromatous degeneration.
    The various forms of fatty and calcareous  transformation of the arterial coats
 that have just been  described, are  constantly found associated  together in the
 vascular system of the same individual, and often indeed in the same vessel.  It
 has been pointed  out by Bizot, that the symmetry of the arrangement of these
 morbid appearances in the  corresponding vessels on opposite  sides of the body
 is remarkably great, the arteries of one limb being often the exact  counterpart
 in this respect to  those of the  other.
    Causes.—The  frequent coexistence  of these various morbid  changes in the
 same portion of the arterial system, point to  their originating from one  common
 cause, under the  influence  of which the  coats of the vessel  may become con-
 verted either into fatty or calcareous matter.  Indeed, it is quite evident, that
 these are " retrograde metamorphoses, " to which all fibrous tissues are especially
 liable under the influence of want of proper nutritive activity in the  part.  And,
 indeed, any circumstance that induces  a depravation of  healthy assimilation  in
 the system generally, will specially tend to occasion a transformation of the tex-
 ture of the more lowly organized tissues into  products still lower in the scale of
 organization.   Under such  influences as these, the  fibrous tissues of which the
 arterial walls are composed,  rapidly undergo disintegration and  conversion into
 fatty, granular, and earthy matters.
   That influence under which  the vital forces of the system are  most commonly
 diminished in activity, is old age; and this diminution may be  looked upon  as
 natural at any period after the organization has reached its full maturity, whether
 this be early or late.  So frequent, and  indeed constant, are these transformations
 of the arterial coats during the decline of life, that they may be considered as
 the natural result of the  diminution of the  nutrient activity consequent upon
 advance in years.   Gmelin has found that there is a progressive  increase in the
 earthy matters  contained  in the  coats of healthy arteries  as  the individual
 advances  in life.   Thus, he has  ascertained  that the  ash of the arteries of a
 newly-born child yield 0-86 phosphate of lime; the healthy arteries of an adult
 1_5; and those of an old man  2-77 of  the same salt; whilst the  ossified arteries
 of an aged man  contain 4-01.  There is no precise period of life  at which these
 changes set in;  age is a relative term, and so soon as the system has passed  its
 full maturity, in whatever year  of life this may happen, there  is a tendency for
 these deposits to take place in considerable quantity.   These  senile transforma-
tions,  therefore, can scarcely be looked upon as pathological changes in many
instances.   But the same  process of degradation of tissue may commence  at
any, even  the earliest periods of life, under  the  influence of causes that impair 
460
DISEASES  OF  ARTERIES.
the vital forces; and it is in this way that phthisis, granular kidneys, chronic
gout, constitutional syphilis, &c, have  a direct tendency to  occasion  these
changes in the arterial coats.  It is a favorite supposition with many pathologists,
that these changes  result directly from inflammatory action ; this certainly does
not appear to be the  case, but it is by  no means improbable that an artery in
which the  inflammatory process has taken place, may thereby have its nutrition
so modified as to become more susceptible to early and extensive  degeneration,
and  that the plastic matters thrown out  as the result of the inflammation will
be especially  liable to  undergo those  changes that ultimately  result in their
conversion into fat  and calcareous matter.
   Some arteries are more liable  to these structural lesions  than others; thus, the
ascending aorta is most subject to  fatty degeneration, whilst the calcareous trans-
formation is most frequently met with in  the arch and abdominal portion of the
vessel.  The  arteries of the  lower extremities, viz., the  femoral,  the popliteal,
and  the tibial, are chiefly affected with calcareous deposits, whilst the fatty are
commonly met with in the vessels of the brain;  and some arteries appear to be
exempt from disease;  thus, Tiedemann states that he has never found the oeso-
phageal ossified.   The  difference  in  the  liability  of different arteries  to disease
is, no doubt, in a great measure to be accounted  for by the different degrees  of
development of the longitudinal  fibrous  coat in  different  parts of the arterial
system; this being, I believe, in most instances the primary seat of the affection.
Thus, in the  aorta, the coronary  arteries, and those of the brain, in which it
abounds, we find these transformations frequent.  The distance of the  tibials
from the centre  of  circulation, and the consequent diminished nutritive activity
of their coats in old people, may account  for the frequency of their degenera-
tions.  Those points of the arteries  likewise  upon  which the shock of the on-
ward wave of blood is most directly received, are more subject to degeneration
than neighboring parts of the continuity of the wall of the vessel.   This is espe-
cially observable at  the origins of the arteries that spring from the arch of the
aorta, and at the bifurcation of the iliacs.  It is also not improbable  that the
increased pressure of the blood upon the coats of arteries that lead to diseased
organs through which  the circulation is obstructed, may tend to their degenera-
tion.  Sex exercises but little general influence on the liability to disease in the
arterial system; though it specially tends to the occurrence of those changes in
certain arteries.   Thus Bizot states that the arteries of the upper extremity are
most frequently diseased in women, and those of the lower in men.
   The structural lesions  that have just  been described produce  certain local
effects, often of considerable importance,  on the parts which the  affected vessels
supply with blood.   For the proper and healthy nutrition  of a limb or part to be
carried on, two great conditions are required so far as its  arteries are concerned.
1st,  that the integrity  of the structure of the walls of the vessels continues per-
fect; and 2dly,  that their channels  remain pervious; for although the arterial
system possesses remarkable conservative power in its arrangement and distribution
that tends to counteract these effects, yet, by slow degrees, a deterioration of func-
tion and disintegration of structure take place in  the part immediately supplied
by the diseased  vessel.   Thus in  the limbs we have all the signs of a defective
circulation,  coldness of the feet, cramps,  and spasms of the muscles.   Whilst  in
organs, softening of tissue, fatty degeneration, and other evidences of the want
of a proper supply of blood leading to impaired  nutrition manifest themselves.
Besides these various changes that take place in the parts to which the diseased
arteries are distributed, ulterior effects are produced upon  the vessels themselves,
which may lead to  important consequences.   These  consist in ulceration of the
coats of the artery;—their spontaneous rupture ;  the contraction or occlusion  of
the interior of the  vessel; and, lastly, its dilatation into some  of the various
forms of aneurism. 
             NARROWING AND  OCCLUSION  OF ARTERIES.        461

    The ulceration  of arteries, though frequently spoken of, in reality  seldom
 occurs.   The  so-called ulceration  being in general an erosion occasioned by a
 patch of softened  atheroma and its  investing membrane having  been  carried
 away by, and  into the current of blood, which then washes the base of  the de-
 pression thus produced in the middle coat, but is prevented extending between
 the coats by the process of fusion and cohesion which takes place in them  around
 the. patch.   This apparent ulcer is deepened by the deposit around  its margin of
 plastic matter, often in large gelatinous-looking masses.   When true ulceration
 of an artery takes place, it is by destructive action from without, and not by any
 of these disintegrating processes commencing within the vessel.
    The spontaneous rupture of an artery is of rare occurrence, and never happens
 without disease of its coats.  Experiments made by Dr. Peacock, which  I have
 repeated, and  the  accuracy of which I can  fully confirm, prove that a healthy
 artery will  sustain  a very great pressure from water injected into it, without its
 walls giving way.  But if these have  been softened or weakened by disease, they
 may be  unable to  resist even  the ordinary impulse of the blood, and if this be
 driven on by any unusual forcible action of the heart, as  under the influence of
 sudden violent strains or exertions, they may give way.   This occurrence would
 be much more frequent than it is  in  atheromatous  and calcareous patches, were
 it not for the conservative consolidation of the external coat of the vessel supply-
 ing that resistance which has been lost by the destruction of the  internal and
 middle tissues.   Hence this rupture is most  frequent in those vessels, the outer
 coat of which  is thinnest; and  in  which consequently it can  least supply the
 place of the others, as in the arteries of the brain and the intrapericardial aorta.
   The contraction  and occlusion of arteries are by no means rare  sequences of
 the structural lesions of these  vessels.   We  have already seen  that these condi-
 tions may arise from inflammation of the coats in any way excited, as  by the
 pressure of tumors; but, besides this, the structural  changes that take place may
 produce narrowing and closure of the vessel in various ways.  Thus the diseased
 patch may project  into the artery  in such a manner that plastic matter and
 coagulum are gradually deposited upon it until the interior  of the vessel is blocked
 up; or the irritation of the morbid products  may give rise to chronic inflamma-
 tion in the coats, occasioning contraction, the effusion of  lymph, and their con-
 sequent occlusion.   In one or other of these ways, arteries  of all magnitudes may
 be  gradually narrowed and at last completely  closed, and yet the patient survive;
 and the parts supplied by the obstructed vessel maintain  their vitality in  conse-
 quence of the collateral circulation being sufficiently active to keep up the supply
 of blood to them.   The vessels that are most frequently blocked up in this way
 are the tibials; next to these perhaps  the carotids; the  other  arteries are but
 rarely so occluded.   Yet  many instances have  been collected by Tiedemann of
 this morbid process affecting most vessels;  but more especially the  iliacs, the
 brachial and axillary arteries, and the different branches of the abdominal aorta.
 Tiedemann records from various sources no less than eight cases in which the
 abdominal  aorta  was completely closed, in  all of which  so full and  efficient a
 collateral circulation had been set  up, that the vitality of the lower part of the
 body was perfectly maintained, and in most the morbid state not suspected durino-
 life.  Besides these cases, he states that there are twelve  instances  on record of
 great narrowing  of the  aorta  at  that  point where  the ductus arteriosus is
 implanted into  it in foetal  life.  These would  appear in  some  way connected
 with the closure of the duct, as  in  every case the  indentation  was greatest on
 the convex part of the aorta, which  had been drawn  in towards the mouth  of the
 duct, as  if  the vital  contractile force  necessary for  the closure  of this had
 extended itself to the aorta, and produced a similar change in it.
  When any of the arterial narrowings, or occlusions, occur in a gradual manner
in  early  life, or inr a part where the collateral circulation  is free, no  ill  effects 
462
ANEURISM.
result;  but in an opposite condition the interference with  the circulation  leads
to the local death of the part supplied by the diseased vessel.   This is particu-
larly the case in the lower limbs of old people, where the circulation is extremely
feeble, both as the effect of age and in consequence of distance from the heart,
and it is in this  way that the true senile gangrene or mummification of the limb
occurs.   The pathology of this affection has already been adverted to, but it may
not be out of place to state here, that whilst some have considered the  gangrene
as entirely the result of arteritis, others look upon it as consequent on the occlu-
sion of  the vessel from disease of its coats, and  each party  has laid  down  prin-
ciples of treatment in accordance with their view of the pathology of the  affec-
tion.   From wnat has preceded, it  would appear that the arteries of a limb may
be occluded, and  that consequently gangrene may result from either condition.
The occlusion from  acute arteritis followed by gangrene, most frequently occurs
in the  upper  extremities  and  in young or middle-aged people, is preceded by
local and constitutional symptoms of inflammation, and, in it, the artery presents
on examination the true inflammatory plug.   The occlusion from calcification and
atheroma chiefly occurs in the lower extremities, and in old people, is  preceded
by a rigid condition of the vessels,  by cold feet, cramp, numbness, and  weakness
of the  legs, and after removal, the arteries will be found  to be converted  into
rigid, unyielding calcareous tubes, with some deposit of atheroma, and with waxy-
looking masses of fibrine filling up their interior.   Besides these two distinct
forms of the disease, there is a third and very common variety, in  which a low
form of inflammation takes place in previously  diseased arteries, and in which
we find a combination of  the two conditions.
  With regard to the treatment of  narrowing, or occlusion of the arteries uncon-
nected  with gangrene, I  have  little or nothing to say, except that  if  there be
reason to suspect such occurrence in a limb, care must be taken to keep the  part
warm by means of appropriate clothing, and if there be much pain, to allay this
with opiates.  If gangrene have come  on, it must be  treated with reference to
its cause; when  connected with  arteritis, it has already been discussed, but when
it occurs from structural  disease of the coats of the vessel, then the treatment
must be directed by the existence,  or not, of any complicating inflammation, in
accordance with those principles that  have been laid down in discussing the
general  management of  gangrene.
                         CHAPTER XXXVI.

                               ANEURISM.

  When the arterial walls  have undergone more or less  fatty degeneration,
whether that consist in the distinct deposit of patches of atheroma, or in a sort of
molecular deposit of fat globules in the tissues comprising their coats, their natural
elasticity  and resiliency become  lost, proportionately  to the amount of fatty
change  that has taken place within them.  Hence as the artery becomes less and
less able to contract on its contents, and to recovemluring the diastole  the tension
exercised on its walls during the systolic  impulse, it gradually becomes distended
by the repetition of the shocks which it sustains, and thus either complete or par-
tial dilatation of its cavity takes place.  I believe that this loss of elasticity and of
power of contracting on its contents, which eventually results in the dilatation of
the vessel, never occurs except as the result of previous disease of the coats.  In 
FUSIFORM AND SACCULATED  ANEURISMS.         463
the very numerous  specimens of dilated arteries that I have examined, I have
never found  one that had not  undergone fatty degeneration, or  atheromatous
deposition.   Calcification, on  the other hand, rather prevents dilatation of the
artery, by hardening the coats  and converting them into rigid inelastic  tubes;
but atheroma softens them,  and causes yielding of that  portion of the vessel
affected by it.  I have frequently observed that the whole of the artery may be
healthy except at one part, where there was an atheromatous patch, and that there
the vessel was dilated, or that the whole of its  coats might be calcified except at
one spot, where atheroma was deposited, and where consequently the coats  had
yielded under the  outward  pressure of the  contained blood.  This general or
localized dilatation of the arteries is termed aneurism, an affection that  is, I
believe, invariably  dependent upon the coats  having been  softened, atrophied,
and disintegrated by fatty degeneration, and consequently  yielding to the eccen-
tric pressure  of the contained blood.
   Aneurism  is universally recognised  by surgeons as being of  several distinct
kinds;  these I think arrange themselves under the heads of the fusiform, the
sacculated, and the dissecting.
   The fusiform or tubular  aneurism is a preternatural dilatation of an artery,
all the coats of which are equally expanded through the whole circumference of
the vessel.   It most frequently occurs in the aorta, but may, though rarely, be
met with elsewhere. These fusiform aneurisms are not mere dilatations of the  ves-
sel, but there is elongation, thickening, and degeneration of its walls as well.  The
elongation of the artery in  these  fusiform  aneurisms is as marked as its dilata-
tion, and is always  very  considerable.   Thus, the arch of the aorta may attain a
length of several inches, with a considerable space between the origins of the
carotids, the  innominata and the subclavian, at the same time that its walls are
greatly thickened,  nodulated, and rugged.   Sometimes several of these tubular
or fusiform aneurisms are met with in the same vessel with healthy  portions of
the  artery between  them.    From these dilatations sacculated aneurisms  not
uncommonly spring.  On examining the structure of a fusiform aneurism, it will
be found that it is always composed of a uniform expansion of all the coats of the
artery, which are at the same  time  somewhat altered in  character.  Thus, the
outer coat is  thickened, the middle rigid and inelastic, and the inner one stiffened,
rugged,  and  tubercukted, by the deposition beneath it of various  plastic  and
atheromatous masses.   No coagula, however, are found in these dilatations, but
a few  filamentary shreds of  fibrine are occasionally seen to be attached to their
inner wall.   The arteries that are usually the seats of these peculiar  changes are
the arch of the aorta, the iliacs, and  the femorals; this particular form of aneur-
ism never occurring in any vessels  in which  the yellow elastic coat is not largely
developed, and hence not being met with in  arteries below the femorals in point
 of size.
   These fusiform  dilatations, especially when seated in the arch of the aorta,
 may attain a very considerable  magnitude,  and may consequently exercise very
 injurious pressure  on  contiguous  parts;  thus  producing great distress  and
 danger of life to  the patient.  They are usually extremely  chronic, increasing
 but very slowly, and being compatible with existence for many years, but at last
 they usually  destroy the patient, and they may occasion  death in several ways.
 Thus, if situated  in the aorta, the  great mass of blood in the  sac may, by im-
 peding the circulation, overpower the  heart's  action, so that it may be unable
 to recover itself,  and a fatal syncope  be  induced.  Then, again,  death  may
 result by their pressure on  important points, as on the bronchi or  oesophagus;
 this, however, rarely occurs,  unless it be that a sacculated  aneurism, springing
from the fusiform one, has given way.   Though,  when the tubular  aneurism of
the arch of the aorta occupies  the intrapericardial portion  of the vessel, it not
unfrequently happens that, owing to  the absence of an external coat  in this situ- 
464                             ANEURISM.
ation, the artery may rupture at this  point.   It most  commonly happens, how.
ever, that a fusiform aneurism remains  in  a quiescent state, being a source of
discomfort, but not of death,  to  the patient, until  the sacculated  form of the
disease spring from its side, and  that  this becoming the more formidable affec-
tion, may destroy life in some of the ways peculiar to it.
   Sacculated aneurism.—By the sacculated aneurism is meant a  tumor that
springs from the side of an artery or of  a tubular aneurism, with the interior of
which it communicates by a narrow aperture, called  the  mouth  of the sac.  It
is generally divided  into  the  true  and false varieties.   By the  true sacculated
aneurism is meant a partial dilatation of all the coats of the  vessel; by the false
sacculated  aneurism the  dilatation  of one,  or  at most of two,  coats with the
rupture of the others.
  The existence of true  sacculated aneurisms has been denied; thus, Scarpa
doubts the occurrence  of such a disease, and Bizot seems  disposed  to coincide
with him.   With these  eminent  pathologists, however, I cannot  agree, and
though I am willing to admit that many of the so-called true aneurisms are not
so in reality, yet I cannot doubt from repeated observation that Hodgson is right
in saying that in their early stages aneurisms  are  not  unfrequently of the true
kind.  Thus, we occasionally  meet,  as Dr. Peacock  has pointed out,  with small
digital pouches springing from the walls of some of the larger arteries, through
the whole of which the external, middle, and internal coats can be demonstrated
by maceration to exist; and in those  aneurisms which are  formed by the dila-
tation of a comparatively large portion of the arterial  wall, it not unfrequently
happens  that the tumor remains of the true kind for some  time, as I have had
occasion more than once to ascertain by careful dissection.   But after an aneurism
has attained a certain  size, its coats become so fused  together, and so closely
incorporated with the neighboring tissues, that their precise structure  cannot be
made out.   Indeed,  for a sacculated aneurism to be of the true kind, I believe
that two conditions are necessary: 1st. That the tumor itself be small;  and,
2dly.  That the mouth of the sac be of tolerably large dimensions.   Porter says,
that he  has never met with  a  true aneurism larger than a small orange, and,
certainly, none of those that I have seen,  provided  they were of the sacculated
kind, have exceeded this size.   In  true sacculated  aneurisms, also, it is neces-
sary that the mouth of the sac, or that portion of it which communicates with
the interior of the artery, should be of a good size, and not bear too great a dis-
proportion  to the wall of the tumor.   I cannot conceive a large sac with a small
mouth to be a true aneurism, for, as the mouth  of the sac  corresponds exactly
in size to that portion of the arterial coats which have been  originally dilated, it
is not easy to understand how a large sac can be expanded out of a small segment
of the wall of the artery;  though, as in  all cases of true aneurism, however
small they may be, the size of the  sac  greatly exceeds that of its mouth, it is
clear that there must have been, not only expansion, but a degree of hypertrophy
and overgrowth of the wall of the vessel, just as in the  tubular aneurisms.
  By false  sacculated aneurism is  meant  that variety  of the disease  in which
the internal, or the internal  and middle coats, have  been ruptured, and are
consequently deficient.   These are by far the most frequent forms of  sacculated
aneurism, and are those which  are  met with of so great a  size.   In by far the
majority  of these cases, the internal  coat and the innermost layers of the middle
coat have  been  destroyed by atheromatous  degeneration, leaving  an erosion or
depression  in the interior of the artery, with weakness  of the corresponding por-
tion of its wall, which becomes expanded by the outward pressure of  the bloc*
In these  cases the sac  is principally formed by the expansion of  the  outer coat,
to which some of the layers of the  middle may still  be adherent; but which is
essentially strengthened and thickened by plastic deposits, and by adhesions to
neighboring parts, which have fused into its composition.  In these cases there 
DISSECTING ANEURISM.
465
 is outgrowth, hypertrophy, and new deposit in and upon the external  coat, as is
 evidenced by its  actually becoming thicker, instead of its  being thinned, as it
 would be were it  only expanded.   The formation of an aneurism  by the herniary
 protrusion of the  internal and middle  coats through an ulcerated  aperture in the
 external coat, has been  described, but though  there  is a preparation in  the
 Museum of  the College of Surgeons, that is supposed  to  illustrate this fact, I
 doubt the existence of such a form of the  disease; and after careful examination
 think that the preparation in question looks rather  like an artificial  dissection
 than a true rupture of this dense and  elastic coat.
   A false aneurism may always be readily distinguished from a true one, by the
 greater  magnitude that it attains, by the size of the sac being out of all propor-
 tion to that  of its mouth, and  on a section of this  being  made, by the middle
 coat being seen to terminate abruptly in a thick and dense ring immediately
 around  the  mouth and  neck of the  sac.    A false  aneurism may either  be so
 from  the very first,  the  internal  and middle coats having been destroyed by
 softening and  erosion, and the externa] expanded and hypertrophied into a
 sac; or it may originally have been a true aneurism, some of the  coats of which
 having given way, the conversion into the false variety of the disease  has  taken
 place.
   Surgeons generally recognise two varieties of false aneurism, the circumscribed
 and the  diffused.   By the circumscribed false aneurism, is meant that form of
 the  disease in which the blood is still  contained within a sac, formed by at least
 one of the arterial coats, however expanded and altered in its structure this may
 be.   The  diffused form  of false  aneurism includes two  distinct varieties of
 the  disease.   In  one  case there is rupture of the  sac, and general  and wide-
 spread extravasation of blood into the  cellular tissue of the limb or part.  In the
 other case it  happens that the sac formed  by the  dilatation  and  hypertrophy of
 the  outer coat of the artery is ruptured, and the blood, although  effused beyond
 this, is still confined in a sac of condensed cellular tissue, formed  by the matting
 together with coagulum and lymph of the  structures  into which the  blood has
 been effused.
   The dissecting aneurism is a  remarkable form of  the disease,  originally
 described by Mr. Shackleton, in which the sac  is situated in the wall of the
 artery between its coats.   It originates in  consequence of  the internal coat of
 the vessel becoming eroded, and giving way before any of that adhesion and
 matting together of the tissues around the patch has taken place, which usually
 occurs in this disease; and which  prevents the blood being forced between the
 different tunics of the  artery.   The rupture, although originating  in the internal
 coat, always  extends between  the  layers  of the  middle one, splitting this up
 into two laminae, and in some cases it also diffuses  itself  between the middle
 and  external  tunics of the vessel.   On examining the  artery in  a case of dis-
 secting aneurism, its coats will always  be found  to be easily separable from one
 another, and  to be very lacerable, often appearing soft and  sodden as  if mace-
 rated.   For the production of this  disease, indeed, two conditions  are necessary.
 1st.  That there  be atheromatous disease of the  artery, destroying a portion of
 the  internal  and  innermost layers of the middle coat;  and,  2dly. That there
 be not only a want of plastic  matter effused  about the diseased part of  the
 vessel,  but also a general softening of the tissue  of the middle coat;  with
 want of cohesion  between the different tunics  of the artery;  this indeed
 may  be considered as  the essential point  that  disposes  to  the formation  of a
 dissecting aneurism; and that causes the disease to assume this, rather  than the
 sacculated form.
  The  rupture constituting dissecting aneurism always takes place  longitudinally
along the middle  coat, and  may often extend to  a very considerable distance.
Thus it may reach from the arch of the aorta to the  iliacs, or from the  same
                                     30 
466
ANEURISM.
part to the bifurcation of the carotids.   The disease only occurs, however, in
the aorta, and in its principal branches;  in those arteries indeed in which the
middle coat is highly developed, and the yellow elastic tissue abundant.
  These  dissecting aneurisms arrange themselves  into  three  distinct classes.
First, those in which the blood, after  having passed for a  distance of several
inches, or even  more, though the substance of the  middle coat bursts through
the external coat, and becomes effused into the cellular tissue outside the vessel,
and around the seat of  rupture, or into the neighboring  cavities.   In these
cases, which constitute the most  common variety of the disease, death usually
rapidly occurs, the  patient feeling intense pain along the line of rupture, and
falling into a state of syncope.   In the next class of cases, the  external coat
has become so thickened and strengthened by the deposit of plastic matter, that
it  resists  the impulse  of the  blood,  which  consequently   continues  to  pass
between the layers  of the middle  coat,  until it meets  a softened  and atheroma-
tous patch, and then again bursts  into the canal of the artery.  In  this class of
cases the patient may live for years after the occurrence of the rupture, the new
channel that the blood has taken becoming lined  with  a dense smooth  mem-
brane,  and resembling closely the interior of the artery, from which, however,
it  is separated by  a kind of septum or mediastinum.   The appearances pre-
sented by the vessel in this form of the disease have occasionally been  erro-
neously described as constituting a double aorta.  In the  third  class of cases
the blood finds its way between the laminae of the middle coat, but does not
escape again by rupture of the external, or by the  giving way of the lining
membrane of the vessel.   A sac is consequently formed in the substance of the
middle  coat, which may become chronic, but will at  last give way by external
rupture.
  The progression  of changes leading to the formation of an aneurism is, con-
sequently, briefly as follows :—The coats of the artery undergo fatty degenera-
tion, and atheroma  is deposited  at one part; this softens, and the lining  mem-
brane  covering  it,  with perhaps  a  portion  of the  inner layers  of the middle
coat, becomes eroded; or the walls of the vessel may be weakened at this point
without any destruction of their coats.   Cohesion, however,  takes place between
the  tissues  of the vessel  at the  eroded or weakened  spot;  and the outer coat
becomes strengthened and thickened by the deposit of plastic  matter. Dilata-
tion next takes place at this point;  if  of the  entire coats, a true aneurism is
formed; if of the  eroded tunics, a false aneurism occurs:  but if no cohesion
have previously taken place between the different coats of the vessel,  the blood
becomes effused into and between them, thus constituting a  dissecting aneurism.
   Structure of an  Aneurism.—An aneurismal  sac,  if  it  be  composed  of a
dilatation of all the coats of an artery, may be recognised on  dissection by the
atheromatous and calcareous deposits which are met with in the tissues of which
it is composed.   If it be a false aneurism, it will be found that there is little, if
any, of those  deposits in the walls of the sac, that the  middle coat usually
terminates abruptly at its mouth,  and that the external coat is greatly thickened
and strengthed by  the deposition of plastic matters.   Aneurismal sacs may vary
in  size from tumors not  larger than  a cherry,  to growths  the magnitude of a
cocoa-nut or large melon.  The mouth, which is oval  or  round in shape, varies
greatly in  size, being  always very small  in  proportion  to that of  the  sac.
Usually the interior of  an  aneurismal sac contains  a quantity of decolorised
fibrine, arranged in concentric laminae of but moderate thickness; these laminae
of  fibrine are of a  pale-buff color, dry and somewhat brittle  where they are most
closely applied to the wall of the  sac; the more  external  ones appear to be those
that are  first formed, and occasionally are found to have undergone  a kind of
atheromatous  degeneration;  as we approach  the  interior of the vessel, they
become  softer and more  colored;  and, at last, in  the  central  portions dark 
LAMINATED FIBRINE — PRESSURE-EFFECTS.         467
 masses  of coagulum are often met with.   This decolorised  fibrine appears to
 proceed from twq sources; it is partly deposited from the blood which is beaten
 up in the  interior of the sac, and thus deposits its fibrine much in the same
 way as when it is whipped in an  ordinary vessel;  this is probably the  manner
 in which the principal masses are deposited.  In some cases,  however, it would
 appear as if it were formed by  deposition from  the wall of the  aneurism ; for
 the mass not being  out of the current of the circulation,  cannot well have been
 deposited from the blood, but must in all probability have been the result of the
 effusion of plastic matter from the wall of the sac; under these  circumstances
 there is little or any of that stratified arrangement that is so  observable  in  the
 fibrine that is deposited from the blood.   The black coagulum that is occasion-
 ally met with in the middle of aneurisms differs in every way from  the laminated
 fibrine just described, and is evidently the result of  simple  coagulation.   The
 use of the  deposited fibrine appears to be in a great measure  to strengthen  the
 walls of  the  sac, and thus to prevent the too rapid increase of the tumor
 Another great purpose that it serves is to lessen  the capacity of the sac  and
 thus to dimmish  the distending force  of the blood which is injected at 'each
 stroke of the heart;  the outward pressure depending as much on the area of the
 sac as on  the force with which  the blood  is driven  into it.   Then, again  the
 lining of the walls  of the  sac with such a tough and  elastic  material as'  the
 stratified fibrine, must greatly tend to deaden and break  the force of the shock
 of the  wave of blood that is  projected against what would otherwise  be an
 unprotected and expanded membrane.  In those cases in which the laminated
 fibrine is small in quantity or altogether deficient, the aneurismal tumor rapidly in-
 creases, with a forcible pulsation that is not met with under other circumstances.
   As the sac of an aneurism enlarges it exercises  injurious and often fatal effects
 by its pressure upon contiguous parts.  These pressure-effects deserve attentive
 consideration and  study, as they constitute an important,
 and,  in some instances,  the sole element in the  diagnosis         Fig. 144.
 of the  existence  of this disease.   The  compression  ex-
 ercised upon  the veins  not unfrequently gives  rise to
 narrowing,  or even complete  obliteration,  of the largest
 of these; thus occasioning oedema of the parts from which
 they  take  their origin, a varicose  and greatly enlarged
 condition of the subcutaneous veins, and  in some cases
 even gangrene of the limb.   The pressure of  the sac,
 also,  on  neighboring arteries, or even on the upper part
 of the very vessel from  which it springs, and its inter-
 ference with the general capillary circulation of a part, is
 commonly associated with  the venous compression, and
 may considerably  increase  the  ill-consequences  resulting
 from  it.   By its  pressure  upon  neighboring nerves,  an
 aneurismal sac may give rise either to great pain in, or to
 disturbance of function  of the parts supplied by them;
 the nerves themselves becoming, in some cases, expanded
 or flattened out, and ribbon-like (Fig. 144), and  in other
 instances, rendered tortuous, waving, and being consider-
 ably elongated.  This pain in the nerves is often one of
 the earliest signs  of the  existence of an aneurism.   On
 the bones, an aneurism may  produce very important effects
 by its pressure, eroding or wasting away the osseous tissue
 in some instances,  and in others giving rise to true caries.
 If the bone be a flat one, as the sternum, the  aneurism
 may perforate it by making as smooth and round a hole in it as if this had been
worked by the trephine.    Organs  and  their  ducts  in   the  neighborhood  of
  Flattening of posterior
tibial nerve uy pressure of
an aneurism of the calf. 
468
A N E U 111 S M.
aneurisms suffer  the  most injurious effects from the  pressure of these tumors,
their  functions being arrested, and the passage of their secretions interfered
with; «o, also, by the pressure exercised on the trachea and oesophagus, respira-
tion and deglutition may be seriously impeded.
  Aneurisms, though usually single, are not very unfrequently multiple._ _ There
may be more than one tumor of this kind in the same limb; thus, the  iliac and
femoral arteries on the same side may both  be affected.   In other cases, corre-
sponding  arteries in  opposite  limbs are the  seat of aneurism, thus,  the two
popliteals  are not unfrequently found  to be the seat of this disease, and occa-
sionally an aneurism  may occur  in one of the limbs, and others in the arteries
of the interior of the body.  When more than one aneurismal  tumor occurs in
the same individual, the patient  is said to be laboring under the " aneurismal
diathesis."   Numerous  aneurismal tumors  are  at times  met with in the same
person.  Thus, Pelletan records  a case in  which no less than sixty-five were
thus observed.
  The  duration  of an aneurism varies very greatly.   In  young full-blooded
persons it often makes  progress with great rapidity,  whereas, in elderly people,
of feeble constitutions, or in those of a cachectic habit of body, accompanied with
more  or less debility of the heart's action, the disease may assume a very chronic
form.   Thus, Hodgson  relates the case of an aneurism of the femoral artery, of
twenty years' duration.  Much  also will depend on the situation of the aneurism,
the size of the mouth of the sac, and the relation of the sac to the impulse  of the
blood  into it.  The larger  and more direct the mouth of the tumor, the more
readily will the blood be projected into it at each impulse of the heart,  and the
more  quickly will the tumor expand.
   The symptoms of an aneurism are of two kinds : those that are peculiar  to this
disease, and those that are simply dependent on the presence of the tumor occa-
sioned'by the enlarged sac.   The peculiar or pathognomonic signs are those that
are dependent on the communication of the sac with the artery.   They consist
of signs afforded by the manual and  auscultatory  examination of  the tumor.
Those that are dependent on the  mere size of-the growth, are  the pressure-effects.
It is of course only in external  aneurisms that those signs that are ascertainable
on  manual  examination  of the tumor can  usually be recognised.  In internal
aneurisms, in the majority of cases, the auscultatory signs  and the pressure-
effects  afford the best  indications of the  presence and nature of the tumor;
though, when this approaches  the surface, much information can be gained by
palpation.
   Symptoms of an external circumscribed aneurism.—The tumor is usually
round or oval, distinctly circumscribed, and is  situated upon, and in close con-
nexion with some large artery.   It is  at first somewhat compressible, but after-
wards becomes  more and more  solid, as fibrine is  deposited  in  it.  The most
marked sign is perhaps the pulsation that is felt in it from the very first.   This
is of a distensile, eccentric, and expanding character, separating the hands when
laid upon either  side of the tumor, by a distinct impulse from within outwards.
This pulsation is more forcible  in those aneurisms in which there is but little
laminated fibrine, and  as this increases in quantity  it gradually loses  its hard
expanding character, being converted into a dead thud, and in some cases ceasing
entirely.   When obscure, the  compression of the artery below the sac will cause
it to  become more distinct, or it  may be increased in force by elevating the limb
 or part affected.  AVhen the  artery above  the sac  is compressed,  the flow of
blood into the tumor is  necessarily arrested, and a considerable quantity of its
 more  fluid contents may be squeezed out by gentle pressure.  If the hands are
 then laid upon either side of the tumor, and the pressure suddenly taken off the
 artery, the blood will be found  to rush into and distend the  sac by a sudden
 stroke, separating the hands from one another.   This sign may be looked upon
 as one of the most characteristic of aneurism. 
SYMPTOMS OF INTERNAL  ANEURISM.             469
  The bruit, or sound emitted by the blood in its passage through an aneurismal
sac, is a sign that was first noticed by Ambrose Pare.   These sounds are of very
various characters, being usually  of a  loud  rasping or  sawing nature ^loudest
and roughest in the tubular aneurisms.  In many cases they are altogether absent;
this especially happens in sacculated  aneurisms with small mouths, or in  those
that are  much distended with coagula and blood.  The absence of any sound,
therefore, in a  tumor must not be taken as an indication of its not being an
aneurism.  The sounds are usually best heard  in those tumors that are not too
fully distended with blood;  indeed they are usually most distinct when the sac
is  partially emptied  of its contents.   Thus, for  instance, it  not unfrequently
happens that  in an aneurism of the ham or thigh no bruit, or but a very faint
one, is perceptible so long as the patient is standing up; but if he lie down, and
elevate the limb so  as  to  empty the sac, then it is  very  distinctly audible.
Another sign of considerable importance consists in the diminution in the size of
the tumor, and the cessation of the  pulsation of the bruit in  it, that occurs on
compressing the vessel leading to the sac, and the immediate and sudden return
of these signs on removing the pressure from the artery.  All  the symptoms
that have just been described are peculiar to and characteristic of aneurism,
being dependent  on  the  communication  that exists between the artery and  the
sac.   Those that  result from the pressure  of the sac upon neighboring parts are
common  to aneurism and  to any other kind  of tumor; but though not  of so
special a  character as  those that have just been described, they are of consider-
able importance in determining the nature of the disease, when taken in conjunc-
tion with the  other symptoms.
   One of the most common pressure effects of aneurism is the occurrence of
oedema of the  limb or part, owing to the  compression  exercised by the tumor
upon  the large and deep  venous trunks in its vicinity.   The consequent obstruc-
tion to the venous circulation in the  interior of the limb may also give rise to a
distended or varicose  condition of  the subcutaneous vessels, and in some instances
it  may even go on to the production  of gangrene.
   The compression exercised  by the tumor on neighboring nerves and tissues
may,  in many cases, be the cause of extreme suffering to the patient.  The pain
is  usually of two kinds, either lancinating and  radiating along the course of the
nerve that is  compressed, or, when the tumor presses severely upon neighboring
parts  and tissues, more especially if it give rise to erosion of the bones, as in
Fig. 145, an  aching,  burning, tearing, or boring sensation is often experienced
in the part subjected to  the
pressure.    In other cases
again important modifications
in the function of parts take
place, in  consequence of  the
pressure  that  is exercised
upon  their nerves.   Thus,
for instance, the compression
of  the  recurrent laryngeal
will  occasion  hoarseness of
voice  and difficulty of breath-
ing, depending on spasm of
the glottis.    Besides these
more  immediate effects, vari-
ous   remarkable  symptoms
may be produced by the pres-
sure of aneurisms on  different organs or mucous canals  in their vicinity, and by
the consequent interference with  the function of these  parts.
   Symptoms of a Diffused Aneurism.—AVhen an aneurism becomes diffused, the
 
470
ANEURISM.
sac having given way, but the blood being still bounded by the tissues of the
limb, the patient experiences a sudden  and acute  pain in  the  part, and usually
becomes pale, cold, and faint.   On examination it will be found that the tumor
has suddenly and greatly increased in  size at the same time that it  has  lost its
circumscribed  and distinct  outline.   The limb  may also become cedematous,
or will suffer in other ways from the diffused effects of  the pressure of the aneu-
rismal swelling upon  the neighboring veins and tissues.  At the same time, the
circulation in it  being greatly obstructed, the  limb may become cold and livid,
and a sensation of weight and general inutility will be experienced in it.   Under
these circumstances the aneurismal  swelling usually becomes harder, in conse-
quence of the coagulation of the blood in the cellular  tissue around  the sac, by
which indeed the farther extension of  the disease is arrested, and  a fresh boun-
dary is often formed, so as  to  limit the  extravasated blood.  If it be left to
itself, the tumor will  now usually rapidly increase in size,  with much pulsation,
and perhaps  evidence of inflammatory action around it, so  that at  last it may so
choke and obstruct the circulation through the limb as to  occasion gangrene of
it; or, if it advance towards the surface, external rupture of the sac will speedily
ensue.
   In other  cases, again, it happens that when rupture of the sac takes place,
the effused blood, instead of being limited by the  surrounding cellular  tissue,
becomes suddenly  and widely  extravasated  into the substance  of the limb.
When this untoward  accident occurs, the shock and local disturbance are  very
great and the patient is suddenly seized with a very severe lancinating and numb-
ing pain in the part.   This pain is most severe in those cases in which the  rup-
ture occurs under the deep fasciae, by which the effused blood is  tightly bound
down ; and may be so severe as  to occasion syncope.   In  other instances again,
faintness occurs from the sudden loss of blood out of the current of the circula-
tion into the substance  of the  part; the swelling being  greatest in those instances
in which the blood is suddenly and largely effused into the  cellular  tissue.  If
the extravasation happen in  a  limb,  this  will become greatly  swollen, hard,
brawny, and  cold.  The superficial veins are  congested, and the  circulation in
the lower parts of the member is speedily completely arrested by the  pressure of
the extravasated  and semi-coagulated blood upon its vessels, more particularly
the larger venous trunks.   In  consequence of this, gangrene of a moist kind
usually makes  its appearance, and speedily destroys the patient's life.
   Suppuration with  sloughing of an aneurismal sac, is not of very frequent oc-
currence, but is especially apt to happen in those  cases in which the  disease has
increased rapidly, with  much heat and tension of neighboring parts.  It is pecu-
liarly likely to happen in tumors of a large size that have become partly diffused,
that are filled with masses of decolorized fibrine, and that are situated in places
where the cellular tissue is loose and  lax, as in the axilla.  The symptoms of
this condition impending, are swelling, tension with heat, throbbing, and redness
of the parts around the tumor, the integuments covering which pit on pressure,
and are evidently deeply inflamed, at the same time that there is a good deal of
fever and general  constitutional irritation.  As the suppuration advances, the
ordinary signs  of congestive abscess occur; the skin covering the tumor becomes
red and livid at one part, where pointing takes place ;  and if the surgeon make
an  incision into it, or if the tumor burst, as assuredly it will if left to itself, a
quantity of sanious pus mixed with  large masses of broken down coagula and
fibrine will be  let out.   The  discharge of the contents of the aneurismal sac
disintegrated by, and mixed up with the  results of suppurative  action, may be
followed by so profuse a gush of arterial blood that the patient is suddenly ex-
hausted.  Most commonly, however, no immediate arterial  hemorrhage occurs,
but  in the course of  a  few hours or days, as the  deeper coagula  are loosened,
this sets in, and recurring from time to time  speedily carries off the patient. 
         SUPPURATION OF SAC  AND  SPONTANEOUS  CURE.      471

In some extremely rare cases it has happened that the inflammation thus set up
occludes  that portion of the artery that communicates with the aneurismal sac,
and that  thus a spontaneous cure  results  by its obstruction, and  by the adhesive
inflammation of the vessel.
  The occurrence of a spontaneous cure in an aneurism is a matter of very rare
occurrence.   The manner in which it  happens has  been especially and  ably
studied by Mr. Hodgson, and more recently by Dr. Bellingham, and the  patho-
logy of this process is of considerable interest from its bearing upon the cure of
the disease by surgical operation.   The spontaneous cure  of an aneurism, as has
already been stated, may accidentally, though  very rarely, occur by the  inflam-
mation of the tumor  and consequent obliteration of the artery;  but this is not
the way in which it has  most frequently  been found to happen.   It is  by the
gradual deposition of laminated fibrine in the interior of  the sac that it  is filled
up  completely.  This process can  only occur in  arteries  of the second or third
magnitude, and never in  aneurisms of the  aorta, and can  only happen in the
sacculated aneurisms, the fusiform  not admitting of it; it being necessary that
the blood flowing through the sac be somewhat retarded  in its passage, so as to
give time for the deposit of its fibrine upon the interior of the tumor. This pro-
cess, which is a very  different one to the coagulation of the blood, is an  increase
of a natural condition always going on in the sac.  In  all cases of sacculated
aneurism, there is  a  tendency to the production of a spontaneous cure, though
this is so rarely accomplished.  The tendency to it takes place by a contraction
and partial occlusion of the artery below the sac,  and the  consequent diminished
force of  the circulation through  it, by which  the deposition of fibrine is greatly
increased, at the same time that the collateral vessels given off  above  the sac
often enlarge to a considerable extent, and  thus  divert blood away from it that
would otherwise have passed through it.  This condition  of the vessel below the
sac, may be looked upon  as the first and most important step towards the conso-
lidation of the tumor.   This process is  also materially assisted by the mouth of
the  sac  being small, and so situated that the blood  cannot  be directly driven
into it.
   For the spontaneous cure to take place, it is however  necessary that the cur-
rent of blood should continue to circulate through  the sac..  If it  be suddenly
arrested, coagulation of the blood which happens to  be in the  sac, may take
place in its interior, which  thus becomes filled with a large  dark soft clot of
blood; but the essential element in the consolidation of  the tumor, the deposi-
tion of stratified fibrine,  does  not take place in this way; the sudden formation
of the dark  coagulum, which acts as  a foreign body, is indeed apt to induce
suppuration and sloughing of the sac and neighboring tissues, hence it is rather
prejudicial than otherwise.   But though the blood continue to circulate through
the sac,  the deposit of fibrine will  not take place unless the impetus with which
that fluid is sent into and through the tumor is  considerably diminished.   This
may happen from some or other of those conditions occurring in the distal portion
of the artery or the mouth of the sac that have already been described.   So also
it has been found  that in those  cases in which two aneurisms are situated upon
one artery, the second or distal one is very apt  to undergo partial or even complete
consolidation, the blood  losing its impetus in its passage through the first sac.
Any constitutional cause or condition also, by which the  impulse of the heart is
lessened and the force of the flow of blood through the  sac diminished, as the
occurrence of  phthisis for  instance, will favor greatly the deposit of laminated
fibrine, and the consolidation of the tumor.
   As  the  aneurism  undergoes  spontaneous cure, the pulsation  in  it gradually
becomes more and  more feeble, until it ceases entirely, the bruit proportionately
lessens the tumor becomes harder, and at last completely consolidated.    At the
same time the anastomosing circulation is sometimes found to be  established in 
472
ANEURISM.
some of the  collateral vessels of  the  limb.   Eventually the  solidified tumor
shrinks in size, undergoing a species  of drying and absorption, with ultimate
conversion into a small mass of fibro-cellular tissue.
   An  aneurism may prove fatal in various ways.  It does so when internal,
most frequently by the pressure that it  exercises on parts of importance in its
vicinity, the  patient being destroyed by the exhaustion induced by interference
with their functions;  this is  usually the way in  which aneurisms of the aorta
occasion death.   Then again, death may result by the occurrence of syncope,
more especially if the aneurism be of large size, and situated near the root of the
aorta.   External  aneurisms most commonly prove fatal  by rupture of the  sac;
this  may either take place into the interior of a limb, giving rise to one or other
of the diffused forms of aneurism, that have just been described, and terminate
fatally by the induction  of syncope or gangrene; or they may kill  by rupture
occurring on  one  of the surfaces  of  the body.   AVhen an aneurism is  about to
burst upon the surface, the skin covering it becomes inflamed;  at the most pro-
minent  point  a slough forms, by a process  somewhat analogous to that  of the
pointing of an abscess; as this loosens and separates, trickling of blood occurs,
an occasional gush takes place, usually after coughing, or  any exertion, and the
patient  is exhausted by these repeated hemorrhages.   In other cases again, a
sudden and forcible gush  is immediately fatal on the loosening of the slough.
On the mucous surfaces,  as of the  oesophagus or trachea, rupture occurs in a
similar manner (Fig. 146).  On the serous surfaces, as into  the pleura and peri-
cardium, the aneurism may burst by a fissure or stellate opening (Fig. 147) form-
Fig. 146.                          Fig. 147.
Aperture in cesophagus produced by        Stellate rupture ot an aortic aneurism
  pressure of an aortic aneurism.                 into pericardium.
 ing  in  this membrane.  The rupture of an aneurism is not always immediately
 fatal, the aperture  in  the sac being plugged up by a mass of coagulum, as hap-
 pened in case Fig.  146, which may not be loosened for some time, and through
 which the  bleeding recurs in small quantities at intervals.   An aneurism  has
 been known to give  way and discharge blood for some  weeks before it proved
 fatal, and it may even happen that after the rupture has occurred, no hemorrhage
 may take place, but death result from the pressure  of the tumor.  Thus, in  the
 case of the late Mr. Liston,  the sac of the  aneurism which caused the death of
 that great surgeon,  had actually given way, a mass  of coagulum projecting from
 it into the trachea, but yet death resulted by the irritation induced from pressure
 upon the inferior laryngeal nerve,  and not by  hemorrhage.
  The  diagnosis of aneurism may in many cases  be effected with the greatest
possible ease; in other  instances, again, it requires a vast amount of care to come 
DIAGNOSIS OF ANEURISM.
473
to a correct conclusion as to the nature of the tumor.  This is easily done when
the aneurism is superficial, recent, and circumscribed, the blood in it being fluid,
and all the signs of the  disease well marked.   It is often replete with difficulty
when  the  aneurism  is  deep-seated, or, if external, when old  and filled with
coagula; or if  suppurative action has taken place about it, or if it has  become
diffused.
   In effecting the diagnosis of aneurism, we have, in the first place, to ascertain
the  existence or not of a tumor, and after this has been  done,  to ascertain
whether it is aneurismal or of some other character. This point is* most  difficult
to determine in internal aneurisms; in the external this difficulty cannot exist,
for the doubt here is  not as to the presence of a tumor, but as to its nature.  The
tumors with which aneurisms may be confounded may conveniently be  divided
into two classes, those that do and those that do not pulsate.
   It is of great importance to bear in mind that every pulsating tumor is not an
aneurism.  Thus there may be  pulsation in various kinds of encephaloid  tumors,
or in growths composed  of erectile tissue.   In such cases as these, many of the
signs of  aneurism are present; thus  the size  of the tumor may be diminished
by compression, and the distinct influx of blood into it may be felt again on the
removal  of the pressure, the tumor  returning to  its  original size with a soft
swelling  pulsation; there may  also be a bruit,  often of a loud and distinct cha-
racter.  But these tumors may generally be distinguished from aneurisms in not
being quite so distinctly circumscribed, in being soft, spongy, and elastic,  without
the sensation of fluid that is met with in some forms of aneurism, or the solid
coagula that occur in others.  Then, again, the bruit is either of a soft, blowing,
and more prolonged character, or else sharp and superficial. The pulsation, also,
is not so distinct, and is more of the nature of a general  swelling and heaving of
the tumor than of a distinct thump.  Much light is also occasionally thrown upon
these affections by their being met with in  situations where aneurism cannot occur
from the absence of any arteries of sufficient size to give rise to it; as, for  in-
stance, on the head of the tibia, or the side of the pelvis; but if it so  happen
that a tumor of this  kind  is situated upon or under a large artery in the  usual
site of an aneurism, then the diagnosis is  certainly replete with difficulty, and
cannot indeed  in many cases be  made.  Several  instances  have of late years
occurred, in which surgeons  of  the greatest skill and experience have ligatured
arteries, on the supposition  that they had to do with an aneurism, when in reality
it was one of the pulsating tumors just described, that closely simulated  it.
   Pulsation may be communicated to a tumor  of a fluid character, seated upon
an artery;  here the diagnosis, though  often difficult, is more readily made than
in the last  case.   Attention  to  the  history of the case, to the impossibility of
diminishing the tumor by pressure,  either directly upon it, or  on the artery
leading to it, its  fluctuation  and want of  circumscription will  usually  point out
its nature.   Especial  attention should likewise be  paid to the  fact that the pul-
sation is  a distinct heaving up and down of the tumor, and neither eccentric nor
distensile, and  that  the swelling  may often be  wholly  or partly separated, by
raising it up from the artery  lying beneath it.   By attention to these points, ab-
scesses in the axilla, under the pectorals, at the root of  the neck, and in  other
situations where pulsation may readily be communicated to the  fluid mass, can
be distinguished from aneurism; but yet errors  in diagnosis have happened, and
will continue to do so, from  the intrinsic difficulty of these cases, and from no
want of skill or care on the part of the surgeon ; and those will  be most charitable
in their criticisms on  the mistakes of others who have most frequently had occa-
sion  to experience these  difficulties in their own practice.
   Tumors  that  do not ptdsate either by their  own vessels or by those that lie
beneath them, are not so readily confounded with aneurism as the class of affec-
tions that has just been  described.   But  yet it must be  borne in  mind,  that in
some instances aneurisms do not even pulsate, or but very indistinctly so, having 
474
ANEURISM.
become filled with a dense and firm coagulum.   The non-pulsating tumors that
chiefly require attention are glandular, scirrhous, or ganglionic swellings, seated
over the carotid artery, at the  root  of the  neck, or in the popliteal space.   If
these be of a fluid character, their  fluctuation, unvarying size, and the want  of
pulsation in them sufficiently indicate that they are not connected with the artery,
from which they may also frequently be separated, and  upon which they may  be
distinctly moved.   If solid, they are usually irregular and nodulated on the sur-
face, and can frequently be detached by the fingers being passed underneath them,
and raising them from the subjacent vessel.   I believe there is more danger  of
mistaking a consolidated aneurism which is undergoing or has undergone spon-
taneous cure, and  in which there is  consequently no pulsation, for a solid, per-
haps a malignant tumor of some kind, than the reverse.  I have known one in-
stance in which the thigh was amputated for a very painful solid tumor  of the
popliteal space, which proved on dissection to be a consolidated aneurism, press-
ing upon the posterior tibial nerve (Fig.  144).
  AVith rheumatism it would at first appear to  be difficult to confound an aneu-
rism, but in practice it is not so.  I have known several cases in which the lan-
cinating pains of an aneurism, more  especially when the  tumor was internal, have
been mistaken and treated for rheumatic affections;  and I have even known the
pain occasioned by the presence of a large  aneurism of the thigh treated  for
several  weeks as  rheumatism.   In  such  cases as these, it is of course obvious
that a little care and proper examination will usually serve to establish the diag-
nosis.   The aneurismal may be distinguished from the rheumatic pain by its
having a twofold character, being both lancinating and intermittent, as  well  as
continuous, aching, and burning.   AVhen  this kind of pain is persistent, espe-
cially about the back, the  side of the head and neck, or arm,  it ought always  to
cause the surgeon's attention to  be  directed to  the condition of  the neighboring
large vessels.
  The causes of aneurism are divisible into those that  predispose to, and those
that excite, the  disease.  Aneurism is predisposed to  by  any affection of the
arterial coats that  lessens  the elastic resiliency of the  vessel, and at  the same
time weakens its resisting  power.  The affection that we have already seen does
this  to  the greatest extent, is  the  fatty degeneration of arteries, or atheroma;
under the influence of this condition, not only is the natural  elasticity lost, but
the walls are so softened  that they are  readily expanded, either uniformly,  or
dilated at one side.  Though calcification  destroys  the  elasticity of the  artery,
it at the same time  makes it rigid  and  unyielding, and but little  disposed  to
expand under the influence of the outward pressure of  the blood.
  Age exercises a powerful predisposing influence on the  occurrence  of  aneur-
ism.   This disease is  of  excessively rare  occurrence before  puberty, yet it  is
occasionally met with at early periods of life.  Thus Syme mentions  a case  of
popliteal aneurism in a boy of seven, and Hodgson has a preparation of a carotid
aneurism in a girl of ten.   It  is during  the  middle period of life, about the
ages of thirty and forty, that aneurisms are most frequently met with; at those
ages,  indeed, when the arteries have already  commenced to lose their  elasticity,
in consequence of disintegrating changes, whilst, at the same  time, the heart
has  not lost any  of its impulsive  force, or the  general  muscular system its
contractile  vigor;  and when  the  weakened  and  inelastic  vessels  becoming
exposed to powerful  causes of distension, may readily give way and be  expanded
at some one  weakened point.   A  forcible, irregular, and, occasionally, greatly-
increased action of the heart, is  the immediate cause of the over-distension and
dilatation of the vessels, and thus of the  production of aneurism.  Hence, we
find  that this disease  is  especially apt  to be  induced  in  those individuals  in
whom the muscular  system  is called upon to  make sudden, violent, and inter-
mittent exertions;  as, for instance, in men  who habitually lead somewhat 
CAUSES  OF  ANEURISM.
475
sedentary lives, occasionally and suddenly changing their habits, and indulging
in sports, which they might without risk have practised  in early life;  such as
hunting, rowing, or a long day's shooting;  but which  cannot  be taken up with
impunity at an age when the arteries having become weakened, are unable to
bear the same strain upon their coats as heretofore.   I agree with Mr. Porter, in
thinking that continuous, steady, laborious employments do  not  predispose to
aneurism, as this disease is seldom met with amongst those of the lower classes,
who labor  hard and  uninterruptedly, but  it rather  occurs  in those who, after
long periods of comparative inaction, are occasionally and suddenly called  upon
to make very violent muscular  efforts, dispi^portioned to their strength, or, at
all events, to their previous  habits.   It is  in this way that soldiers, sailors, and
the members in the higher classes in  society, are rendered peculiarly liable to
aneurism.   As violent muscular exertion predisposes to  this disease, we should
necessarily expect to meet with it more frequently among men than in  women;
and, accordingly, Dr. Crisp  finds that  of 551 cases  of  aneurism of all kinds,
more than seven-eighths occurred in men.  It is  important,  however, to observe
that different kinds of aneurism occur with varying degrees of frequency in the
sexes;  thus, this affection of the  carotid  artery is met with about  as  often in
women as in men, whilst the other external  aneurisms occur  in the proportion
of thirteen cases in males to every one that happens in a female.  It is remark-
able, however, that in the dissecting  aneurism the proportions are reversed, and
for every one case in  men two occur in women.
   Climate exercises  an important influence on the  occurrence  of aneurism,
which is far more frequent in cold  than in hot countries.  If we may judge of
the prevalence of aneurism  in a country by the number of published reports of
cases, I should say  that it is of more common occurrence in Great Britain and
Ireland than elsewhere; indeed, Roux states  that it is  less frequent in France
than in England.   In America it is  also of frequent occurrence, but in the
East Indies it is rarely met with.
   Cachexy induced by any  cause, such as syphilis, chronic gout, or rheumatism,
the  abuse of mercury, &c,  has a tendency to occasion disease of the coats of
the  arteries, and thus to predispose to aneurism.   But though mercury and
syphilis are commonly said  specially to tend to the production of this disease, I
am not aware that we  are in possession of any facts  that would warrant us in
coming to this conclusion;  though there can be no doubt that the cachexy thus
induced may dispose to it  equally as  if it arose from any other cause.   It is
remarkable that phthisis is antagonistic to aneurism, though probably this may
arise from the fact of the heart's  action being feeble in this disease, and that
violent muscular  exertion  is seldom undertaken by those laboring under it.
Any obstacle to the free flow of blood  through an organ  or the  capillaries of a
part, exercises an important influence in disposing to aneurism, as it throws an
increase of  pressure  on the interior of the artery.   Dr. Chevers believes  that
obstruction  in the abdominal organs frequently occasions aneurisms of the  abdo-
minal arteries.
   The only exciting or direct occasioning causes of aneurism  are  blows, violent
strains, and wounds of an artery.   When  an atheromatous artery is concussed
by a blow, the lining membrane covering  the softened patch may be ruptured,
the  atheroma being  poured out into  the interior of the vessel, and thus the
external coat, with perhaps a  portion of  the middle adherent to it, becoming
exposed to the pressure of the contained blood before it has been fully consoli-
dated by inflammation  and  plastic deposit, the foundation of an  aneurism may
readily be laid.   In very violent muscular  strains or efforts  an artery may occa-
sionally be completely torn across, and  it is easy to understand how, under these
circumstances, the  increased pressure that  is thrown upon its  interior may give
rise  to dilatation  of an already weakened  portion  of the  vessel.   AVounds 
476
ANEURISM.
implicating arteries are common causes of those various forms of aneurism that
have already been discussed in considering injuries of arteries.

                        TREATMENT OF ANEURISM.
  The treatment of aneurism is of two kinds—constitutional and local.  In
many cases, as in the various forms of  internal aneurism, for  instance, the con-
stitutional  treatment can alone be employed, and in all cases of external  aneur-
ism it should be had recourse to as  an important adjunct to any local measures
that are adopted.  In the constitutional  or  medical treatment of aneurism, the
great object is to bring about the same condition  as that by which  the sponta-
neous cure of the disease is effected; and, indeed,  to  put the patient and the
part in the most favorable state for nature to consolidate the tumor; and though
it may not be possible in the great majority  of cases to effect a cure in this way,
at all events the  disease may be  palliated,  and its  progress retarded.    The
sacculated  is, however, the  only form of aneurism  that can ever be  cured by
constitutional means; in the fusiform variety, all that  can  be done is  to  retard
the progress of the case.
  In the constitutional treatment of aneurism the principal objects to be held in
view are in the  first place to lessen the force of the heart's  impulse, so as to
diminish the eccentric pressure upon  the  arterial  coats; and, secondly,  so to
modify the condition of the  blood as to dispose it to the deposition of its fibrine.
In carrying out these indications, it should be borne in mind that there are two
opposite conditions of the system in which  aneurism  occurs; in one  there is a
plethoric, and in the other an anemic tendency.  The plethoric and irritable
state of system chiefly occurs in young subjects, in whom  the progress  of the
disease is acute  and rapid,  attended by much impulse and excitability  of the
heart, and throbbing of the arteries generally.   The other condition of the system
principally occurs in elderly people, in whom there is a feeble pulse, a quiet heart,
a cachectic state of health, and a tendency  to  anemia;  in such a habit of body
the disease makes slow progress.   In  these opposite  conditions it  is  perfectly
clear that the same  plan  of treatment cannot succeed; and  the  constitutional
means must  accordingly be  modified  according  to  the state  in which the
patient is.
  In the acute or hyperemic state, the plan of treatment originally introduced
by Aralsalva,  and hence called  by his name, by which plethora is removed, the
irritability of the heart and the force of its action lessened, and the blood brought
into a healthy condition, may be advantageously employed, in the modified man-
ner that has  been recommended and adopted by some modern surgeons. Pelletan
and Hodgson especially report very favorably of this treatment, and I  have seen
several instances in which it has proved decidedly beneficial.   As recommended
by Valsalva,  this method of treatment was intended to carry out  two important
points.   1st. By a process of gradual starvation  and depletion  to reduce the
quantity of blood in the system, the power of the heart's action, and consequently
the pressure exercised  upon  the walls of the aneurism; and, 2dly, after the
patient had in this way been, reduced, the  plasticity of the blood was to be im-
proved by feeding him up in a gradual and careful manner, so that the tendency
to the deposit of laminated fibrine  might be increased.   Aralsalva  endeavored to
carry out the first of these objects by subjecting the patient to small and repeated
bleedings, and by gradually reducing the quantity of food that was  daily taken,
until it was lowered to half a pound of pudding in the morning, and a quarter of
a pound in the evening.   In  this  way the  patient's strength was reduced until
he could scarcely be raised up in bed without fainting; the quantity of food was
then gradually augmented, so that the plasticity of the blood might be restored.
It is seldom that surgeons carry out Valsalva's plan of treatment in the  precise
manner indicated by him.   It is most  commonly found to be more convenient 
TREATMENT OF ANEURISM.
477
to modify it somewhat according to the circumstances of the case, though the
principles on which it is conducted are  essentially the same.
   In adopting  any constitutional  treatment in cases of aneurism the  first and
most essential point  to be  attended to is to keep the patient perfectly quiet in
bed  and free from all mental or conversational excitement.   The diet should at
the same time be very carefully regulated, being gradually reduced in quantity,
and  being made to consist principally of farinaceous food, with but a very small
quantity of meat, but little liquid,  and a total absence of all stimulants.  Perhaps
the best regimen is that recommended by Bellingham, consisting of two ounces of
bread and butter for breakfast, two ounces  of bread and the same quantity of meat
for dinner, and  two  ounces of bread for  supper, with a  little milk and  water,
occasionally sipped in small quantities.  At the same time purgatives should be
administered, especially such  as gives rise to watery  stools and that remove ob-
structions of the portal and renal  system; with this  view 9i. of the compound
jalap powder may be given twice a week.
   In some cases, if the heart's action be particularly strong, small bleedings may
advantageously be had recourse to from time to time.   By judiciously carrying
out  this plan of treatment and modifying it according  to the circumstances of
the  case, consolidation of the aneurismal tumor may occasionally be lodked for;
or, if this be not  attained, the progress of the disease will  be very materially
retarded.
   AVhen aneurism, however,  occurs in feeble, cachectic, and anemic  patients,
this plan of treatment is altogether inadmissible : here, the blood being deficient
in fibrine, and  the system  in  an  irritable state from debility, the best results
follow such a course of treatment as will improve the plasticity of the blood, and
regulate the action of the heart.  With this view, complete rest, the administra-
tion of the preparations of iron, and the exhibition of a dry but nourishing meat
diet, with the occasional employment of opiates to relieve pain and to quiet the
system, will  be attended  by the best results.   In  aneurism occurring in elderly
people, and amongst the poorer classes, this plan of treatment is  perhaps more
successful than  any other.
   In the local treatment  of aneurism but little can  be  done with the view of
checking its progress, except by the employment of direct surgical means. The
application of ice  to  the surface of the tumor is said to have acted beneficially in
some cases, but it is a painful remedy, and one that may occasionally be  attended
by the inconvenience of  sloughing of the skin to which it  is applied.   AVhen
the  pain attending the increase of the tumor is considerable,  much relief maybe
obtained by the application of belladonna plasters, or the use of an embrocation
composed of equal parts of oil and of the strong tincture of aconite.   These means
comprise the only local measures  that can be  adopted in those cases  of internal
aneurism, which are beyond the reach of surgical interference.

                THE SURGICAL TREATMENT OF ANEURISM.
   In all those cases in which it is  possible  to delay with safety, no surgical pro-
ceeding  should be undertaken for the cure of aneurism until the patient has
been subjected  to proper constitutional treatment for some time;  the success of
the  more  direct surgical  means depending greatly in the hyperemic forms of
aneurism on the heart's impulse being lessened, and in the blood being got into
as healthy a state as possible; whilst, in  the anemic form of the disease, an in-
crease in the plasticity of the blood is essential for the cure of the case; for as
the  occlusion and consolidation of the sac, after surgical procedure, depend on
the  same conditions  being induced that are  successful after medical treatment,
the  same  constitutional means should be adopted in one case as  in the other.
Before proceeding to the employment of  any direct surgical means for the cure
of an external  aneurism, it is necessary to ascertain that there be no internal 
478
TREATMENT  OF  ANEURISM.
aneurism present, and  that the heart is free from disease.   From want of this
precaution, it has happened that patients have died on the operating table at the
moment that the artery was being ligatured, or that they have  expired shortly
afterwards, from the disturbance of circulation  consequent  upon  the  necessary
surgical procedures.
  Surgeons are in possession of three modes of treating external aneurisms,  viz.,
by ligature, by compression, and by galvano-puncture.  The employment of the
ligature was the only means adopted by surgeons, for the cure of aneurism, up to
a very recent date; the use of compression, in the treatment of the  disease, as
at present employed, being one of the most modern, as well as one of the greatest
improvements, in surgical practice.
  The manner in which the ligature should be applied, and the  various cautions
respecting  its use, have  already  been sufficiently discussed (page 155 et seq.)
The question as to the part of the vessel to which it should be applied in cases
of aneurism, however, remains for consideration, and this involves some  important
points.  There  are three situations in which the ligature  may be applied : either
immediately  above and below  the aneurismal sac; on the artery at its cardiac
side; or, on the vessel on  the  distal side of the tumor.   The application of the
ligature to  the artery, on either side of the aneurismal sac, is seldom practised at
the present day, when the aneurism arises from disease of the coats of the vessel;
but, in those cases in which it occurs from traumatic  causes, it  may  frequently
be adopted as the best means of cure.   The older surgeons, however,  were only
acquainted with this mode of treating aneurisms.  They slit up the sac, turned
out the contained coagula  and masses of fibrine, and then passing a probe upwards
and downwards, into the artery, through the mouth of the sac, tied the vessel on
either side, immediately  above  and below the aperture in it.   This operation,
when performed on any of the larger arteries, as the popliteal for instance, was
not only so difficult in itself, that surgeons were seldom willing to undertake it,
but was so fatal in its results,  being so commonly attended by secondary hemor-
rhage  in  consequence of  the  artery being ligatured in a  diseased part, or by
diffuse inflammation and suppuration in the deeper tissues of the limb operated
upon, that recovery after its performance was considered  a marvel, and most sur-
geons preferred submitting the patient to  amputation at once, than to the risk of
so hazardous a  procedure.
  The ligature of the artery on the cardiac side of the aneurism, without open-
ing the sac, was first done by a French surgeon of the name of Anel, in the early
part of the last century (1710), in a case of brachial aneurism.   This operation,
though attended with the risk of wounding or inflaming the sac, which was in
close proximity to the seat of  ligature, constituted a considerable advance in the
treatment of the disease,  inasmuch as it did not necessarily lead to the opening
up  of the aneurismal tumor and to the attendant dangers that  were inseparable
from that  mode of  procedure.  As Anel, however, performed his operation as  a
mere matter of convenience in a particular case, and without the recognition of
any new principle of treatment being involved in it, it attracted but little attention
at  the time, and does not appear to have been repeated by any of the surgeons
of  his day.
   It was reserved for John Hunter to make the great improvement in operative
surgery of ligaturing the artery at a distance from the sac,  where its  coats  were
healthy, and where there  was no danger of interference with the aneurism itself.
In  this way the objections to Anel's operation were avoided,  for though, like
Anel,  Hunter tied  the artery only on the cardiac side of the sac, yet he differed
from him  in doing so in  a healthy part of its  course, and at a considerable dis-
tance above the tumor, where the application of the ligature would be attended
with less risk of hemorrhage, and with no danger of opening, irritating or inflam-
ing the sac, which are inseparable from Anel's operation.  The  following are the 
HUNTERIAN AND DISTAL  OPERATIONS.
479

^y  Hv3
Hunter's
operation.
reasons, given in Sir Everard Home's own words, that induced John Hunter to
adopt the operation that is now generally known in surgery as the Hunterian.
" Mr. Hunter proposed, in performing this operation, that the artery  should be
taken up at some distance from the diseased part, so as to diminish the risk of
hemorrhage and admit of the artery being more readily secured should any acci-
dent happen.  The force of the circulation being thus taken off from the aneur-
ismal sac, the cause of the disease would, in Mr. Hunter's opinion, be removed,
and  he thought  it highly probable that if the parts were left to, themselves, the
sac, with the coagulated blood contained in it, might be absorbed, and the whole
of the tumor removed by the actions of the animal economy, which would conse-
quently render any opening into the sac unnecessary."
   Hunter's first operation  was  per-
formed in  December,  1785, in a   Fig. us.         Fig.i49.            Fig.150.
case of popliteal aneurism, in which
the  femoral artery  was  ligatured
rather below the middle part of the
thigh, underneath the sartorius mus-
cle; and  since  that  time was  uni-
versally employed by surgeons as
almost  the  only mode  of  treating
aneurism, until the introduction of
compression in 1842.
   The  effects produced upon  the
aneurismal tumor by the ligature  ^
of the vessel, according to the Hun- (
terian method, deserve careful atten-
tion.    The  immediate  effects, on
drawing tight the ligature, consist    1   \
in a cessation of pulsation and bruit   /    \
in the  tumor, which  at the same
time  subsides,  becoming  partially
emptied of its  blood.   The supply
of blood to the limb being in a great
measure cut off, it becomes numb
and cold, with a diminution of  mus-
 cular power.  The more remote effects consist in an increase of thq activity of
 the  collateral circulation, by which the vitality of the limb is maintained.   At
 the same time, and, indeed, in  consequence of this, the temperature of the limb
 often rises, until it becomes.higher than that of its fellow.
   The consolidation of the aneurismal  tumor begins as  soon as the  ligature is
 applied, and is usually completed in a few days, by changes taking place within
 it similar  to those that occur  in the spontaneous cure  of the disease.  This
 important change is effected  by the  gradual deposit  of stratified and decolorised
 fibrine in concentric layers within the sac, and not by the sudden coagulation of
 its contents.  For this deposition to take place, it is necessary that, though the
 direct flow of blood  through the tumor be arrested by the ligature of the main
 trunk, yet  that  some should be carried  in by  collateral  channels.   This  is  a
 necessary condition for the success of the  ligature, for if it happen that all the
 flow of blood through the tumor be  arrested, coagulation of that which happens
 to be contained  in it  will ensue, followed  by gangrene, suppuration of the sac,
 and other unfavorable results;  the  coagulum appearing to act as a foreign body,
 and to be insusceptible of those changes that are necessary for the consolidation
 of the tumor.   It is  of importance to observe, that  the proper consolidation  of
 the aneurismal tumor, by the deposit of laminated fibrine, will  occur even though
 a very considerable  quantity of blood continue to  flow through it.   In the
 
4S0
TREATMENT OF  ANEURISM.
Fig. 151.
  Museum of University College  there  is an  exceedingly interesting  preparation
  that illustrates  this point; it is  one in which  Sir  Charles  Bell  ligatured the
  femoral artery for popliteal aneurism.   The  patient died a week after the opera-
  tion from erysipelas;  on examination, it was found, and is shown by the pre-
  paration, that the femoral artery was double, and that though only  one  portion
  of the vessel had been ligatured, the tumor, which continued to be supplied  by
  the other, was completely consolidated.  Hence, it  would appear that  if one-
            half of the influx of blood only be arrested, obliteration of the sac  by
            deposition of laminated fibrine may be expected  to occur.   After the
            aneurismal sac has  been thus occluded,  it progressively diminishes
            in size, and is at last converted into a small fibro-cellular mass.  The
            artery that has been ligatured becomes closed at two points—at the
            part  deligated (Fig. 151  a), and where it  communicates with the sac
            (Fig. 151 b).   In both these situations, it will be  found  to  be con-
            verted into fibro-cellular tissue, whilst between them there is an open
            space,  through the medium of which the collateral  circulation  is
            freely carried on.
              In some  cases in which the ligature cannot, for anatomical reasons,
            be applied on the  proximal side of the aneurism, as in the arteries
            about the root of the neck, it was  recommended  by Brasdor  that an
            endeavor should be made to obliterate the  aneurism by ligaturing the
            vessel on its distal side.   This operation was first practised by Des-
            champs and has been especially commented upon by AAkrdrop. In
            principle it resembles the Hunterian  operation, the object being to
            arrest so much of the flow of blood through the  sac that the consoli-
            dation of this may take  place in  the  usual way, by the  deposit of
            laminated fibrine.  In  the Hunterian  operation, this is effected by
            deposit from  the  lessened  quantity of blood that flows through the
            sac;  and, in the distal  operation, it is sought to be  accomplished in
            the same way, and the success  of the operation must necessarily
            depend, in a great measure, upon the extent to which the  flow of
            blood through the sac is interfered with.   These  operations, however,
            are rarely successful, for, independently of the  ordinary dangers re-
           sulting from the application of the ligature to a  large vessel, the sac
           will continue to be  distended with, and to receive the direct impulse
           of the  blood  that  is driven into  it,  though it  be  not transmitted
           through it; and hence, though the progress of the  aneurism may
           be arrested for a time, it will often speedily increase again, and may
           perhaps eventually destroy the patient by suppuration and sloughing.
           The operation, however, we shall consider more in detail in speaking
           of the particular cases in which it has  been practised
   The ligature of the artery for aneurism, by the  Hunterian  method, succeeds
best in those cases in which the  tumor is circumscribed, of  moderate  size, slow
in its growth, having a  tendency to consolidation,  and unaccompanied  by much
oedema of the hmb.   When the aneurism is undergoing  spontaneous cure, no
surgical interference should be had recourse to, but the case  left to  nature.  In
this way it occasionally happens, during the preparatory treatment of the disease,
that the aneurism becomes consolidated.
   All operations  should  be avoided when  there  is any serious disease in the
heart  and in cases of multiple aneurism where the second tumor is situated in-
ternally; but it has happened that two aneurisms in one limb, as of the popliteal
and femoral arteries, have  been cured by one  ligature applied to the external
iliac.  Two aneurisms seated in corresponding parts of opposite limbs, affecting, 
           ACCIDENTS  AFTER  LIGATURE  FOR  ANEURISM.       481

 for instance, the two popliteal arteries, may be successfully operated upon.  But
 if two aneurisms be seated on different parts of the body, as in the axilla and
 groin for instance, at the same time, the  aneurismal diathesis would be indicated,
 and it would certainly not be expedient to operate.
    In  certain  cases  the Hunterian operation seldom succeeds, and these, there-
 fore, may be considered as unpromising  to it.  This happens in those instances
 in which it is  necessary to apply the ligature very close to the sac, so as indeed
 rather to perform Anel's operation, as here  there is the double danger of inflam-
 ing or wounding the sac, and of interfering with the collateral circulation of the
 limb.   Those  cases again, in which the  aneurism  is very acute in its progress,
 increasing rapidly with forcible  pulsation,  having very fluid contents,  a large
 mouth to the sac, and consequently the  blood driven  into it by a full  wave at
 each pulsation of the heart, are rarely favorable for  the  use of the ligature, inas-
 much  as stratification  seldom occurs.   AVhen the  aneurism  is situated in the
 midst of loose  and very yielding tissues, as in the axilla, where it rapidly expands
 to a large size, not being bound down by the surrounding parts, suppuration and
 sloughing of the sac are especially apt  to occur after the ligature.  AVhen it is
 diffused widely through the limb, with coldness and a tendency to incipient gan-
 grene, the circulation  of  blood  through  the part is so much choked that the
 deligation of the vessel will in all probability arrest it entirely, and thus produce
 mortification.   AA'hen  arteries can be felt to be ossified, it is a question whether
 they can be safely  ligatured,  as in all probability they will  be cut of broken
 through by the noose,  and the changes  necessary for their occlusion would not
 take place.  Porter, however,  recommends  that the ligature  should be  applied
 in such case, though I cannot but doubt the propriety of this advice.   When
 inflammation has been set up in the sac, with a tendency to suppuration of the
 tumor, it is a debateable question whether the ligature  should be applied or not.
 In these cases  I agree with Hodgson, that the artery should be tied; for even if
 the sac eventually suppurate, there will be less risk to the patient if this event
 occur  after the application of the ligature, than if it  happen when  the artery
 leading into the tumor  is pervious.
   In some instances, there is no resource left to the surgeon, but to amputate.
 This is the case when the  aneurism is associated  with  carious  bone, or diseased
 joints, as when the popliteal aneurism has given rise to  destruction of the knee.
 If the aneurism have attained so great a magnitude, that it has already interfered
 seriously with  the circulation  through the  limb, as indicated  by considerable
 oedema, lividity, and coldness of the part, with distension of the superficial veins,
 it is a question whether the application  of the  ligature  may not immediately
 induce gangrene, and  whether the patient would not have the best chance of
 recovery by submitting to amputation at once; this is more particularly the case
 when the aneurism has become diffused with impending gangrene, when removal
 of the limb must not be delayed.
   The  ligature fails from various  causes in a very  considerable number of the
 cases in which  it is employed for the cure of aneurism.   Thus in the 256 cases
 of ligature of the larger arteries for aneurism that have  been collected and tabu-
 lated by Dr. Crisp, it would appear that the  mortality amounted to about 22 per
 cent.  And Porta finds that out of 600  cases of ligature of arteries for diseases
 and injuries of all kinds, the mortality amounted to 27 per cent.   It  must be
 borne in mind,  that  these  are collections  of previously reported cases, and that
 if the unrecorded cases could be got at, the rate of death would, in all probability,
 be found to be much higher even than that above  stated.

              ACCIDENTS AFTER LIGATURE FOR ANEURISM.

  The accidents that may follow the application  of the ligature in a case  of
aneurism, are the continuance, or the return of pulsation in the sac; the occur-
                                     31 
482
TREATMENT  OF  ANEURISM.
rence of suppuration and sloughing of the tumor, with or without hemorrhage
from it; and gangrene of the limb.
  The continuance or  return of pulsation in  an aneurismal sac after the liga-
tion of  the artery leading to it, is an interesting phenomenon, and one that de-
serves some attention.   AVhen the Hunterian operation is successfully performed,
though  the pulsation in the sac be entirely arrested, a certain quantity of blood
continues to be conveyed into and through it  by the anastomosing channels, and
it is from this that is deposited the laminated  fibrine by which the consolidation
of the tumor is ultimately effected.   This stream of blood furnished by regurgi-
tation, or by  transmission through the smaller collateral channels, is continuous,
and not pulsatory; occasionally however it is  transmitted in  sufficient quantity
by some more than usually direct and open anastomosing,  or feeding branch, and
thus gives rise to a continuance, or a return of  the  pulsation.   It is interesting
to observe that in some of the cases in which  this has happened, there has been
a return of the  bruit,  but that in the majority no sound  appears to have been
emitted.
  The period of the return of the pulsation in the sac after the ligature  of the
artery varies  greatly.   In by far  the majority of cases, at least two-thirds, of
those in which it has happened, a certain degree of thrill or of indistinct pulsa-
tion has been found in the sac shortly after the application of the ligature;  at
all events within the first twenty-four hours.   This may be looked upon as being
rather a favorable sign than otherwise as it is indicative of a free state of the
collateral circulation, and generally soon disappears spontaneously, the sac under-
going consolidation.  Next  in order of frequency are  those cases in which the
pulsation returns in about a month or six weeks after the ligature of the  artery,
when the collateral circulation has  been  fully established, and, after continuing
for  some length  of time, gradually ceases.   It  more rarely happens that the
pulsation returns  between these two periods; that is to  say, about ten days or
a fortnight after the application of the ligature, though  in some instances the
slight vibratory thrill,  scarcely amounting to  a  pulsation, which perhaps is per-
ceptible a few  hours  after an  artery has been tied, gradually  strengthens  at
the end of a week or ten days into as distinct and forcible  a beat as had been
noticed   before the operation.   In some rare instances the pulsation has reap-
peared  after  the lapse of some months,  the aneurismal  tumor  having  in the
meanwhile undergone  absorption, when indeed it may with justice  be  looked
upon as constituting a secondary aneurism, and as indicating a recurrence of the
complaint.
  The cause  of the continuance, or of the return of the pulsation in an aneur-
ismal sac, must be looked for in too great a freedom of the collateral circulation.
Indeed, I consider it an essential requisite for  the manifestation of this phenome-
non that there should  be so free and direct a communication between the artery
on the  proximal side  of the  ligature, and that portion  of the  vessel situated
between the ligature and the sac, or with the  sac itself, as to enable the impulse
of the  heart to be transmitted in a pulsatory manner into the tumor.   No re-
gurgitant blood coming upwards from that portion of  the artery  which is distal
to the  sac, however free it may be, can  communicate an impulse, as it never
flows per saltum except in the special case of a  continuous circle of large anas-
tomosis such as are met with between the carotid arteries within the skull, or in
the palmar and plantar arches.  If any of the  direct collateral or feeding ves-
sels happen to be sufficiently large at the  time of the operation to transmit the
wave of blood, the pulsation in the sac will be continuous, or will return almost
immediately  after the  application  of the ligature.   If they be not of sufficient
magnitude for this, they may become enlarged as part of the anastomosing cir-
culation, and  then the pulsation will return  so soon as  their calibre  is  suffi-
cient to transmit a pulsation.   Besides  these conditions existing in the size 
SECONDARY  ANEURISMS.
483
and  distribution  of the vessels of the part, it is not improbable, as has been
supposed by Porter, that certain states of the blood in some individuals may,
from causes with  which we are unacquainted, render it less liable to coagulate
than usual, and thus dispose to a return of the pulsation in  the sac, which re-
mains filled with  fluid blood.
  The phenomenon under consideration has been noticed in all parts of the body
after the performance of the Hunterian operation, though it occurs with different
degrees of frequency after the ligature of different arteries,  and is certainly of
more common occurrence after operations  for  carotid  aneurism  than for any
other form of the disease.  Thus, of thirty-one cases in which the  carotid artery
has been tied for aneurism, I find that pulsation in the tumor  continued  or
returned in  nine instances.  AVhereas of ninety-two cases of inguinal aneurism,
in which the external  iliac artery was ligatured, the  pulsation  only recurred
in six cases; and in several of these it is  interesting to note that there were
two  aneurismal sacs  in the same limb—one in  the  groin, the other in the
ham; and the pulsation, though permanently arrested in the  popliteal, recurred
in the inguinal aneurism.  In the ham and axilla,  pulsation occasionally though
very rarely  recurs.   The cause of this difference in the frequency of the recur-
rence of pulsation  in different aneurisms, is evidently owing to the different
degrees of  freedom of  communication that exist between the sac  and collateral
branches in various forms of the disease.   Thus in a carotid aneurism, the im-
pulse of the heart  may at once  be brought  to bear upon the contents of the
sac, through the 'medium of the circle of Willis.  But in the case of inguinal,
femoral, or popliteal aneurisms, the anastomoses, consisting rather of the inos-
culations of terminal branches than of open communications between large trunks,
are less able to transmit the blood in a pulsatory stream.  For the same reason,
viz., the great freedom   of the communication between the vessels of opposite
sides, the pulsation has more frequently been found to continue uninterruptedly
and distinctly, though reduced in force, after the ligature of the artery in carotid
aneurism than in those in any other  situation.   The cases in which  it  returns
after the cessation of a few hours only are perhaps as frequent in  the groin and
ham as  in the neck.  In those  instances in which the pulsation returns within
the first twenty-four hours after the ligature, it usually ceases again in a few days,
though it sometimes continues a week or two.   AVhen it recurs at a later period
it is apt to last somewhat longer.
   The prognosis  of these cases is on the whole favorable, but few of them hav-
ing eventually proved fatal.   Of twenty-six patients in whom pulsation recurred,
I find that three  died,  and in all  of these the  fatal result was occasioned by
inflammation and sloughing of the sac.  In all of the three instances the pulsa-
tion recurred within the first  twenty-four  hours.   When  it  returns at  a more
advanced period,  there  is little risk to the patient, as  it is usually readily ame-
nable to proper treatment.
   A secondary  aneurism is of extremely  rare occurrence; indeed I  believe
there are only two  unequivocal instances of this affection upon record, both of
which  occurred in the ham;  the original  tumor having  disappeared  entirely
after operation, the secondary disease made  its  appearance after a lapse of  six
months, in one case, and in the other, after four years.  It  is of importance to
distinguish  between a secondary aneurism and secondary or recurrent pulsation
in an aneurismal  sac.   The term " secondary aneurism," should be restricted to
those cases only  in which an aneurismal tumor appears in the site of a former
one which has undergone consolidation  and absorption after operation.   The
question may be raised  as to whether aneurisms of this kind are  in reality
secondary,  or whether  they may not originate in  a  portion of the artery con-
tiguous to the seat of the former disease having become dilated.   It is certainly
not very easy to  understand how an aneurismal sac that has once  undergone 
484
TREATMENT OF ANEURISM.
consolidation and absorption, can again become dilated into a pulsating tumor;
and I think it most probable, although the consecutive aneurism may be found
in the same surgical region as the primary one, that  it in reality takes its origin
from a slightly higher part of the artery, where the same structural changes may
have been in progress that determined to the disease in the first instance at a
lower point.   This kind of double aneurism is indeed occasionally met with in
the- ham as a  primary disease.   I have  seen a case in which  an aneurismal
tumor was situated in the ham, and another at, or immediately above  the aper-
ture in the adductor muscle; if the artery in such a case as this had been tied,
before the second tumor had attained any magnitude, we can easily understand
how, when this became  dilated, it might  have been  considered to have  been a
new enlargement of the old sac, whereas,  in reality, it was  nothing more than a
new aneurism forming in  the close vicinity of the old one.
   The enlargement of an  aneurismal sac, without pulsation, after the ligature of
the artery leading to it, is an interesting phenomenon, and  one that might cause
the true nature of the tumor to be misunderstood, as  it closely resembles in  its
slow and gradual increase the growth of a malignant tumor.   It  is  occasioned
by the  distension of the sac, by  the dark  regurgitant  blood brought  into it
through the distal end of the vessel,  without sufficient force to occasion  pulsa-
tion, though with sufficient pressure to occasion a gradual increase in the size of
the swelling.
   Treatment of Recurrent Pulsation.—In by far the greater majority of cases of
secondary pulsation, this  phenomenon ceases  of itself in  the course of a  few
days or weeks by the consolidation of the sac, in the same way  as after ligature
of the artery, from  the deposit of lamellated fibrine.   This tendency to consoli-
dation of the tumor  may be much assisted  by means calculated to lessen the
force of the impulse of the blood into the  sac, such as rest,  the elevated position,
and the cautious application of cold  to the  part; cold, however, must be care-
fully applied, lest, as the vitality of the limb is diminished, gangrene  be induced.
At the  same  time, direct pressure may  be exercised upon the sac, so as to
moderate the flow of blood into it;  this  has in many cases succeeded in pro-
curing consolidation of the  tumor, and  may most conveniently  be applied  by
means of a compress and narrow  roller.   This plan is especially adapted to
the popliteal and inguinal aneurisms, but  cannot  so well be exercised upon
those situated  in the neck.    Care  must be taken  that  the  pressure  be  not
at first too powerful, lest gangrene result; the object here is  not so much to
force out the contents of the tumor or to efface this, but simply to restrain and
moderate somewhat the flow of blood  into it.
   In the event of the  pulsation not disappearing under the  influence of pressure,
conjoined with rest, dietetic means,  and the local application  of cold, we must
either perform the old operation of opening  the sac,  or amputate the limb.   Of
these measures, I should certainly advise amputation, as offering the most favor-
able chances tothe patient,   The operation  of opening the sac, turning out  its
contents, and  ligaturing  the vessel  supplying it, is,  under any circumstances, a
procedure fraught with the greatest danger to  the patient, and full of difficulty
to the surgeon, even when  he  knows  in what situation  to seek the feeding
vessel.  How much greater then must the difficulty be when he is in uncertainty
as to the point at which the artery enters  the sac, and cannot know whether
there is more than one of these branches.  In the event, therefore, of all other
means failing, and of the pulsation in the tumor continuing, amputation  is the
only resource left to the surgeon.
   Suppuration and Sloughing of the  Sac—When, after the ligature  of  its
supplying artery, an aneurism is  about to suppurate, instead of diminishing in
size, it increases with heat, pain, pulsation, and some inflammatory discoloration
of the skin covering it.   This gradually becomes thinned, and at last gives way; 
           SUPPURATION  AND  SLOUGHING  OF  THE  SAC.        485

the contents of the tumor, softened and broken down by the inflammatory action
and the admixture of pus, are discharged through  the  aperture in its  wall in
the form of a dark purplish-brown or plum-colored and  often  fetid fluid, inter-
mixed with masses of soft,  dark coagula, or of the drier laminated fibrine, which
may not inaptly be compared in appearance to portions of raisins or dates.  The
escape of these matters, variously altered, may be accompanied or followed by
the escape of florid arterial blood.  This hemorrhage, which is the  great source
of danger in the  suppuration of  an  aneurismal sac,  may occur in  a sudden or
violent gush at the time of the rupture of the tumor, by which the patient may
at once be destroyed;  or  it  may  contiuue  in small quantities,  which,  after
ceasing, recur from  time to time, thus gradually exhausting  the patient.   It is
this occurrence of secondary hemorrhage  that constitutes 'the  principal  danger
after suppuration  of an  aneurism, which otherwise is not a  source of any very
serious risk to  the patient; about one-fourth only of the  cases in which the sac
has suppurated having  had  a fatal termination, and almost  all those  in which
death resulted, having  proved fatal by  hemorrhage.  The  patient in the few
remaining instances has been  carried off by some special accident,  such  as the
pressure of the  sac on the pharynx or oesophagus, or  its finding its way from the
axilla into the  pleura or bronchial  tubes.  Those cases  are  more  liable to  be
followed by hemorrhage in which the suppuration  occurs a few weeks after the
ligature of the artery, than when a  longer interval has  elapsed.   That  hemor-
rhage  does not occur more frequently  after  suppuration  of the  sac, is  very
remarkable, and must be owing to the mouth of the  aneurism, where it commu-
nicates with  the interior  of the artery, either  being  sealed by  adhesion or
plugged by coagulum.   It  is owing to this plugging  also that in many cases the
fatal bleeding does not occur at the moment of rupture, but not until a lapse of
some days,  or even weeks, and then most usually under the influence of  some
incautious movement of the patient, by which  the coagulum or adhesion is
suddenly disturbed.   Those  cases are most dangerous  in  which pulsation has
returned in the sac after the ligature of the vessel, but before the supervention
of suppuration, as in these the tumor is so freely supplied with blood, that  if it
burst, fatal hemorrhage will with  certainty supervene.
   This accident is much  more frequent in some situations than in others, and
is more liable to  occur  in  aneurisms of the axilla or groin than in  those of the
ham or of  the  neck.  The  cause of the greater frequency of suppuration in
axillary and inguinal aneurisms,  is  owing to the large size  that these  tumors
rapidly attain,  in  consequence of the laxity of their  cellular connexions, and
the difficulty of their removal by the absorbents of the  part.  This accident is
also greatly predisposed to  by the blood contained within the aneurismal tumor
undergoing simple coagulation instead of fibrinous consolidation.   The mass of
coagulum, instead of being absorbed, and thus gradually disposed of, as happens
in a properly stratified  aneurismal sac, is very apt  to break up, and undergo
decomposition, being  converted into an  unhealthy grumous  fluid, that excites
inflammation in the parts with which it  is in contact.   This state  of things is
especially liable to happen in those aneurisms  that are of very large  size,  with
thin parietes, and that contain previous to the operation  much fluid blood and
comparatively little  lamelkted fibrine.  In other  cases  again  it would  appear
that this, though properly deposited, acts as a foreign body, and gives  rise to
inflammation and  suppurative action  in the wall of the sac and the  surrounding
cellular tissue.   Besides  this  it has been very justly remarked by  Mr. Porter,
that the excessive handling and  frequent examination to which an aneurismal
tumor occurring in an hospital patient is  usually subjected, may induce inflam-
matory action and give rise to suppuration in  it.
  The  period  at which suppuration  of  the  sac may occur after the  ligature, 
486
TREATMENT OF  ANEURISM.
varies from a few days to as many months.   In the majority of instances it would
appear to take place between  the third and  eighth week;  later than  this it
seldom happens, though it may do so after  the  lapse of several months, as in a
case recorded by Sir A. Cooper, in which a  carotid aneurism suppurated at the
eighth month.
   Treatment.—AVhen an aneurism is suppurating, and is on the point of giving
way, it will be  better to make  an incision  into it, so as to let out at once the
broken-down and semi-putrefied contents.   Its cavity must then be dressed like
an ordinary abscess, with a view to its filling up  by granulation, Avhich, however,
will necessarily be a slow process, in consequence of the great size  and depth
of the opening.   During the whole of this time a tourniquet should be kept loosely
applied upon the artery above the sac, so as to be  tightened at any moment that
bleeding takes place.   If hemorrhage have already supervened, the  case  is at-
tended with immediate  danger.   In  such a case  as  this, the first indication is
clearly to arrest the immediate flow of blood, so as to prevent the patient dying
at once.   This can best be accomplished by turning out the coagula and plugging
the sac with lint or compressed sponge, retained in situ by a firm, graduated
compress, and well-applied roller.  The  hemorrhage  having thus been arrested
for a time, the surgeon should  take  into  consideration what steps  should be
adopted  permanently to restrain it.  In some  cases  indeed though  these are
exceptional, the plug and compress may be  sufficient to prevent a recurrence  of
the bleeding, but in general it will not do  to trust to these  means  unless the
anatomical relations of the part be such as to preclude the possibility of adopting
any more active measures.
   Various plans present themselves to the surgeon for  the  permanent suppres-
sion of the bleeding.   The  sac may be laid open, and an  attempt made to liga-
ture that portion of the artery from which the blood issues.  But this can scarcely
be expected to  succeed, as  in the majority of the cases there would be  little
prospect of the vessel being found in such a state as to admit of its holding a
ligature, its coats  being soft and pulpy,  even if it  were possible to expose  it
before the patient perished of hemorrhage.   Indeed  though  this plan has been
several times tried, I am not aware that by it the surgeon has ever succeeded  in
arresting the bleeding from a suppurating aneurismal sac.
   The application of the actual cautery to the bleeding orifice would, I think,
hold out a better chance, more particularly  if the blood were  poured out from a
collateral vessel of small size.   In this way Morrison of Monte Arideo, succeeded in
arresting the bleeding of an aneurism in the groin  that had suppurated.  Should
these  means, however,  not  suffice, and they are the only ones that  can be em-
ployed in many situations, as in the groin and axilla, there is no  course left but
in those situations in which it  can be done, either to ligature the artery higher
up or to amputate.  The application of a ligature nearer the  centre of the cir-
culation, even though practicable, appears to me to be of very doubtful utility, for
the probability is, that the  circulation through the limb, embarrassed  as it must
have been by the first ligature, and by the subsequent distension and suppuration
of the sac, will be so much  interfered with when the artery is tied  a second time,
that gangrene will result;  or else if the collateral circulation be sufficiently active
to maintain the vitality of the limb, that it will also keep up the hemorrhage
from the opening in the artery communicating  with  the sac.  Under these cir-
cumstances the only course  left to the surgeon is amputation of the  limb, when
the aneurism is so situated  that it can in this way be removed.
    Gangrene of the Limb.—The general subject of gangrene of the limb, follow-
ing the injury and ligature of  the  main  artery, has  already been described  (p.
 169), and we have, at present, only to consider those cases in which it  occurs
after the operation for aneurism. 
GANGRENE  AFTER  OPERATION  FOR ANEURISM.      487
Fig. 152.
  If the aneurismal sac have  attained a large size with  great rapidity, it may,
by its  pressure on the anastomosing vessels, or  on
the veins  in its vicinity (Fig.  152), produce  such
an amount of disturbance in the circulation of the
limb, preventing the influx of arterial, or obstruct-
ing the  efflux of venous  blood,  as to occasion a
great liability to the occurrence of gangrene.  But
perhaps the principal  source of danger consists  in
the aneurism becoming suddenly and widely diffused,
more particularly in those cases in which the anato-
mical relation of the anastomosing vessels is such,
as in  the ham, that they may readily and uniformly
become compressed by the effused blood.  In these
cases, the additional embarrassment  induced in the
circulation of the  limb by the ligature of its  main
artery will readily induce gangrene, and hence it is
that in diffused aneurism of  the lower  extremity,
the ligature of the artery is so commonly followed
by mortification.
   The loss of blood, either in consequence of secon-
dary  hemorrhage, or  in any other  way,  before or
after the  application of the ligature, is very  apt to
be followed by gangrene;  the more so if this state  of things has rendered it
necessary to apply a ligature to a  higher  point on the trunk of the vessel than
had previously been done.  This  secondary ligature of  a large artery, in cases
of aneurism,  has, I believe  been invariably followed by gangrene»of the limb
when done  in the lower extremity, the interference with  the collateral  circu-
lation by the second ligature being so great, that the vitality of the part cannot
be maintained.
   Besides these causes, the occurrence  of  erysipelas, exposure of the  limb to
cold,  or to an undue  degree of heat, or subjecting it to the compression of a
bandage, may be attended by consequences fatal to its vitality.
   The period of the supervention of gangrene of the limb, is usually from  the
third to the tenth day;  it seldom  occurs before this period, unless incipient
mortification have already set  in  before  the artery is tied.  Gangrene usually
follows the ligature of the external iliac at an earlier period than that of  any
other artery.   In cases of aneurism, the  gangrene  is  always of the dark  and
moist  variety, owing  to its being  commonly dependent  on pressure upon  the
large venous trunks by the aneurismal tumor.
   The general  preventive treatment of gangrene dependent on the ligature of
the artery for aneurism, must  be  conducted  on the same principles as when it
arises after the ligature of arteries generally.  But some special modifications of
it are required so far as the aneurism is concerned.   When the gangrene occurs
from the pressure  of  the sac upon the accompanying vein,  it has been proposed
to lay the  tumor open,  and to turn out its contents, thus removing the compression
exercised  by it.  The  danger of such a proceeding consists in the probability of
the occurrence of hemorrhage from  the  opening made into the sac, and from
the risk attending  suppuration set up in this;  but yet, it would appear that in
two cases in which this practice has been adopted, no bad results followed.  Thus,
Lawrence has related a case of diffused aneurism of the popliteal artery in which
this plan was  had recourse to with  the best results,  and Mr. Benza (" Medical
and  Physical Journal," vol. lv.) has recorded a case of popliteal  aneurism in
which the same practice was  adopted, in consequence of great oedema  and in-

  Fig. 152.—Inguinal aneurism compressing the veins, and thus causing gangrene of the limb; a, artery j
b, vein, compressed at d; c, aneurism. 
488
TREATMENT OF  ANEURISM.
cipient  gangrene of the foot; when after the extraction of a quantity of flesh-
like fibrine from  the sac, the patient made an excellent recovery.   These cases
would  certainly justify the surgeon  in adopting such a course when the danger
of gangrene is imminent, and dependent on the size and pressure of the tumor.
Should, however, the  gangrene  show any disposition to extend, or should there
be hemorrhage from the sac  after it has thus been laid open, the surgeon must
hold himself in readiness to amputate without delay.  AA^hen gangrene has once
fairly set in, there is no reasonable prospect of saving the limb, and the sooner
amputation is done the better. The limb must always be removed high up above
the sac, and,  if possible,  not only at some distance from the  parts that have
mortified, but above the limit to which the serous infiltration that precedes this
condition has extended.  The upper extremity must generally be removed at the
shoulder-joint, the lower,  above the middle of  the thigh.  In these cases there
will generally be a considerable amount of hemorrhage, and  many vessels to tie
in the stump, in consequence of the enlargement of the collateral circulation.

           THE TREATMENT OF  ANEURISM  BY COMPRESSION."

  In consequence of the dangers and difficulties attendant upon the use of the
ligature, surgeons have for many  years past endeavored to  treat aneurism by
compression.   The  employment of direct pressure on the aneurism was almost
naturally suggested as a means to counteract the extension of the disease by the
pressure of the  blood  from  within,  and has consequently been applied from a
very early period in the treatment  of the affection.  This plan of treatment was
first employed by Bourdelot, at the close of the seventeenth century; afterwards
by Genga,  Heister, Guattani, and others.   These surgeons  made the  pressure
directly upon  the sac;  and Guattani and  Flajani relate several cures that they
effected  in this way;  but the method was so uncertain in its results, and so
dangerous from irritating and inflaming the sac, that it fell  into disuse.   The
French surgeons introduced a modification of the pressure plan, by laying open
the sac, clearing out its contents,  and applying the pressure directly over the
ends of the ATessel.  Deschamps exposed the artery leading to the sac,  and com-
pressed this with an instrument he termed  the "presse artere."  These barba-
rous modes of treatment,  however,  were  entirely set  aside  by the  facility and
comparative success of the Hunterian  operation, and compression in  aneurism
was  altogether discontinued  by surgeons  after the great  step  made  by John
Hunter in the treatment  of  this disease.   Pelletan and Dubois appear to have
been the first who employed  the pressure upon the artery above the  sac, instead
of upon the  aneurism itself; this was  in 1810.   Since this period various at-
tempts were made methodically to  treat aneurisms  in this way; but the merit of
having  introduced the  practice of compression in the treatment of aneurism  into
modern surgery, of having given  it a  definite place in our  art, and of having
established the true principles on which it acts, incontestably belongs to the
Dublin  surgeons;  amongst whom the  names  of Hutton, Bellingham, Tufnell,
and Carte deserve especial mention.  In the early trials of the cure of aneurism
by compressing the artery on the cardiac side of the tumor, the surgeons who
employed this method acted on an  erroneous theory, and the  principle not being
understood, the practice was bad.  It was  supposed that it was necessary for the
cure to  take place that the whole flow of blood  through the artery should be en-
tirely arrested, that inflammation  of the vessel at the point compressed should
be set up, and that the consolidation of the aneurism  depended  upon the ob-
struction of the vessel  consequent upon this  inflammation.   This led to com-
pression being exercised so forcibly, with the view of exciting inflammation in

  a For an excellent account of the history of the employment of compression in aneurism, and for an
admirable exposition of the principles and pathology of this method of treatment, I would refer to Dr.
Bellingham's work, published in 1845. 
CURE BY  COMPRESSION.
489
the artery, that the patient could seldom bear it for a sufficient length of time
to effect  a cure, sloughing of the skin commonly resulting as a
necessary consequence of the severe pressure  to  which it was
subjected.   To the Dublin surgeons belong the very great merit
not only  of having pointed out the error of this doctrine, but of
having distinctly laid down as the principle of the practice, that
the aneurism was cured when the artery leading  to it was  com-
pressed,  in precisely the same way as when a spontaneous cure
takes place, or when the Hunterian operation is performed—viz.,
by the deposit of stratified fibrine in the  sac,  and by the conse-
quent consolidation of this (Fig. 153); and that, as in the case
of the ligature of the vessel, it was  not necessary for the whole
of the circulation through the artery to be entirely and perma-
nently arrested, but merely for it to be lessened in quantity and
force to such an extent as to be compatible with the formation of
laminated fibrine in the sac; and it was clearly shown by exami-
nation after  death, that if the pressure were properly  conducted,
the artery was  in no  way injured or occluded at the part  com-
pressed.   This recognition of the true principles  on  which compression of the
artery leading  to the sac cures  the aneurism, has led to important results; for,
as the severe pressure that was formerly considered necessary is now known not
only to be useless, but to be absolutely injurious,  no  amount of compression is
exercised beyond what is requisite  to restrain and moderate the flow of blood
into the  sac; no attempt being ever made to compress  the artery so severely as
to lead to its obliteration by inflammation.
   Though I have stated generally that aneurisms, when treated by compression,
are cured by the deposit of laminated fibrine, I think this remark ought to be
confined  to the common sacculated form of the disease.   In the tubular variety,
which is-certainly of far less frequent occurrence in the extremities, the cure of
the aneurism takes place by contraction of the sac, and by its becoming filled by
fibrine in a somewhat irregular manner.   Illustrative of this mode of cure, there
is a preparation in the Museum  of University College (Fig. 154).
   The success  of the treatment  by compression depends greatly
upon a scrupulous attention to a number of minor circumstances,
which, though trivial in themselves, become of importance when
taken as  a whole.  During the whole of the treatment, also, the
patient's general health should be  attended  to  in accordance
with those dietetic and medical principles that have already been
laid  down in speaking of the constitutional  treatment of the
disease.   The irritability of the heart and arteries must also be
subdued, and the irritation of the system lessened, by the use
of opiates, and  the patient should be put into a comfortable  bed,
with  firm and  well-secured pillows and mattrasses, so that his
position  be not changed.  As it is principally in aneurism of
the lower extremity that this plan of treatment can be  employed, we shall pro-
ceed to describe the method of its application here.
   The limb  having been bandaged smoothly, with a pad upon the tumor, and
kid comfortably on soft pillows, the  thigh should be shaved, and  dusted with
hair-powder.   The apparatus must next be applied, and much of the success of
the treatment will depend upon the kind of instrument used.  The ordinary
horseshoe, or Signorini's  tourniquet, was  the  one first employed, and this will,
in many  cases,  answer the purpose perfectly well; but as it is somewhat difficult
to regulate the  pressure with this instrument, and as it is not unfrequently exer-
cised  too powerfully, it has generally given place,  at the present day, to the very
ingenious apparatus of Dr. Carte, which, as it substitutes an elastic force derived
 
490       TREATMENT  OF  ANEURISM BY  COMPRESSION.
from vulcanized India-rubber bands for  the  unyielding  pressure of the screw,
accommodates itself better to the limb,  and  is less likely to produce  injurious
compression.   This instrument, as well as the other contrivances which have at
various times been  invented for the treatment of aneurism by compression, are
described by Drs. Bellingham and Tufnell, in their works on  this subject, to
which  I must refer  for a fuller account than I can here give.  In some cases the
circulation through  the artery may conveniently be controlled by the pressure of
a weight laid over it in the groin as it passes over the pubes; usually from a four
to a seven pound weight is sufficient for  this  purpose.   In this way, when only
Compressor for the groin.
Compressor for the middle of the thigh.
one compressor is applied on the limb, the flow of blood may be checked during
the time that the screw is  loosened.  Care  must of course be taken that the
weight do not slip off.   It is best made of lead, cast in a conical shape, and may
be retained in  situ by having  a wide leather socket made to fit it, shaped some-
what like the hopper of a mill; its broad end should be upwards, and the narrow
end press on the vessel.
.  In applying the compressor, especial care must be taken that  it is well padded
in every part, so as not to gall the skin.   In some of the early  cases in which I
saw compression employed in London by means of the horseshoe  tourniquet,
much inconvenien.ce resulted  from want of attention  to  this  particular.  The
tendency to fretting  of the skin is much lessened  by powdering the limb, and
the removal of the cuticular hairs by shaving diminishes materially the irritation
produced by the instrument.   In order to keep up continuous  pressure, and at
the same time to  prevent any  one part of the skin being injuriously galled, it is
of very great consequence that two instruments should be used at the same time,
so that when one is  screwed up the other  should  be  loose; these instruments
need not be placed closely together.  If the aneurism be  in the ham, it will be
sufficient for  one (Fig. 155) to be applied to  the groin, whilst  the other (Fig.
156) is put upon the middle of the thigh.   In using the instrument, the great
point, as Dr.  Tufnell most  properly  remarks, is to  control the  circulation with
the minimum of pressure;  in  order to  do this the first  instrument should be
screwed up so that all pulsation ceases in the tumor, but still  not so ti-htly as
to arrest all the flow of blood through  it.   As the pressure exercised by this 
           TREATMENT  OF  ANEURISM BY  COMPRESSION.       491

becomes painful, it must be slightly loosened, and the second one  screwed up.
In this way an alternation of pressure can be kept up without much pain or in-
convenience.  If possible  the  patient should  be taught how  to  manage the
instrument himself, and will often find an occupation and amusement in doing
so.   If however it excite much pain or irritation,  as it does in some subjepts, it
may be necessary to give opiates.  The pressure should, if possible, be continued
during sleep, but if it prevent the patient taking his natural rest, the suggestion
made by  Dr.  Tufnell, of unscrewing  the  instrument slightly,  and,  when the
patient is asleep, gently tightening it again without awakening him, may advan-
tageously be adopted; it  is indeed surprising how  very little  unscrewing will
relieve the pain  of the compression.  A large cradle should then be placed over
the patient's body, so that the weight  of the bed-clothes may be taken off the
apparatus, and that the patient may manage it without risk  of disturbance.
   The effects upon the tumor vary  considerably.   In some cases it rapidly and
suddenly  solidifies;  more  commonly,  however, this is  a gradual  process, the
aneurism  becoming  more painful and  solid,  with  less pulsation  and bruit.  As
the solidification takes place, there is usually a good deal  of restlessness, a feeling
of general uneasiness, and of constitutional disturbance, which  is best quieted
by opiates.   As the pressure is continued, and the tumor begins to harden, the
anastomosing vessels enlarge,  with a  good  deal  of burning pain  in the limb
generally, and arterial pulsation in situations where usually none are  felt.  The
abnormal pulsation, in these cases,  is  always found to occur in much the same
situations, the same vessels appearing to undergo dilatation.  Thus Tufnell has
made a remark, which I have had  more than one opportunity of verifying, that
in the treatment of popliteal  aneurism by compression, three  arteries will be
found to be enlarged, one of which passes over the centre of the tumor, another
over the head of the fistula, and  the third along  the inner edge of the patella;
he also states that the severe burning pain which is felt  in  these cases,  is owing
to the  artery accompanying the communicans-peronei  nerve  being enlarged.
After complete solidification of the tumor has taken place, the compression ought
to be continued for at least forty-eight hours, so as to secure against the occur-
rence of a relapse.
   The duration of the treatment varies very greatly.  In some cases the tumor
has  become solidified in a  few hours or days.  In  other instances again the treat-
ment has been  protracted for more than three  months before  a cure  resulted.
Much of course will depend, in  this respect, on  the  constitution of the patient,
and on the condition of the tumor;  those circumstances which are most favorable
to the spontaneous cure of the aneurism will also influence the rapidity of the
cure by compression.
   Of the great value of compression in the treatment of aneurism there can be
no doubt; but  yet it cannot be looked upon as taking the  place of the ligature
 in the cure of this disease, except in  those cases  in which  the tumor is situated
in the arteries of the lower extremity, below the middle of the thigh.  In  aneu-
risms occurring in the vicinity of the trunk, as in the iliac, the carotid, subcla-
vian, and axillary arteries, it is quite inapplicable. Spontaneous aneurism being
extremely rare in the upper extremity, and as the traumatic forms of the disease
which occur here, generally require that the sac should be laid open, it is seldom
 found necessary to have recourse to it  in this part of the body, though it may be
and has been successfully  applied to the brachial artery.
   The great question with regard  to compression appears to me, after all, to be
whether it possesses any special advantages over the ligature in the treatment of
 femoral  and  popliteal aneurisms to which its employment  is  necessarily chiefly
 confined.   The principal objections that have been  urged against compression
 are  that its employment is more painful and tedious than the use of the ligature,
 and that those  cases  that are  unpromising to the ligature or that require ampu- 
492       TREATMENT  OF  ANEURISM BY  COMPRESSION.

tation rather than it, are equally unfavorable to compression, and cannot be saved
by the employment of this means.
  To these  objections I  think it  may with justice be answered, that the pain
attendant on the employment of compression depends very greatly upon the skill
and care with  which the apparatus is applied and managed throughout, and that
much depends upon the kind of instrument  that is used, being certainly much
diminished when Carte's elastic instrument  is employed.   With regard to the
relative tediousness of the treatment under  the  two plans, it would appear that
in reality there is  but little difference; for although some cases in which com-
pression  is used, are prolonged over a considerable space of time, yet they do not
occupy more than  is often consumed when accidents of various kinds follow the
use of the ligature; and it  not unfrequently happens in compression,  what can
never occur  after the employment of the ligature, that the patient is cured of his
disease  in a few hours or days.   Taking, however, the average of the Dublin
cases, we shall find  that the treatment lasted twenty-five days, and this is not
very different  from what happens with the ligature; for of 54 cases recorded by
Crisp, in which the femoral artery was tied, the  average time for the  separation
of the ligature was eighteen days, and if to  this a week more be  added for the
closure of the wound, and  for  the treatment of the various accidents so often
accompanying and following the ligature, we should probably be within the mark,
and yet only bring the duration of the treatment of the two methods to the same
level.
   After all, surgeons will eventually be guided  in their estimate of the value of
the  two plans of  treatment, not so much by the question of submitting their
patients  to  a slightly more painful or  tedious treatment, as to the comparative
risk of life attendant upon one or other method.   Upon this point the statistics
have yet to  be made; partly because the cases of the treatment of aneurism by
compression have not as yet been very numerous, and partly because the unsuc-
cessful cases of ligature have not been so commonly published as the  successful
ones.  If, however, we compare the 32 cases of femoral and popliteal aneurism
treated  in Dublin  up to February, 1851, as given by  Dr. Bellingham  (Med.-
Chirurg. Transactions, vol. 34) with the results of the  188 cases of femoral and
popliteal aneurism, recorded by Norris, in which the  artery  was  ligatured, we
shall find that of the 32 compression-cases 26 were  cured;  in 1, the ligature was
applied after pressure had failed;  in 2, amputation was performed; in 1, death
occurred from erysipelas;  in 1, from chest disease; and  in 1 case the pressure
was  discontinued.   Thus it would appear that 6 out of the 32 failed, being in
the proportion of  1 to 5-3 cases, and 2 died, being  in the ratio of 1 to 16.  Of
the 188  cases in which the artery was  ligatured,  142 were  cured, 46 died,  6
were amputated,  in  10  the sac  suppurated, and in  2  gangrene of the  foot
occurred.   Thus the deaths after ligature were in the proportion of 1 to 4, and
the failures  or serious accidents, of 1  to  3, showing clearly a very considerable
preponderance in  favor of the treatment by compression.   Besides  which, in
many patients who  recovered after the ligature, various accidents, such as gan-
grene, erysipelas, secondary hemorrhage, &c, resulted as the direct consequences
of the treatment, and these do not happen when pressure is employed.
   It should also  not be forgotten that in some  cases, such as when aneurism  is
complicated with heart disease, or  occurs in a very broken and unhealthy consti-
tution, in which the operation necessary for the application of the ligature would
scarcely, or not at all, be admissible, compression may  be  safely employed.
   After carefully  considering the relative merits of the two plans of treatment,
I think  we  may conclude that, though in some few cases neither method can be
adopted, and amputation is the sole resource, yet, that in others compression can
be employed when it would not be safe to have recourse to the use of the ligature;
and that in all ordinary cases of femoral and popliteal  aneurism especially, com- 
      TREATMENT OF ANEURISM  BY  G AL V AN O-PU N C T URE.   493

pression should be preferred to the ligature, inasmuch as it is not a more tedious,
and  an infinitely safer method of cure.   At the  same time, it must not be for-
gotten that its success depends very greatly on  the continuous care bestowed upon
the case during the progress of the  treatment.

                           GALVANO-PUNCTURE.
   The attempt to procure consolidation of an  aneurismal sac by the employment
of electricity or galvanism is of comparatively recent date.   It appears to have
been first practised by Mr. B. Phillips, about  the year 1832.  Little attention,
however, was  given to this mode of treatment until* a few years back, when  it
was  revived by some of  the French and Italian  surgeons, especially by Petre-
quin and Burci.  The principle on  which this operation is conducted consists in
endeavoring to produce coagulation in the aneurismal sac, by decomposing the
blood contained in it, by means of the galvanic current.   In some instances, the
attempt to do this has induced, and, in all, it must occasion the liability to in-
flammation of the sac and of the surrounding structures; as the change that  is
sought to be effected in  the  contained  blood, consists not in the deposit of its
fibrine, but in the coagulation of it en masse.   It has of late been recommended
to conjoin the employment of compression of  the artery, either above  or below
the  sac, with the transmission of the galvanic current through it, there being in
this way less liability for the coagulum that is deposited to be broken down and
washed away, as would  happen if the  current  of  blood were allowed to pass
through the sac whilst it is in the act of forming.
   The coagulation  of the  blood is effected by introducing  two acupuncture
needles into the  sac  in  opposite directions,  and keeping them in contact with
one  another, after connecting them with a galvanic battery of moderate tension,
when coagulum becomes deposited around one of the needles.  The  operation
should be continued for periods varying from ten  minutes to a quarter  of an
hour,  and requires to be repeated  several times.   Petrequin  recommends that
the  direction of the current be  changed from  time to time, so that a number of
clots may be formed in the sac.  In this way a soft  mass of coagulum  may occa-
sionally be formed in the tumor, so as to fill  it up more or  less completely, and
to prevent the passage of blood through it.   Occasionally it happens,  however,
that the blood has continued fluid, and  the sac pervious, no coagulation having
been effected; and in  other instances, again, the amount of inflammation that
has  been set up in the sac has been  so  great as to  give rise to its sloughing, to
the  occurrence of secondary hemorrhage from it, and to the loss of the patient's
limb or life.   This inflammation  may, in some  cases, doubtless, have been the
result of the injury inflicted upon the sac by the  introduction of the needles, and
by the charring of the tissues by them ; but, in  other cases, I think it probable
that it may have occurred from the rapid coagulation of the contained blood, an
occurrence that we have  already seen tends especially to inflammation, suppura-
tion, and sloughing of the aneurismal sac.  The pain of the operation is always
very considerable, so much so, that patients who have been subjected  to it once
have refused to submit to a repetition of it.
   It is extremely difficult at present to form any just estimate of the real  value
of the galvano-puncture.  Up  to July, 1851, 31. Boinet had collected twenty
three cases  of aneurism treated in this way;  of these, eight were of the brachial
artery, seven of the popliteal, two of the subclavian, and one of each of the  fol-
lowing :  the ophthalmic, the temporal, the carotid, the thoracic aorta, the  ulnar,
and one unknown.   Of  these the  proceedings failed in thirteen instances; nine
cases were reported as successful, but in  seven  of  these, 31. Boinet states that
doubts must be entertained both as to the results and as to the treatment, for the
cure took place not by 'galvano-puncture alone, but  in some by the  conjoined
influence of compression  and the application of ice; and in others, as  the  result 
494           ANEURISMS  OF  THE LOWER  EXTREMITY.
of inflammation  and suppuration of the sac.   There are consequently only two
cases in which the cure can clearly be attributable to this means alone, and with-
out the occurrence of any serious accident.
  AAThen we  compare the galvano-puncture with ligature or compression, in the
treatment of external aneurism, it is I think impossible to hesitate for a moment
in o-ivino- a decided preference to the latter modes of treatment.   Not only is the
principle on  which it is attempted to procure obliteration of the sac in galvano-
puncture a vicious and peculiarly dangerous  one, viz., by the coagulation  of the
blood, and the inflammation  of  the  wall of the  sac; but the results  that have
hitherto been obtained by this method, are not  such as would justify a prudent
surgeon in submitting his patient to experiments of this kind, when he possesses
so certain and comparatively safe a mode of cure  as that by deligation or com-
pression.   In internal aneurisms, or in those cases  in which the disease is so
situated at the  root of  the  neck,  that  the  artery can neither be ligatured with
safety nor  compressed, galvano-puncture may perhaps be employed  with some
advantage, in conjunction with proper medical treatment.
SPECIAL  ANEURISMS.
                       CHAPTER  XXXVII.

            ANEUBIS31S  OF THE LOAVEB EXTREMITY.

                      ARTERIO-VENOUS ANEURISMS.

  Preternatural communications between arteries and  veins, though usually
the result of wounds, occasionally happen from  disease, ulceration  taking place
between the vessels, and thus  causing an aperture to lead from  one  into the
other.  AA^hen such communications are of a traumatic character,  they may, as
has already been stated, either constitute an  aneurismal varix or  a varicose
aneurism.  As the  result of disease,  aneurismal varix only can occur, varicose
aneurism never happening except as a consequence of wound.  These spontaneous
communications  have  been met with between the aorta and the vena cava, and
between the iliac, femoral, carotid, and subclavian arteries, and their accompany-
ing veins.  In nature, symptoms, course and treatment, they so closely resemble
traumatic aneurismal  varix, described at  p. 164, that their  consideration need
not detain us here.

                          INGUINAL ANEURISMS.
  An iliac or inguinal  aneurism may arise from the external iliac or from the
common  femoral artery; most  frequently it springs from the latter, and taking a
direction upwards pushes the peritoneum before it, and thus encroaches somewhat
upon the cavity of the abdomen.  AVhen first noticed it is a small, soft, compres-
sible tumor, with pulsation and bruit, and generally attended by little pain or
uneasiness.  It rapidly  enlarges, however, and may attain  a considerable magni-
tude, being often somewhat lobukted upon  the surface, owing to the unequal
constriction exercised on it by  the fasciae under which it lies.   At the same  time
it usually becomes more solid, and the pulsation in it diminishes considerably, or
even ceases entirely.   As  it  increases in size,  it compresses the  saphena and 
TREATMENT OF  INGUINAL  ANEURISMS.
495
femoral veins, thus giving rise to oedema of the limb; and by stretching  the
genito-crural and some of the  branches of the  anterior crural  nerve, occasions
considerable pain in the thigh and leg.
  These aneurisms are commonly of the circumscribed false variety, though some-
times tubular; they never become diffused, for the reason long ago pointed  out
by  Scarpa, that the femoral artery, above the edge of the  sartorius muscle, is
invested by so dense a sheath and is so closely bound down  by the  neighboring
fascia, that when dilated into an aneurism it does not readily give way.
  The  diagnosis of inguinal aneurism is  not always so easy as might at first
appear.  It has most frequently been confounded with abscess in the groin, car-
cinomatous  tumors in this situation, and  with  ost^o-aneurism.  The diagnosis
from  abscess must be made on general principles, but in some instances  appears
to be replete with difficulty, as there are not a few cases recorded, in which aneur-
isms  in  this situation have been mistaken and punctured for abscess, an error
that has in every instance proved fatal.   The diagnosis of an inguinal aneurism,
solidified by the deposition of  laminated fibrine, and pulsating  but  indistinctly,
from  a pulsating encephaloid or osseous tumor in the groin, is surrounded by  the
greatest difficulties, and cannot, I believe, with the means we at present  possess,
be accomplished with absolute certainty.   The fact of the two diseases having in
two instances been confounded during the last few years, by two of the most dis-
tinguished surgeons of  the day, 3Ir. Stanley and 31r. Syme, is sufficient evidence
of the difficulty attending their diagnosis.
   Treatment of Inguinal  Aneurism.   It occasionally  happens  that  inguinal
aneurisms, even of  very large size, undergo spontaneous cure, or become consoli-
dated by direct  pressure  conjoined with  constitutional  treatment; but  these
instances are of such rare occurrence that such a result cannot be  expected in
any one case.  In  the majority  of instances the tumor, though it may have
encroached on the abdomen, will not have reached too high for the external iliac
to be ligatured;  should it have done so, however, the surgeon may have to tie
the common iliac artery, but in some instances even this may not be practicable,
when his  choice must lie between the slender chance offered by constitutional
treatment and pressure, and the fearful alternative of ligaturing the aorta.
  The ligature of the external iliac was first practised by  Abernethy, in
1796.  Since this period it has been had recourse to in at least 100 instances for
inguinal aneurism (Norris); of these 73 were cured, and 27 died.   In one remark-
able case, both external iliacs were ligatured successfully at an interval of eleven
months, by 3Ir. Tait.   In some few cases also,  there was the complication of an
aneurism in the ham with that in the groin.  Of the 92 cases in which the aneur-
ism was solely seated in the groin, 70 were  cured, and 22.died.   Death  resulted
from  gangrene of the limb in 8, from secondary  hemorrhage in 4, from sloughing
of the sac  in 3, from tetanus in 3, and from causes of a more general character
in 4  cases.
  Pulsation  returned in the sac in six cases; in some not  until several weeks
had elapsed after the operation; and in one instance only was this phenomenon
followed by death.   Suppuration of the sac was of frequent occurrence,  happen-
ing in thirteen instances, doubtless owing to the large size that  these tumors are
often allowed to attain  before being  subjected  to surgical  interference.  It is
remarkable, however, that in three cases only was this accident fatal, and in two
of these three instances  the sac had been opened before the operation, on  the
supposition of its being an abscess.  Secondary  hemorrhage occurred but in  six
cases, four of which proved fatal;  a very small  proportion when compared with
what  happens in  other situations.   This must doubtless be attributed in  a great
measure to the absence of any collateral branches  springing from the trunk of
the external iliac, the  distance between the point ligatured, and  the  epigastric
and circumflex ilii arteries, affording abundant  space for the safe obliteration of
the vessel.   In one of the fatal cases pulsation  had previously  returned in  the 
496         ANEURISMS  OF  THE  LOWER  EXTREMITY.

sac; in the other three the patients died on the seventeenth, the twenty-seventh,
and the forty-third days, respectively.
   Gangrene of the limb is certainly the most common cause of death after deli-
gation of this vessel, occurring in nine instances, of which eight proved  fatal;
one being cured by amputation.   The period at which the mortification occurred
varied from the third to the fourth week.  The principal cause of this gangrene
is certainly narrowing, or obliteration of the neighboring venous trunk by pres-
sure of the tumor.  In the accompanying wood-cut (Fig. 157) this is well illus-
trated; the vein opposite the aneurism being completely closed.
   It  is a very remarkable circumstance in the  history of this operation that
three deaths  have resulted, from tetanus, a most  unusual occurrence after the
ligature of arteries.
   The ligature of the external iliac for aneurismal varix in the groin affords a
striking  contrast with that for  spontaneous aneurism; the four cases recorded
all proving fatal, two  dying  of  gangrene,  and two of hemorrhage.   In  these
cases,  Mr. Guthrie has recommended  that  the tumor should be laid open, and
the artery ligatured above and  below the  aperture in it.   But with whatever
rapidity and dexterity such a  proceeding were accomplished in  the groin,  there
will be great risk of such a  loss of blood  ensuing as  to endanger  the patient's
life, there  being no  possibility of commanding the  artery above the  seat of
disease.
   Aneurism  occasionally occurs in the groin and  ham of the  same  side; here
the ligature of the external iliac will cure both diseases.  Of four cases in which
                        this complication  occurred, the operation was success-
                        ful  in  three, one  patient dying  of  gangrene, and in
                        him the popliteal  aneurism was on the point of burst-
                        ing  at the time of the operation.   In two of the three
                        cases that recovered, pulsation returned in the inguinal
                        aneurism, but disappeared after a time.
                          There  are two  modes  of tying the  external iliac
                        artery; the  one  originally  practised  by Abernethy,
                        somewhat modified by  Liston,  and  the other intro-
                        duced by Sir A. Cooper.  Abernethy's method modi-
                        fied, consists  in commencing an incision two  fingers'
                        breadths  above, and somewhat to the inner side of the
                        middle of Poupart's ligament, and carrying  it upwards
                        and  outwards  to  the extent  of about four  inches, so
                        that it terminates at about  three fingers' breadths to
                        the  inner side of the  anterior  superior spine of the
                        ilium.  After dividing the skin and superficial fascia,
                        the  fibres of the external oblique  tendon are carefully
                        cut  through.   The  internal  oblique and the transver-
                        salis muscles are then cut through with great caution,
                        when the transversalis fascia is reached, which is re-
                        cognised by its dull white appearance.   A small portion
                        of this membrane, at the lower angle of the  wound,
                        where it is thinned and expanded for the  passage of
                        the  cord,  is now carefully raised with the forceps, and
                        scratched through with  the  point of the scalpel.  A
                        director is then introduced, and passed underneath it,
                        when it should be laid open  upwards  and outwards to
                        the  full extent of  the wound; the whole of the inner
                        side  of the wound is next drawn towards the mesial
                        line, the  peritoneum being  separated from its  loose
                        cellular connexions in the iliac fossa  by the surgeon's
fingers j it must be  kept out of the way by an  assistant, who holds  it up with
 
          LIGATURE  OF  THE  EXTERNAL  ILIAC  ARTERY.       497

a broad bent copper  spatula.   The artery  may  now be  felt pulsating at the
bottom of the wound,  covered by a dense fascia, and having the vein lying to its
inner side, and somewhat  behind it.  The investing sheath must be scratched
through in two situations, and  the needle passed from the inner side between
the vessels, the ligature being then tied in the usual way.
  In Sir A. Cooper's operation, an incision about  three inches in length is made
a little  above  and nearly parallel  to Poupart's ligament, beginning  above the
inner margin of the abdominal ring, and ending near the anterior superior spine
of the ilium.  By this incision the tendon  of the external oblique is exposed,
and must be divided to the full extent of the external wound, wlien the spermatic
cord will be seen  passing under the lower edge of the internal-oblique and trans-
versalis muscles.  Some loose cellular tissue and fascia have now to be scratched
through, and the finger being passed  under the cord, will come in contact with
the external iliac  artery, close to the spot where the epigastric is given off from
it;  the upper side of  the incision  must now be well raised by a copper spatula,
when the  vessel  will  be exposed, covered by  a  dense sheath, and  having the
vein to its inner side, the sheath  must be  cautiously  opened, and  the  ligature
passed in either direction.
  On comparing the two operations, it would appear that the principal disad-
vantage of Abernethy's is, that it is apt to leave a tendency to hernial protrusion,
in consequence of the abdominal wall being much weakened by the free incisions
through the muscular planes that are necessary;  the great advantage attending
it is, that the external iliac  may be ligatured at any part of its course, and that,
if requisite, the  incision  might  even be extended  upwards,  and the  common
trunk secured.   In Sir A. Cooper's operation, the line of incision lies directly
across the course  of the epigastric artery, which, as well  as the circumflex ilii,
if it arise high, and the circumflex vein, which  crosses the iliac artery at this
point, and is often somewhat funnel-shaped, may be in  danger of being wounded.
The spermatic cord is likewise  somewhat in the way in this operation.   Dupuy-
tren actually wounded the epigastric artery in one case, and Houston had much
difficulty from the circumflex vein in another instance.   This operation has also
the disadvantage, that by it, it is impossible to prolong the incision upwards so
as to deligate any portion of the vessel except that which  lies immediately above
the crural arch; but the peritoneum is less disturbed than in the other case, and
there is  less tendency to hernial protrusion afterwards.  As  a general rule, I
think we may conclude, that, in cases of spontaneous aneurism, in which it might
from the size of the tumor or the  diseased state  of  the vessels, be found neces-
sary to apply the  ligature to a higher point than  was intended before the opera-
tion commenced,  it  will be safer to have recourse to Abernethy's plan, modified
as above described; as in this way we shall be able  to ligature  the vessel at any
part of its course.   Whilst in cases of hemorrhage after amputation, or in trau-
matic femoral aneurism, in which the artery is not likely to be diseased, Cooper's
operation should be had recourse to, more particularly if the patient be thin and
the  abdomen flat.
  In connexion with  the ligature  of the external iliac  artery, there are  some
practical points that  deserve mention.   Before the operation  the colon should
be emptied by  means of an enema, and  the pubes shaved.  The incision in the
abdominal wall must  be sufficiently extensive,  but should never be allowed to
implicate the external ring, lest it give rise  to a tendency  to hernial  protrusion.
Care should be taken not to wound the  peritoneum, for although two patients,
in whom this was done by  Post  and Tait, both  recovered, yet it is of course a
dangerous  accident, and should if possible be avoided.   The peritoneum must
not  be torn up more than is absolutely necessary,  lest hemorrhage or subsequent
peritonitis occur,  and  especial care must be taken that the fascia transversalis be
properly divided,  otherwise the iliac fascia  may be  stripped  up with the  perL-
                                    32 
498         ANEURISMS  OF THE  LOWER EXTREMITIES.

toneum, and the artery in this way dragged out of its normal situation into the
upper and inner angle of the wound, occasioning great embarrassment  to the
operator, who may not be able to find it.  Before attempting to pass a ligature
round the vessel, the dense fascia covering it must be scratched through with the
point of a scalpel, and lastly, the sac must not be injured by having its peritoneal
covering stripped off.
  Ligature of the  Common Iliac—If the aneurism in the groin extend so
high that there is not sufficient space for the exposure and ligature of the external
iliac artery, it becomes necessary to tie the  common trunk.  This may be done
by extending the incision that serves  for the ligature of the external iliac up-
wards, and slightly inwards towards the umbilicus, to an extent corresponding to
the degree  of obesity  of the patient, so  that  it assumes a somewhat  semilunar
form.  The incisions are then successively carried through the different planes of
muscular  fibre with great  caution and  on a grooved director, until the transver-
salis fascia is exposed;  they must be carefully opened and freely divided, so as to
expose the peritoneum, which now comes bulging into  the wound, pressing
forwards with its contents.  This must  be held  aside,  drawn upwards by the
fingers of an assistant, and gently stripped from  the iliac fossa by the surgeon
carefully insinuating his hand  beneath it.  AVhen he arrives at the brim of the
pelvis, he will readily be conducted to the external  iliac  artery, which guides
him to the parent trunk.  The ligature  must  then be passed under  the artery,
a slight scratch having been made through the fascia covering the vessel.
  In planning the incision for the ligature of  this artery, care should be taken
that it be not carried too low down or too far forwards; nothing can  be gained
by doing so, and there is  besides the  additional risk of the  circumflex ilii or
epigastric being wounded, as  happened to Mott,  and  as these  are principal
agents  in  the  anastomosing  circulation,  their  injury  is a serious accident.
Should any muscular branches  bleed they had better be ligatured, so as not to
obscure the  after-steps of the operation.   The fascia transversalis  should be
opened at the lower part of the wound, where it is thinned for the  passage of
the cord, by pinching up a portion of it with  the forceps,  and dividing it  care-
fully with the edge of  the knife laid horizontally.   It will  be found to"be much
thicker  and  denser at the  upper  and outer   part of the  wound, than in this
situation.   AVhen the peritoneum is well drawn upwards to the mesial line by
the assistant's fingers or copper spatula?,  the ureter which  crosses the artery in
this situation will be carried up with it,  so  as not to  be seen at all.  In  this
stage of the operation, the patient should be turned on his sound side, in order
to prevent  the  intestines falling over and pressing the  peritoneum into the
wound.
  In determining the length of the incision, and calculating the point at which
he would  expect to meet with and ligature the artery, it  is a matter of the veiy
first importance for the surgeon to remember the different  bearings of the parts
in the neighborhood of the vessels, and the relative frequency with  which the
origin and termination of the  artery correspond with  certain fixed points that
may readily be detected.
  The points of importance are the relations of the vessels to the lumbar verte-
bra?, to the crest of the ilium and the umbilicus.   The ordinary place  of division
of the abdominal aorta is on the body of the fourth lumbar vertebra,  or  on the
intervertebral disk below it; according to 3Ir. Quain, this was the case in three-
fourths of the bodies  he  examined, or in 156 out of 196.   In  regard to the
relations between the  situation of the  bifurcation of the aorta and the crest of
the ilium, we find  it, according to the  same anatomist, to have ranged in about
four-fifths  of the  cases about  half an inch above and  below the level of the
highest point of this part of the  bone.   With reference  to  the  umbilicus no
definite rule can be kid down, but in  general terms it  may be stated that the 
LIGATURE OF  THE AORTA.                   499
bifurcation of the aorta is a little to its left.  As a general rule, that given by
Hargreave is  perhaps sufficiently good  for  ordinary purposes.   If a point be
taken about half or three-quarters of an inch below, and a little to the left of
the umbilicus, and a line be drawn  on each side from this point to the centre of
Poupart's ligament, we obtain about the direction of the common and  external
iliac arteries.  On dividing these lines  into  three  equal parts, the  upper third
will correspond to the primitive trunk, and the two lower thirds to the external
iliac, and the  junction of the upper with the middle third to the bifurcation of
the common iliac artery.
   The point of division of the common iliac artery, is, in the majority  of cases,
between the middle of the fifth lumbar vertebra and the middle of the sacrum,
both points inclusive; and if it is not in this  situation  the division will probably
be lower down.
   The length of the vessel varies greatly; according to Quain, in five-sevenths of
the cases, it ranged between one and  a half and three inches.
   AVhen we look at the depth at which this artery  is situated, its great size and
proximity to the centre of the circulation, and consider the force with which the
blood rushes through it, we  cannot but be struck with the success which has
attended its ligature.   Of seventeen  cases in which it has been tied, nine were
cured and eight died.   In  eleven of the cases the  ligature was  applied for
aneurism, and of these seven recovered.   The  four that died, perished rather
from  the magnitude and extent of  the disease than from  the effects  of the
operation, and it is remarkable,  as showing the power of the anastomoses in
maintaining the  vitality of parts, that in no  instance  did gangrene ensue.   In
two  of  the fatal cases, the  peritoneum  was  opened during the operation, and
this circumstance  doubtless  contributed  to the fatal result.   In both these*
instances, also, the tumor had been opened before the artery was ligatured, in
one by mistake for abscess, in the other by the suppuration and sloughing of the
sac.
   Ligature  of the Aorta.—It is impossible not to contemplate with admi-
ration the man whose mind was the first to conceive, and whose hand  was the first
to carry out the determination to apply a ligature to  the abdominal aorta, and who,
guided by pathological observation and physiological experiment, dared to arrest
at once the circulation through the main channel of supply to the lower half of
the body, trusting to  the collateral circulation for the maintenance of the vitality
of the parts thus  suddenly deprived  of blood.  Sir A. Cooper was the first to
place a  ligature on the  aorta, in 1817.   Since that  period, the  operation  has
been  three times  performed;  viz., by James,  of Exeter; by 3Iurray,  at  the
Cape of  Good Hope; und by 3Ionteiro, at Bio Janeiro.
   In Sir A. Cooper's case, the inguinal aneurism had  burst, and the vessel was
tied about three-quarters of an inch above its bifurcation, by making an incision
three inches in length through the abdomen, a little to the left of the umbilicus,
the fingers being passed between  the  convolutions of the intestines, and  the
peritoneum covering the artery scratched through.   The patient survived forty
hours.  James ligatured the aorta much in the  same way as Sir A. Cooper  did,
in a case in which he had previously  employed the  distal operation for an ingui-
nal aneurism, but without success, the patient speedily dying.  3Iurray ligatured
the vessel, by making an incision on  the left side, in front of the projecting end
of the tenth  rib,  and carrying it  downwards  for six inches,  to  the  anterior
superior spine of the ilium.   The parts were then  carefully divided to the peri-
toneum, which was separated from the iliac fossa and the psoas muscle, when,
with great difficulty, and  by scratching with the  end of an elevator  and  the
finger nails, room was made for  the  passage of the ligature  round  the artery,
which was tied three or four lines above its  bifurcation.   The  patient died in
twenty-three hours.   The  most interesting case on record is that  by Dr. Mon- 
 500        ANEURISMS  OF  THE  LOWER  EXTREMITIES.

 teiro, who tied the aorta for a large false aneurism on the lower and  right side
 of the abdomen;  here the incision was made much as in Murray's  case, and the
 artery ligatured with great difficulty; the patient lived till the tenth  day, when
 he died of secondary hemorrhage.
   In this operation, there are not only all  the dangers attendant upon the liga-
 ture of arteries of the first magnitude, but also the risk of producing  fatal  peri-
 tonitis, whether the abdomen be cut through, or the vessel sought for by stripping
 up  the  peritoneum  from the iliac fossa;  and  it  appears  to  me that a patient
 sufferino- from so large  an inguinal  aneurism as to justify the ligature of the
 aorta, would have a  better chance of  recovery,  or rather of prolongation of life,
 by the adoption of proper constitutional  treatment, together with pressure upon
 the tumor and the distal ligature  or compression of the artery.
   Ligature of the Internal Iliac.—Aneurism  of the trunk of the internal
 iliac artery is extremely rare, but its principal branches, such as the gluteal and
 sciatic arteries, are  more frequently affected.   The  pudic artery is very seldom
 indeed the seat of this  disease, and I am  only acquainted with one instance in
 which it has been met with in this situation, which is exhibited in  a preparation
 in the 3Iuseum of the College of Surgeons.   The aneurisms  of the gluteal and
 sciatic arteries are more frequently traumatic than spontaneous.  In their symp-
 toms and diagnosis there is nothing peculiar, though these affections have been
 confounded with  pulsating encephaloid tumors of the gluteal region, as in a case
 in which 31r. Guthrie ligatured the internal iliac artery for disease of this kind.
   Since Stevens first tied the internal iliac in 1812, in a negress laboring under
 gluteal aneurism, this artery has  been ligatured six  times; of these cases  four
 recovered and three  died.  The success that has hitherto attended this operation
* is certainly remarkable,  when we  take into  consideration the depth  at which the
 artery is situated  and its great size; and must, I think, be accounted for by the
 fact, that although in these cases the patients run the ordinary risks attendant
 on the ligature of the larger pelvic arteries from  the exposure and handling of
 the peritoneum, yet, that he is saved  the danger resulting  from the  supervention
 of gangrene; the anastomosis between its branches and that of the neighboring
 vessels being so free, and  the course traversed by%the blood  so short, that no
 difficulty can arise in the maintenance of the collateral circulation.
   The steps  of the  operation  necessary for the  exposure of the internal  iliac
 artery are precisely analogous  to those requisite for  the ligature of the common
 trunk.  When the vessel  is  reached, it must be  remembered that both the
 external  and internal iliac veins  are in close relation to it; the one being to its
 outer side, the other behind it.  As those vessels are large, and their coats thin,
 it is necessary that they should be separated by the finger-nail, or the  blunt end
 of an aneurism needle, before the ligature is passed round  the artery;  care must
 also be taken not  to put the vessel too much on the stretch in applying the liga-
 ture, lest the ilio-lumbar artery be ruptured.  As the length of the artery varies
 much, usually ranging between one and two inches, and as when it is short it
 has a tendency to be placed  deeply  in  the pelvis,  it would, I think, be more
 prudent, and occasion less chance  of secondary hemorrhage, for  the surgeon,
 under such circumstances, to ligature the common trunk.

                  FEMORAL AND POPLITEAL ANEURISMS.
   We have, in the preceding section, considered aneurisms affecting the groin,
 which are by no means of very unfrequent  occurrence.  Aneurisms of the thigh
 are, however, much  less  frequently met with,  but those  in the ham are  very
 commonly encountered.  Thus, out  of 551 cases  of aneurism recorded in the
 British medical journals of the  present century,  Dr. Crisp has found  that 137
 affected  the popliteal, and only 66 the femoral artery.   Of these 66, 45 were
 situated either in  the groin or upper part  of the thigh, and 21 only were truly 
FEMORAL  AND POPLITEAL  ANEURISMS.
501
femoral, or femoro-popliteal.   The reason of this difference  in  the frequency of
the occurrence of aneurism in different parts of the vessel, may be accounted for
by attention  to its anatomical relations.   In looking at the main artery of the
lower extremity, in its course from Poupart's ligament to where it terminates in
the anterior and posterior tibials, we see that it may be divided  in relation to the
muscular masses that surround it into three principal portions.  1st. That which
is situated between Poupart's ligament and the anterior margin of the sartorius,
which may be considered inguinal.   2d. That  which  intervenes between this
point and the aperture in the adductor tendon, which may be considered femoral.
And, 3d, that division of -the vessel  which corresponds to the ham,  and which
may be considered popliteal.  Of these three divisions, the first and last are
comparatively superficial, and being unsupported by  muscle, readily expand,
while the  central portion of the artery is closely  surrounded on  all sides by mus-
cular masses, and is less  likely to be dilated into an aneurismal tumor.  AVe also
find that  the inguinal portion of  the vessel is  closely and firmly invested by a
dense and resistant fibro-cellular sheath, and is well supported by  the fascia lata;
whilst in  the popliteal space the artery is merely surrounded by the ordinary
cellular sheath,  and  receives no aponeurotic support.   This difference in  the
connexions of these two parts of the vessel may, to a
certain extent,  explain  the  greater  frequency  of
aneurism in  the ham' than in the upper part of the
thigh.
   Aneurism  of the profunda femoris artery is of ex-
tremely rare occurrence; indeed, I  am not acquainted
with any  recorded case.  The only instance  with
which  I am acquainted, is  that represented  in  Fig.
158, taken from a  patient who died of  pneumonia,
under  Dr. Garrod's care, very shortly after admission
into the Hospital.   On  examination after death a
large tumor of the  thigh, which had  not been very
closely examined during  life, proved to be a circum-
scribed aneurism of the profunda artery.
   Femoral and popliteal aneurisms commonly occur
about the  middle period  of life, and are almost inva-
riably met with in males, being at least twenty times
more frequent in them than  in women.   Both sides
are affected with equal frequency, and occasionally
at the  same time.  According to Crisp, sailors would
appear to be more liable to this variety of the disease
than any other class.  These aneurisms are most'frequently sacculated;  in the ham
they are always so,  but in the thigh they are sometimes tubular.
  The symptoms of femoral aneurism present nothing peculiar, the tumor usually
enlarging with considerable rapidity, with all the characteristic signs  of the dis-
ease, and  assuming a pretty  regular ovoid shape.  Popliteal  aneurism usually
commences with stiffness and a good deal of pain about the ham and knee, which
I have more than once seen mistaken for rheumatism; there is also  a difficulty
in straightening the  limb,  which is generally  kept semi-flexed.  The tumor
increases usually with great rapidity, and has a great tendency  to become  dif-
fused;  these  conditions will,  however, materially depend on  the side of the
artery from which it springs; when from the anterior aspect, next the bone, it
increases slowly, being compressed by the firm structures  before it.  In this
case, however, there is the great danger that, by  its pressure upon the bones and
knee, it may  give rise to caries and destruction  of the joint.   AVhen it springs
from the  posterior part  of the artery, where it is  uncompressed, it increases
Fig. 158.—1, Common femoral; 2, superficial femoral; 3, profunda; 4, aneurism. 
502         ANEURISMS  OF  THE  LOWER EXTREMITIES.

rapidly, and may speedily diffuse itself.   The  diffusion  of an aneurism in this
situation may take place in two directions.  If it be femoro-popliteal, it  may
give way into  the general cellular tissue of the thigh, the blood diffusing itself
as high perhaps as Scarpa's triangle.   AVhen it is  confined to the ham, it may
either "■ive way under the integuments, and into the superficial structures of the
limb, or else under the deep fascia of the leg, where  it will  compress the pos-
terior tibial nerve and artery.  .In all cases the  diffusion  of popliteal aneurism is
likely to be followed by gangrene of the limb.
   The diagnosis  of  popliteal aneurism has to be made from chronic abscess, from
bursal  enlargements, and from solid tumors.   From chronic abscess no serious
difficulty can well be experienced ; but it may happen that when an aneurism has
suppurated, considerable difficulty arises in determining its true nature; whether
it is merely an abscess or not.   On such  cases  as these the state of the circula-
tion in  the lower  part of the limb will throw much light.  Bursal tumors,  often
of large size and  multilocular, are  not  unfrequently met  with in the ham, but I
have never found any great difficulty in determining their true nature, their elas-
ticity and  roundness, together with their mobility and want of pulsation, being
sufficiently indicative of their character.   The most serious diagnostic difficulty
may arise from confounding solidified  aneurisms of the ham with solid tumors,
either of sarcomatous character,  or  springing from  the tibia and femur:  and I
have known one  case of aneurism  in  this condition, in which  amputation was
performed on the  supposition of its being a solid tumor (Fig. 144).
   The treatment  of femoral  and popliteal aneurism may be conducted either by
ligature or compression  of the vessel leading to the sac.   As a general rule, for
the reasons already stated, compression should be employed in preference to the
ligature; but yet  the cases may arise when, from the  failure of compression, or
for other reasons,  it may be necessary to ligature the femoral artery.
   In looking at the femoral artery, it might at first be supposed that the common
trunk,  situated superficially between the inferior edge of Poupart's ligament and
the origin of the profunda, would be the most convenient situation for the appli-
cation of the ligature;  but experience  has shown  that  deligation of the vessel
here is in the  highest  degree unsuccessful.  This  arises from the shortness of
the trunk, rendering it necessary to tie the artery between and in close proximity
to those collateral branches  that will constitute the most direct and immediate
agents in the anastomosing supply, viz., the circumflex ilii and the profunda, so
that the internal  coagulum would not  readily form.  In  addition to this, how-
ever, a  number of small inguinal branches, such as  the superficial epigastric and
circumflex ilii, the superficial  and deep external pudic, and very commonly one
of the circumflex  arteries of the thigh,  more especially the  internal, arises from
the common trunk in its short course, and these  vessels, though small in size,
constitute a source of great embarrassment to the surgeon during the operation,
for if  wounded near their  origin  they bleed  most furiously, and cause  con-
siderable  danger  afterwards, by interfering with  the proper plugging of the
vessel.   Of twelve recorded  cases, in which this artery  has been tied, it would
appear that three  only succeeded, whilst in the remaining nine instances  secon-
dary hemorrhage  occurred, which proved fatal  in three, and in six was arrested
by the ligature of the external iliac.   This operation I think, therefore, ought to
be banished from surgery, and in all  those cases of aneurism that  are situated
above the middle of the thigh, and in which sufficient space does not intervene
between the giving off of the profunda and the upper part of the sac for the ap-
plication of a ligature to the superficial femoral, the external iliac should be tied,
unless  compression can  be employed.
   Ligature of the Superficial  Femoral.—The superficial femoral artery,
in its course from the origin of the profunda to  the aperture  in the tendon of the
adductor, is divided  by  the crossing of the sartorius muscle into two portions of 
ligature  of  the  femoral artery.
503
unequal length, which have different relations to neighboring structures.   The
upper division of the artery, which lies above the anterior margin of the muscles,
is of most interest to the  surgeon, as it is in this part  of its course, that it is
invariably ligatured in cases of aneurism.   It  is true that John Hunter, in the
operation that he introduced for popliteal  aneurism, exposed and tied the vessel
in the lower third of the thigh, but his example has not been followed by modern
surgeons, on account of the far greater difficulty in reaching the vessel here than
in the first part of its course.
   The superficial femoral,  where it lies in Scarpa's triangle, being merely covered
by the common integument, the superficial fascia, and  the fascia lata, may be
reached by as simple an operation as any that the surgeon  has to perforin for the
ligature of the larger vessels.  An incision from three and a half to four inches
in length, should be made from a point, two inches below Poupart's ligament,
and as nearly as possible midway between the anterior  superior spine of the
ilium, and the symphysis  pubis, and carried downwards  in a direction parallel to
the axis of the limb.   The skin and superficial fascia, having been divided, the
fascia lata, which is here very thin, is exposed and opened to the same extent as
the incision in the integuments;  the inner margin of the sartorius  now comes
into view, and immediately to the inner side of, and perhaps slightly overlapped
by this, is the sheath of the vessels; this  must now  be cautiously opened, the
long saphena nerve being respected, and  the aneurism  needle unarmed passed
between  the artery and vein, from  within  outwards, about four inches below
Poupart's ligament;  it should then be threaded, withdrawn, and the ligature tied.
The edges of the wound  must now  be brought into contact  with a couple of
stitches and two strips of  plaster; the limb being semi-flexed, somewhat raised,
laid on its outer side, and  wrapped in soft flannel or cotton  wadding.   The severe
pain which is usually complained of about the  knee after the tightening of the
ligature, may best be relieved by a full dose of opium.
   In this operation there are several points of considerable  importance that
require special attention.  The ligature should always  be employed about four
inches below Poupart's ligament, so that sufficient space may intervene between
the origin of the profunda, which  is usually one  or two inches below the
crural arch, and the point deligated, to admit of the formation of a proper coa-
gulum in the vessel.   It has, indeed, happened that the  ligature has been placed
within three-quarters of an inch of the origin of the profunda, without any inju-
rious consequences resulting.   The proper point, however, for the deligation of
the artery is that indicated, which is usually the very spot at which the sartorius
crosses it; though, if this muscle be very broad, it may be necessary to draw it
to the outer side, and the vessel tied below it.  In cutting  down upon the artery,
the saphena vein, or  any  parallel branch,  should if possible be avoided.   After
the sheath has been opened, it will sometimes be found  that rather a large mus-
cular branch is given off from the artery at about the part  where it was intended
to ligature it; if so, this  must be carefully avoided, as  well as  any small veins
that cross the main trunk in this situation.
   The femoral vein which lies behind  and somewhat to the inner side of the
artery, is best avoided by passing the needle  from within outwards between
the two vessels, the inner side of the sheath  being at the same time put upon
the stretch by drawing upon it with a pair of forceps.   After the needle has
been brought up on the outer side  of the artery, a small  portion of the sheath
will sometimes be found to be pushed up by it;  this must be divided by being
carefully touched with the point of the scalpel, and the needle thus carried round
the vessel.
   AVound  of the  femoral vein is without doubt the most serious accident that
can happen in the operation for ligature  of the  superficial  femoral  artery, and
is one of which there is especial risk when this operation  is had  recourse to for 
504         aneurisms of the lower  extremities.

aneurism, as in this disease the fine cellular tissue which naturally connects the
two vessels often becomes thickened and indurated, in consequence of inflamma-
tory action having extended upwards from the sac to the sheath of the vessels.
It is best avoided by passing the needle in the way that has been already recom-
mended, unarmed,  and without the employment of force.   This accident^ is
almost invariably fatal, there being  but very few instances on record  in which
patients have survived it;  death usually resulting from diffuse phlebitis, or the
supervention of gangrene.   The true cause of the fatal result in these cases was
first pointed out by^Ir. Hadwen, Avho showed that when the vein is wounded
by the aneurismal needle, it is transfixed at two points, between which the thread
is drawn across;  and when this is  tied, a  segment of  the vein is necessarily
included with the artery in the noose.  It is this inclusion of the ligature within
a portion of the vein, where it acts like a seton, and keeps up constant irritation,
that prevents the occurrence of adhesive phlebitis, and occasions diffuse inflam-
mation in the interior of the vessel;  and  it  is consequently this circumstance,
and not the mere wound of the vein, that  determines the great fatality  of this
peculiar accident.   Guided  by this view of the mechanism of the injury, the
indications in  its treatment become obvious.   They consist  in  removing the
ligature at once, and thus, by  taking away the main source of irritation, con-
verting the wound into  a simple puncture  of the vessel,  which readily assumes
adhesive action.   The surgeon  should, therefore, as soon as the accident is per-
ceived, withdraw the ligature,  and opening the sheath about half-an-inch  higher
up, reapply it to the artery there.   The hemorrhage  from the punctured vein
readily ceases on the application of a compress.
  The ligature of the femoral artery for popliteal aneurism, is  an operation that
has been so frequently performed, that surgeons seldom think  of recording cases
of this  description, unless they present complications  or sequela? of unusual
interest or severity, hence but little importance can be attached to any statistical
deductions from reported cases as to the fatality of this operation, although they
may serve as a rough estimate of the proportion maintained between the different
accidents, such as hemorrhage, gangrene, &c, that follow it.   That the ligature
of the femoral artery is attended with more success than that of any of the other
large  trunks, can admit of no  doubt.   This is  not only  in accordance with the
general experience of surgeons, but is confirmed by the  statistics of published
cases, even without making allowance for the probability of more of the  unsuc-
cessful than successful having been recorded.   Thus of 110 instances, collected
by Dr. Crisp, in which the femoral artery has  been  ligatured for popliteal aneu-
rism, only twelve are reported to have died; amongst  these, four deaths occurred
by secondary hemorrhage,  three by gangrene, and the others by phlebitis, tetanus,
chest  disease, &c.
  The occurrence of secondary hemorrhage after the ligature of the superficial
femoral is a troublesome accident, and one in which the surgeon, to use 3Ir.
Fergusson's  expression, " will  most  assuredly  find  himself in  an eventful
dilemma;" and in which it is necessary that his line of action should have been
well considered beforehand, as he may not  have much time to spare for reflection
when the occurrence has taken place.  In these cases four lines of treatment present
themselves, viz., the employment of pressure;—the ligature  of the vessel at a
higher point;—the deligation of the bleeding apertures in the wound, or ampu-
tation of the limb.
  Pressure  may be applied by placing a graduated  compress of lint or  com-
pressed sponge over the  bleeding  orifice, and fixing it there  firmly by a horse-
shoe tourniquet.   This means, although extremely  uncertain, occasionally suc-
ceeds ; should it not do so, however, and  bleeding recur a  second  time, it is
useless to continue it, as experience has shown that the hemorrhage will continue
until the patient is worn out. 
FEMORAL  AND POPLITEAL  ANEURISMS.
505
  The ligature of the  superficial femoral at a higher point, or if the artery has
been tied too high for this, the deligation of the external iliac, presents itself as
a probable means of arresting the hemorrhage.  Such an operation,  however, is
fraught with danger, and has, I believe, invariably been followed by gangrene of
the limb.  It might at first be supposed that the  limb would not be placed in a
worse situation after the  ligature of the external iliac, whether the superficial
femoral  had been  previously tied or not, the anastomosing channels  remaining
the same in either  case.  But in reality  it is not  so;  for although the blood
might find  its way through the  epigastric, the circumflex ilii,  the  gluteal and
sciatic arteries,.into the profunda and its branches, yet from this point the diffi-
culty of its transmission through the limb would be materially increased.   If the
superficial femoral be open, it serves as a direct and easy channel for the con-
veyance, to the vessels of the leg and foot,  of the  blood  brought by the anasto-
moses.   But when  the superficial femoral is tied, this blood  must find its way
through a second chain of anastomosing vessels,—those intervening between the
branches of the profunda and the articular arteries  of the knee;  and here the
real difficulty would arise, its impulse not being sufficient to  overcome the ob-
struction to  its passage through these small channels, which might not improbably
be still further obstructed by the pressure of the  aneurism.   Should the anasto-
mosing circulation be sufficiently free to maintain the  vitality of the limb, it is not
improbable  that the recurrent blood would escape from  the  distal  side of the
ligature, and thus keep  up the hemorrhage exactly as in a case of, wound.   It
appears, indeed, that the femoral artery, in a case of secondary hemorrhage after
the application of the ligature, is in very much the  same condition as an  artery
which has been wounded, and in which the bleeding, having been suppressed
for some days, has returned with violence;  and I think the best course for the
surgeon  to pursue  is the same practice  that he would  follow in  the event of
secondary hemorrhage occurring from a wounded vessel, viz., by  cutting down
upon  the bleeding part and applying a ligature to it.    That such an  operation is
surrounded with  difficulties  cannot be doubted;  but yet none  would present
themselves that care and skill might not  overcome.   The surgeon would cer-
tainly have to cut into a part infiltrated with blood, in which the different tissues
could not readily be distinguished, and the vessel when reached would be  found
to be  soft, friable, and granulating, yet by free dissection above and below the
wound,  a portion of it might at  last be  exposed, where its coats would hold a
ligature; or should  this not be found, the wound might be firmly plugged from
the bottom with compressed  sponge;  or the bleeding aperture touched with the
actual cautery.  Should these means fail, it would, I think, be safer to amputate
the limb than to endeavor to arrest the hemorrhage in  any other way.
   Gangrene of the limb is perhaps the most frequent source of danger after the
ligature of the femoral artery for popliteal aneurism.  It seldom occurs, how-
ever,  unless the tumor be of considerable magnitude, have become  diffused, or
otherwise interfere  seriously with the circulation through the limb.   I  have,
however, seen it follow after the operation where the popliteal  aneurism had not
attained a larger size than that of an orange;  but, in this case, there was  much
oedema of the  limb, and  congestion of the veins  before the operation, and on
examination afterwards, it was found that the popliteal vein had been obliterated
by the pressure of the tumor.  The gangrene may, in some cases, be prevented
by the treatment that  has been pointed out at page  171.  When it has fairly
declared itself, there is  necessarily no resource left but amputation, and this
operation is  sufficiently successful;  for I find that of fourteen cases  in which it
was done there were ten recoveries, and but four deaths.
  The return of pulsation in the sac after  the  operation for popliteal  aneurism
is by no means of frequent occurrence, but yet, it has been met with in some
instances, and secondary aneurism  has  also been  found  in this  situation.  In 
506         ANEURISMS  OF THE LOWER  EXTREMITIES.

these cases the patient should be put upon a  careful dietetic plan, the limb be
kept elevated and at rest, and  pressure applied by means of a  compress and
bandage, or a horse-shoe  tourniquet.  In this way cures have been  effected by
AVishart, Turner, Briggs, and  Liston.  In  conjunction with  such treatment, or
in the event of its not sufficing, the compression of  the  common femoral artery
as it passes over the pubes, would in all probability effect a cure.   Should it not
do so, and the tumor continue to increase, threaten to suppurate, or  to occasion
gangrene, amputation would be the sole resource.
   In the  case of double popliteal  aneurisms, the artery has  been occasionally
ligatured with advantage on both  sides,  either  simultaneously, or, more safely,
consecutively.  But these cases  appear to  me to be especially adapted for the
employment of pressure, so  as to  avoid  that  disturbance of the balance of the
circulation  which is  certain to  ensue when one vessel  is  ligatured,  and which
may act injuriously upon the opposite aneurism.  AVhen the popliteal aneurism
is conjoined with  a  similar disease of the groin, the ligature of the external
iliac is the proper course to pursue, and will effect a  cure of both affections.
   AVhen a circumscribed popliteal aneurism suddenly becomes diffused, the
patient  is seized with faintness or sickness, with  pain, numbness,  and a hot
trickling sensation in the limb, the temperature of which falls at  the  same  time
that its bulk increases, and the integument  assumes a white, shining, mottled
appearance, with more or less purplish  discoloration.  This  condition  usually
occurs after a circumscribed aneurism has existed in the ham for some weeks or
months, and on the occurrence of  some sudden exertion.   In some  cases,  how-
ever, the disease appears to have been diffused from  the very  first, the  coats
having given way, and extravasation having taken place into the  cellular tissue
of the limb, without the previous  consolidation of the parts around  the artery,
or any attempt at the formation  of a sac.   In these  cases the extravasation into
the limb may either be conjoined with much  oedema, or it may be  confined to
the cellular tissue of the ham, and to  the  upper and  back part of the  leg.
AVhen  the patient comes under the observation of the surgeon, the tumor is
found to be  solid, elastic, and  irregular, without pulsation  or bruit, the  limb
cedematous, cold, and congested.   It is this form of  aneurism that it  is not very
easy to distinguish from  malignant tumor of the ham.
   The danger  attending on popliteal aneurism is  greatly increased by its be-
coming  diffused.   Under these circumstances  the ligature of the artery usually
affords but a  slender prospect of success, the collateral vessels  being so  com-
pressed  and choked by the pressure of the effused blood as not to admit of the
circulation  being carried on through them; hence, in many of these  cases, the
only resource left is amputation.
   The question of amputation  in cases of diffused popliteal aneurism is not
very easily submitted  to any very positive  or definite rules, except in those
instances in which the  impending gangrene  is so  evident as not to admit of
doubt.   There are, however, certain general  considerations that  may guide the
surgeon in coming to a decision on this point.
   In some cases the sac has  either given way to a very limited extent, or else
its walls having become thin and expanded, are  yielding rapidly  under the
pressure of the blood, becoming fused with the surrounding parts.  Here we
should ligature the artery without delay;  for, although  it  is but  seldom that a
limb can be saved when  once the  blood  has  become infiltrated into the general
cellular tissue, yet it is possible  such a fortunate occurrence may happen.
  ^ In other instances the aneurism has not from the  first been very distinctly
circumscribed.  It has followed the infliction of some mechanical  injury, and
in the course of a week or two has acquired a considerable size, without definite
or distinct limitation, being solid  or but little compressible.  Such  a  case as
this can scarcely be considered,  strictly speaking, a diffused aneurism; but yet, 
              AMPUTATION IN POPLITEAL  ANEURISM.          507

if by circumscribed we mean that  the blood is contained in a defined cyst with
walls, it  scarcely complies with such a definition, the fluid blood being rather
prevented escaping widely by a temporary barrier of coagula entangled  in  the
loose cellular tissues of the part, and the vessel being ruptured to a considerable
extent, or completely torn across.   Here we are certainly justified in  having
recourse  to ligature with a good prospect of success.
  AVhen the  ham is occupied by a  large, rapidly-increasing tumor, extending
perhaps  some way down  the calf  and up the  thigh, and encroaching  on the
knee, the skin covering it being more or less discolored, there  being no pulsa-
tion perceptible in the tibials, and the  veins of the  limb being full and  even
somewhat congested,  the foot cedematous, and several  degrees  in  temperature
below that of the  opposite limb, the  difficulty of coming to a  decision  is con-
siderable. '
  In such a case as this, I think the existence or non-existence of pulsation of
a distensile  character would  be a  circumstance of very great  importance, and
may serve to guide the surgeon.
  If there be distinct impulse of a distending character, which  can be arrested
by compression of the femoral artery, with  some diminution of the size of the
tumor, it is an evident indication of the transmission of blood through the sac,
and  that  this contains some fluid blood.   Under these circumstances it will, when
the  artery is  tied, subside to a considerable extent, thus  allowing more space
for the conveyance of the collateral circulation, and  it would be but right  to give
the patient the chance of preserving his limb by ligaturing the  vessel.
  If, however, the tumor have, from the very first that it attracted the patient's
notice, been more  or less solid and incompressible;  and though it may at an early
period of its existence have pulsated, if this pulsation has suddenly ceased, the
aneurism at the same time having undergone  rapid and great increase of bulk
with much tension and lividity of  the integuments,  oedema and  coldness of limb,
with a tendency perhaps to vesication and ulceration of the skin covering the
tumor, there is no resource left but amputation.
  It must, however, be borne in mind that  the aneurism may become diffused,
and  extensively so, without any very great change in the shape  and size  of the
limb.  It is only  when the  sac ruptures in  such a position that the blood is
effused into  the  general cellular  tissues of the limb or under the skin, that
much tension of the  integuments and  increase in the  bulk of the part takes
place.
  AVhen the rupture  occurs in a part of the  sac that is more deeply seated, so
that the  blood is extravasated underneath the deep fascia of the leg, it is bound
down by this and  the superincumbent muscles, and deep-seated disorganization
of the limb may be the result, without  much, if any, change in its bulk or in
the  color of the integuments, but with  deep-seated  pain, which is excessive.
There must always be  considerable risk in such a  case as  this  of  confounding
the arterial disease with solid tumor, and the diagnosis can only be effected  by
a reference to the  early history of the case, and more  particularly to the exist-
ence or not of pulsation at this period.   Indeed, the existence or non-existence
of pulsation in these cases is  of the very utmost  importance in reference  to the
question  of  treatment.   The pulsation  may have ceased in a  case  of diffused
popliteal  aneurism, in consequence of the blood that has been extravasated being
so confined and bound down by the fascia and muscles under which it is effused,
that it compresses  or seals the mouth of  the artery  leading into the sac, to  such
an extent as to arrest the passage of blood through it, either wholly or  so that
it enters  in a feeble stream, of insufficient force to communicate impulse  to the
fluid that has been extravasated into the  limb.   This  pressure  may, as  in the
case of which an illustration has been given  (Fig. 144), be confined to the deep 
 508         ANEURISMS  OF THEyLOWER EXTREMITIES.

 parts of the limb and not give  rise to  much, if any, general  tension of it, the
 blood being confined below the  deep fascia, where it communicates the sensation
 of a hard, solid, elastic tumor, devoid of pulsation; attention should consequently
 not be  too exclusively directed to the state of general tension of the surface of a
 limb, as this is by no means necessarily an  indication of the state of the  parts
 beneath.   But the  surgeon should  rather  look to the presence  or absence of
 pulsation.  If pulsation still  exist, the blood continues to find its way into the
 sac, and  most probably  through it, the  tension of the  parts not  having yet
 reached its maximum.   If there be no  pulsation,  he may  be  sure  that the
 entrance  of blood into the diffused aneurism  has ceased  in consequence of
, compression exercised on the mouth of the artery leading  to it, by the tense
 condition of the surrounding and  enveloping  tissues reacting on the mass of
 blood  effused  beneath them.   In  such a  state of  things as this, the vitality of
 the lower part of the limb can only be maintained  by the blood  that may find
 its way through the anastomosing channels;  and this may, if the  tension of the
 limb be not general,  the  extravasation  being confined to below the deep fascia,
 be sufficient for this purpose.   If surgical  interference be delayed in such a case
 as this, the deep fascia will  soon give way by rupture or ulceration, and the
 blood will be infiltrated into the general cellular tissue of the  limb, and then, by
 compressing those collateral branches  that  have hitherto maintained a feeble
 circulation  in it, will infallibly occasion gangrene.   If,  on the other hand,  liga-
 ture of the main artery be had recourse to, the anastomosing  circulation, which
 may have been barely sufficient  to keep up a feeble vitality in the leg and  foot,
 will be so much interfered with that gangrene  of the  limb  inevitably ensues.
 The only resource, therefore, that is  left in  these  cases is to amputate at once,
 in order  that  the patient may  be saved  the  shock of the  constitutional dis-
 turbance occasioned by the setting in of mortification, as well as  the pain and
 risk of a previous unnecessary operation.
   AVhen gangrene threatens; the leg  and foot  having become  cold, the  skin
 being  either pale, tallowy, and mottled, or discolored, of a purplish hue, with
 perhaps vesications and much oedema, whether the ligature have been previously
 applied to the femoral artery or  not, or  (whatever the condition of the aneurism
 may be, whether circumscribed or diffused), the patient will stand a  better
 chance  of ultimate  recovery by having the  limb  removed at once  above the
 knee.   The part at which amputation should be performed is a point deserving
 some consideration in these cases.   If  the femoral artery have been ligatured,
 the thigh should be  amputated on  a level with the  ligature, the artery being
 cut just above  this.   In this way the double risk that the patient would other-
 wise run of secondary hemorrhage from the  seat of the ligature, as well as from
 the face of the stump, will be reduced to a single chance of hemorrhage from
 the stump.   If the amputation  be the primary operation, it should be done at
 the  lower  third  of  the   thigh,  provided  the  extravasation  be confined to
 below the  knee,  or higher up,  if the effused  blood have extended  above  this
 joint.
   Aneurisms of the tibial arteries  are extremely rare,  except as  the result of
 wound^ but yet they are  occasionally  met  with;  and in  the museum  of St,
 George's Hospital is a preparation of a small aneurism of the posterior  tibial.
 These arteries  may, however, require ligature either for injury or  disease.
   Ligature of the Tibial Arteries.—The posterior tibial artery may be tied
 in two parts of its course.   Either behind the  ankle or in the calf of the  leg.
 Behind the  ankle it may be reached by making a semilunar incision three
 inches long, about three-quarters of an inch behind the malleolus, towards which
 its concavity should look.   After dividing  the integument and superficial fascia,
 the deep fascia must  be laid open, which  closely invests the vessel,  nerve, and
 tendons in  this  situation  when the  artery will be found, accompanied by two 
                 ANEURISMS  OF  THE  INNOMINATA.              509

veins, from which it must be separated before the ligature is  passed.  Anterior
to the vessel, and nearer the bone, are the tendons of the flexor digitorum com-
munis, and tibialis posticus; behind is the nerve  and the tendon'of the flexor
proprius pollicis.
   In the middle of the leg, the posterior tibial  artery should only be tied for
wound in that situation.   Under such circumstances no regular operation can
be  performed, but  an  incision of sufficient length, taking  the wound for its
centre, should be made through the gastrocnemius and soleus, parallel to their
fibres, when, after these have been cut through, the deep fascia will be exposed.
This must next be  opened, when the artery will be found, accompanied by its
veins and having the  nerve to the outer side.  From  the depth  at which the
vessel is situated, and the free incisions that it is necessary to make  through
muscular parts, it is extremely difficult to apply the ligature in this situation.
The later steps of the  operation may be  much facilitated by flexing the leg on
the thigh, and extending the foot, so as to relax the muscles.
   The anterior  tibial  may be tied  in several  situations, but the same remark
applies to this as to the posterior tibial, that it should  not be ligatured except
for injury.  The difficulties of the  operation are lessened as the  ankle  is ap-
proached, where the artery becomes superficial, and may easily be secured.   In
the upper third of the  leg it lies deep between the tibialis anticus  and extensor
communis digitorum muscles,  surrounded by veins, and having its  nerve to the
outside.  If it be ever found  necessary to tie it in this situation,  the incisions
requisite to expose it should be made  at least four or five inches in length, and
especial care should  be  taken not to cut into the muscular substance, but  to get
into the first  intermuscular space to the outside of the tibia, at the bottom of
which the vessel will  be  found.  In  the middle third of the leg,  the artery is
crossed by the extensor pollicis, and will be found between the  tibialis anticus
and this  muscle; it is best reached  here by keeping well to the inside of the
tibialis anticus.
  The dorsalis pedis may be felt pulsating, and may readily be  secured, as it runs
forwards from the ankle-joint  to reach the space between the first and  second
metatarsal bones, lying between the tendon of the extensor pollicis and that of
the extensor brevis  digitorum.
                       CHAPTER  XXXVIII.

      ANEURISMS OF THE NECK AND UPPER EXTREMITY.

                    ANEURISMS OF THE INNOMINATA.

  Aneurisms of this artery may either be of the tubular or the sacculated kind,
and usually give  rise to  a train of serious and dangerous symptoms from their
pressure  upon important parts in their neighborhood.   Indeed, a glance at the
relations  of this artery will show the important effects that must be produced by
the pressure of a tumor springing from it.   Before it lie the left innominata vein
and the superficialis cordis nerve; to its left is found the trachea, and more pos-
teriorly the oesophagus; on its right are the innominata vein of that side, and 
510              ANEURISMS  OF THE  INNOMINATA.
the summit of the pleura costalis;  externally and  posteriorly it is in relation
with the par vagum, and  more posteriorly and internally it lies before the right
recurrent laryngeal nerve.
  The general symptoms  of an aneurism of this  artery are  the existence of a
pulsating tumor of a  globular shape behind the right sterno-ckvicular articula-
tion, attended with pain, and perhaps oedema  of the right side of the face and
arm, with some difficulty  in respiration, laryngeal  cough, and dysphagia.  The
tumor is usually soft and compressible, filling  up more or less  completely the
hollow about the sternum, and even rising  as  high in the neck as the lower
margin of the cricoid cartilage; it pushes forwards first the  sternal, and after-
wards  the clavicular portion of the sterno-mastoid muscle, and  has occasionally
been seen to extend into the posterior inferior triangle of the neck ; and indeed
is  generally most distinctly defined towards  its brachial aspect.   In some-cases
no tumor rises into the neck, but the sternum, clavicle, and costal cartilage of
the first rib, are found to  be considerably pushed forwards beyond their natural
level.  In  the space  around the  right sterno-ckvicular articulation, and about
the upper part of the  sternum, there will  be dulness on percussion.   In very
many instances there is no bruit, but merely a strong impulse with the heart's
sounds, as distinct, or even more so than in the  cardiac region, but in other cases
there is every variety of bruit.
  The most important symptoms are occasioned perhaps by the pressure  effects
of the tumor  upon the  neighboring  parts, affecting the pulse, the venous circu-
lation, respiration, and deglutition.
  The pulse is usually influenced,  being much smaller and feebler in the radial
artery of the  affected than of the sound side, and  in some instances being com-
pletely arrested;  owing,  doubtless,  to  the occlusion of the subclavian.  The
pulsation in the right  carotid and  its branches  is also frequently much less
powerful than in the opposite vessel;  these signs commonly occur before any ex-
ternal  tumor is seen or can be felt, and hence constitute an important element
in the early diagnosis of the disease.
  Enlargement of the superficial veins of the neck and right upper extremity is
of frequent occurrence, the external  jugular being the vessel that is usually first
dilated;  at  a more advanced period the superficial subcutaneous veins of the
upper part of the right side of the  chest often become tortuous, and form a dense
plexus in this situation, while many anastomose with the cephalic and thoracic
veins above, and the superficial epigastric below.   As  the  pressure increases,
oedema commences in the right eyelids  and hand, and may speedily extend to
the whole of the head, face, and arm, which become  hard  and  brawny in con-
sequence of serous infiltration.  In  one  case  I have seen the left arm become
suddenly cedematous,  the  left innominata vein being pressed upon.   In  these
cases the eyes become  staring and  prominent, and the lips, nose, and features
livid and turgid with blood, as well as cedematous, so as materially to alter the
patient's expression of countenance.
  Pain of a dull aching character is experienced in the situation of the tumor,
from  the compression of the neighboring structures.  But early in the disease,
and among some of the  first symptoms, the patient  often experiences sharp shoot-
ing pains, apparently of a rheumatic or neuralgic character, in the arm and side
of the head and face.   This is from pressure upon, and irritation of, the cervi-
cal and brachial plexuses of nerves, and taking the course of the ascending and
descending filaments of the former, the pain shoots up the side of the head and
neck, over the shoulder and upper part of the chest;  or, from pressure upon the
brachial plexus, radiates down the  hand and arm, being usually especially severe
about the elbow and fingers.  At the same time the muscular power of the right
arm commonly becomes impaired. 
         TREATMENT  OF  BR ACHI0-CEPHALIC  ANEURISM.      511

  Dyspnoea is of very common occurrence, and very varying degrees of intensity,
from slight difficulty in breathing up to
fatal asphyxia.   It may  proceed either                Fis-159-
from  irritation of the layrnx, in conse-
quence of compression of the recurrent
nerve; or,  from pressure on the  trachea,
or the right bronchus.  AVhen dependent
on laryngeal irritation, the voice is hoarse,
husky, or whispering; and there is a dry,
croupy,  and paroxysmal  cough, usually
accompanied by expectoration of frothy
serous mucous.   In  these  cases,  after
death the  recurrent nerve will be found
to be stretched out and greatly elongated
by the pressure of the tumor (Fig. 159).
Compression of the trachea, which becomes
flattened and curved over to the  left side
by the protrusion of the tumor, is a com-
mon cause  of dyspnoea,  and  is  not un-
frequently associated with the laryngeal
irritation.   More rarely by far, the right
bronchus is compressed by the extension  of the tumor downwards.
   Dysphagia is of sufficiently frequent occurrence, and varies from slight uneasi-
ness in deglutition to an impossibility in swallowing anything  except  fluids.   I
have never  seen it occur without its  having been  preceded  by dyspnoea; and
in every instance that has fallen under  my observation, it has been  associated
with laryngeal irritation.   This  coincidence of these two symptoms  is readily
explained by the anatomy of the parts;  the recurrent  nerve lying as it  does
between  the artery and oesophagus, must  suffer compression before  the mucous
canal can be interfered with.
   The prognosis of brachio-cephalic aneurism is in  the highest degree unfavorable,
though the  disease frequently does  not run a rapid course.   If it extend up-
wards and outwards, the tumor may acquire a very large size before any very im-
portant organ or part is implicated ;  but  if it  press backwards and  inwards,  it
may prove  fatal at an early period.  I know of no case  in which such an aneu-
rism, if left to itself, has undergone spontaneous  cure, and but few instances in
which the rupture of the  sac has taken place.  The  most frequent cause of death
is by asphyxia, from spasmodic closure of the layrnx induced by irritation of the
recurrent nerve ; or by pressure  on the trachea.
   Treatment.—There are several instances  on record in which a properly con-
ducted course of constitutional  treatment has  cured a patient.   Thus  a  case of
3Ir.  Luke's was permenantly cured by small and repeated bleedings, conjoined
with the administration of digitalis.   In  connexion with such  treatment, distal
pressure  might be employed, as in a case that derived  benefit from this plan in
Mr.  Syme's hands.
  In aneurism of the innominata, the vessel is  so short and the sac so situated,
that it is impossible  to attempt to apply  a ligature  on  the cardiac side  of the
tumor.   AVhat recourse then does  surgery offer in  these  cases beyond the em-
ployment of constitutional and dietetic means ?  It may be answered  to this, that
if these measures fail  in arresting the disease,  our choice must lie between two
alternatives; leaving the  patient to his fate, or  having recourse to the application
of the ligature on the distal side of the tumor.   On looking"on the innominata
artery with  reference to the distal operation, we are struck by two  peculiarities

  Fig. 159.—Aneurism of the innominata nrtery compressing and  stretching the recurrent laryngeal nerve,
and pushing the trachea to the left side. (Back view.)
 
512
ANEURISMS  OF  THE  INNOMINATA.
in the vessel, which must necessarily modify to a considerable extent not  only
the seat  of the operation, but the  principle  on which it is  conducted.   The
first peculiarity to which I allude is the shortness of the trunk, which makes it
impossible to apply the ligature  to the vessel  itself, but renders it necessary to
deligate  one or both of its terminal branches.  The  other peculiarity  is,  that
under no circumstances can these vessels be so  ligatured as to arrest the whole of
the blood sent into the artery;  for  although the circulation through the carotid
may be entirely stopped, yet it is impossible, from the seat and extent of the
disease, to tie the subclavian at any point except beyond the scaleni, all  that
blood which is  destined for the supply of the branches of this vessel—viz., the
vertebrals, the thyroid axis, the internal mammary, and the first intercostal, must
therefore  continue to  be  propelled  into and  through  the sac.  Three distinct
modifications of the  distal operation have been proposed and  resorted to  for the
cure of aneurisms  in this situation.   1st, the  ligature of the  subclavian alone;
2dly, of the carotid alone; and, 3dly, of both vessels, with an interval of greater
or less extent.
                                   Fig. 160.
  The ligature of the subclavian only (Fig. 160, 1), has been practised in three
cases, the results of which are exhibited  in  the accompanying table; two were
fatal, and the partial success of the third may be fairly attributed in a great mea-
sure, to the accident of the carotid being occluded.   The results of this practice
have certainly not been sufficiently favorable to justify the surgeon in  repeating
an attempt of this  kind, opposed as it is  to the known  principles on which the
distal operation effects  a cure.   For supposing, as we  may safely do, with Mr.
AVardrop, that only one-third of the blood that is sent into the innominata finds
its way  through the extra-scalenal portion of the subclavian, the remainder being
destined for its branches and the carotid in equal proportions, what fact can be
adduced or principle laid down by which we can expect  to obtain the cure of an
aneurism in  close proximity to the heart, by cutting off so small a proportion
as one-third of the supply of the blood sent into it ?
  The ligature of the carotid  only (Fig.  160,  2) has been practised  in seven
cases, as recorded in the annexed table, and in one case only does  the  disease
appear to have  been materially benefited,  and  in that instance the  good effects
can scarcely be attributed to the operation, but must rather be looked upon as
an effort of nature  to effect a spontaneous cure, the sac  becoming inflamed and
suppurating,  and the arteries of the arm and  head on the side affected  having 
   DISTAL  OPERATION  FOR BRACHIO-CEPHALIO  ANEURISM.  513

been obliterated.  Mr. Key's  patient died  in  consequence  of the left carotid
being occluded, and the brain  being deprived of its proper supply of blood.

ANEURISMS OF INNOMINATA  TREATED BY LIGATURE OF  SUBCLAVIAN ONLY.
REMARKS.
Subclavian ligatured im-
  mediately above clavi-
  cle, tumor diminished,
  but  pulsations  con-
  tinued.  Aneurism of
  subclavian,with dilata-
  tion of innominata and
  aorta.
Vessel  ligatured  imme-
  diately above clavicle.
  Aneurism  of brachio-
  cephalic ;  aorta  was
  dilated, and right caro-
  tid obliterated  by the
  pressure of the tumor.
Subclavian ligatured be-
  yond scaleni; the pul-
  sations  in   and  size
  of tumor diminished,
  and  respiration  be-
  came  freer; on  the
  ninth day pulsation re-
  appeared in right caro-
  tid, in  which  it had
  previously  been  ab-
  sent.   (We  may as-
  cribe success of opera-
  tion  to this circum-
  stance.)
  In three  cases  both  the carotid and subclavian arteries have been tied (Fig.
160, 3.)   In the most favorable  of  these, that by Fearn, two years elapsed  be-
ANEURISMS OF  INNOMINATA TREATED  BY  LIGATURE OF  CAROTID ONLY.
OPERATOR.	SEX.	AGE.	RESULT.	CAUSE OF DEATH.	REMARKS.
1. Evans.	m.	30.	Recovered.		The tumor diminished for a few days after operation, but at the end of seven days inflammation of the sac set in, followed by obliteration of the arteries of the right upper extre-mity and the branches of the carotid. At the end of a year, the tumor still existed,with constant pul-sation. The next year the sac suppurated, and discharged much pus. Disease arrested, but not cured.
33
OPERATOR.
1. DtJPUTTREN.
2. Laugier.
3. Wardrop.
SEX.	AGE.	RESULT.	CAUSE OF DEATH*.
m.	40.	Died on ninth	Exhaustion
		day.	following cough and secondary hemorrhage.
m.	57.	Died a month after ope-ration.	Asphyxia.
f.	45.	Died two years after operation.	Exhaustion.
 
514
ANEURISMS  OF  THE  INNOMINATA.
ANEURISMS  OF INNOMINATA TREATED BY LIGATURE OF  CAROTID
                             (Continued.)
OPERATOR.	SEX.	AGE.	RESULT.	CAUSE OF DEATH.	REMARKS.
2. Mott.	m.	55.	Died seven	Asphyxia.	After the operation, the
			months after operation.		radial pulse in the af-fected side disappeared,
					and the tumor in the neck
					was much diminished.
					After death no external
					appearance of tumor, but
					internally it was as large
					as a double fist.
3. Aston Key.	f.	61.	Death a few	Narrowing of	Aneurism of innominata
			hours after	vertebral arte-	and of arch of aorta found.
			operation.	ries, brain not receiving suffi-cient blood for the mainte-	The orifice of left carotid nearly occluded, and ver-tebrals smaller than natu-ral.
				nance of its	
				functions.	
4. Fergusson.	m.	56.	Died on seventh day.	Pneumonia.	Tumor and pulsation de-creased after operation. Tumor nearly filled with firm laminated coagu-lum, no plug in carotid.
5. MOERISON.	m.	42.	Recovered	Suddenly,	Aneurism of innominata
			from operation,	cause not	and carotid found. Arch
			died twenty	stated.	of aorta diseased. Right
			months after-		carotid dilated into a sac
			wards.		as high as part ligatured, and plugged by dense fibrinous laminae.
6. Campbell.	m.	48.	Died on nine-teenth day.	Pneumonia.	Tumor began to disappear after the vessel was liga-tured. After death aneu-rism of innominata and transverse portion of arch, and dilatation of descending aorta as far as diaphragm were found.
7. Hutton.	m.	47.	Died on sixty-	Bronchitis, in-	Tumor diminished after
			sixth day.	flammation, suppuration, and ulceration, of sac into trachea.	ligature. Size and pul-sation less. After death tumor contained purulent matter and grumous blood ; had opened into trachea. Right carotid and subclavian contained firm coagula.
tween the ligature  of the carotid and that of the subclavian, the patient dying
three months after the second operation, and the sac appearing to be filled with
laminated coagulum,  and appearing to  be undergoing spontaneous cure.  The
third case is remarkable  as being the only  instance in which  both  the vessels
were tied simultaneously, and from the patient having lived for six days after the
occlusion of all the  arteries supplying the  brain except the left  vertebral.
   Having thus  given a resume of the cases of  aneurism of  the innominata, in
which the operation of ligaturing the artery beyond the sac has been performed, 
DISTAL  OPERATION FOR BRACHIO-CEPHALIO  ANEURISM.   515
ANEURISMS OF INNOMINATA TREATED BY  SUCCESSFUL LIGATURE OF CAROTID
                             AND SUBCLAVIAN.
OPERATOR.	SEX.	AGE.	CAROTID LIGATURED.	SUBCLAVIAN LIGATURED.	REMARKS.
1. Hearn.	f.	28.	Carotid	Subclavian	Died three weeks after second ope-
			ligatured,	ligatured,	ration from pleurisy. Sac of aneu-
			Aug. 30th,	Aug. 2d,	rism of innominata filled with
			1836.	1838.	dense organized coagulum; except a channel the size of artery for the passage of the blood.
2. WlCKHAM.	m.	55.	Carotid	Subclavian,	Tumor diminished after ligature of
			ligatured,	Dec. 3d,	carotid, and dyspnoea ceased for
			Sept. 25th,	1839.	a time, but symptoms returning,
			1839.		subclavian was tied. Relief of symptoms ensued, but tumor in-creased, and patient died two and a half months after first bursting of sac.
3. Rossi.			Carotid and	Simultane-	Death in six days. Occlusion of left
			subclavian.	ously.	carotid and right vertebral arteries; circulation of brain carried on by left vertebral merely.
the question  arises whether any or all  these operations should retain a place in
surgery.   This question may be examined in two points of view: 1st.  As to
the principle  on  which these operations are performed; and  2dly, as to their
results in practice.   For the success of the distal operation, it is requisite either
that there be no branch given off  from the sac, or  between it and  the ligature;
or that the current of blood through the sac may at least be so far diminished as
to admit of the deposition of  laminated fibrine in sufficient quantity to fill it up
by a process similar  to what happens in a case of aneurism treated  by the Hun-
terian method. In order that this be accomplished, it is certainly necessary that
the greater portion of the blood  passing through it be arrested, for if the current
that is still kept up through it is too free, the tumor will continue to increase, as
we have seen happen in those cases  of inguinal aneurism in which the femoral
artery  is ligatured below the epigastric and the  circumflex  ilii,  the current
through which is  sufficient to feed the sac in such a way that a cure could not
be accomplished.   If, therefore,  but  one of the vessels leading from the brachio-
cephalic, as the subclavian beyond  the scaleni, be tied, and but a  third  of the
blood  circulating through the  main branch be arrested, are we justified  in hoping
that the circulation through the sac would  be so influenced by the deprivation of
this small  quantity  that  the  remaining two-thirds of  the blood, which  would
still pass through for the supply of the carotid and  the branches of the subcla-
vian, would gradually deposit  those fibrous laminoe Uy which obliteration  of the
tumor is  to be effected ?  Should  we not  rather expect that the larger current
would be too  powerful to allow of  the formation of these  layers, and would  con-
tinue to distend  the  sac in such a way as  to prevent its contraction.   Surely if
the comparatively small  and feeble streams  of  blood that pass  through the
epigastric and circumflex ilii are sufficient to interfere with  the cure  of an
inguinal  aneurism after the distal ligature  of the femoral, the strong current
that sweeps through the carotid  and large branches springing from the  sub-
clavian with  the full force derived from close proximity to the heart, will be
sufficient to prevent all lamination  in  an aneurism  of the innominata.   That
the arrest  of the  circulation  through  one of these vessels only  is  not suffi- 
516
ANEURISMS  OF THE INNOMINATA.
cient to influence materially the growth  of the  aneurism, is  evident likewise
from what is not unfrequently observed after death in cases of this kind—one or
other of the vessels  being found compressed and obliterated by the pressure of
the sac, and yet no  alteration in the  tumor resulting.  These  cases, which are
tolerably numerous, would of themselves have been sufficient to  have proved that
something more than this  amount  of obstruction is required  in order to effect
proper stratification of fibrine in the sac; and if we turn to the result of the ten
cases, in which either the carotid or the subclavian has been ligatured, we shall
find that in one case only, that operated on by Mr. Evans of Belper, has a cure
been effected : and in this instance how was it accomplished ?  According to the
principle  on which  it was  attempted to be  established ?  Certainly not, but as
will be seen  by attention  to the details of the case, and  as has  been already
pointed out with much acuteness by Mr. Guthrie, by the accidental setting up
of inflammation in the artery extending to the sac, and thus obliterating it.
  In the only case, that of  Mrs. Denmark, in which Mr. Wardrop  tied the sub-
clavian for the cure of aneurism of the brachio-cephalic, there is some reason for
doubt whether the arrest of the progress of the tumor was owing to the ligature
of the subclavian artery, or whether it was not much influenced by the obstruc-
tion which existed in the  carotid for nine days after the operation, during which
time so abundant a deposit of laminated fibrine might have occurred as to arrest
the  progress of the  disease for  some length of time.   In this  case, also, Mr.
Guthrie supposes it probable that the obliteration of the tumor  might lead to its
inflammation.
  From a careful consideration of all the circumstances of the cases in which
ligature of one vessel only has been  employed for brachio-cephalic aneurism, we
are, I think, fully justified in concluding that in six of the cases the fatal result
was much accelerated, occurring as  a  consequence of the ligature of the vessel.
In two, the progress of the disease was in no way interfered with; in one it was
arrested, the patient living for two years;  and in one case only the disease was
cured.  The improvement in the two last  cases was the result of accidental cir-
cumstances, which were unexpected  and unconnected in  any way with the prin-
ciples on which  the operation was undertaken.  These results would not in my
opinion justify any surgeon  in again undertaking either of these operations.
  We  have yet  to consider the  operations in which  both arteries are ligatured.
This double operation may either be performed  with an interval  between the
application  of the two ligatures, sufficient for the establishment of a  collateral
circulation; or,  the  two vessels may be ligatured simultaneously.  The  former
plan has been adopted in two cases, the latter only in one; not a sufficient number
for  any safe deduction. _ In  one  of the two  cases in which an interval intervened
between the two operations, that by  Mr. Fearn, the tumor seems to have under-
gone a cure, being  filled with  dense laminated fibrine; but the  patient died
eventually of pleurisy.  In the other case,  by Mr. Wickham, no  good  results
followed the operation, death occurring from  bursting of the tumor.   In the case
in which  both vessels  were, ligatured simultaneously, death occurred  in  conse-
quence of the left carotid and right vertebral being accidentally occluded, and
the cerebral circulation being then solely dependent on the left vertebral.   As I
have just said, these cases are not sufficiently numerous or free from modifying
circumstances to enable us to draw any inference from them, we must therefore
revert  to the principle on  which this operation should be undertaken.   This will
differ materially according to whether the  two arteries are  ligatured  simultane-
ously, or with a sufficient  interval for the re-establishment  of collateral circula-
tion.
  If an interval of two years, as in the  first case, or even of two-and-a-half
months, as in the second  instance, be allowed to elapse between the ligature of
the  carotid and that of the subclavian, the operation reduces itself  essentially to 
ANEURISMS  OF THE CAROTID.
517
that of the ligature of  a  single  artery, which, as has  already  been shown, is
insufficient to induce these changes in the sac that are necessary for  the  accom-
plishment of a cure.   If the patient  survive the  effect of the ligature  of the
carotid for a few weeks, sufficient time will be afforded for the proximal  end of
the  subclavian, the  vertebral artery, and  the  thyroid axis to  have taken  upon
themselves a great  increase of development,—the collateral  circulation being
carried on by them and not by the left carotid;  so that by the time that the sub-
clavian comes to be ligatured beyond the scaleni, the sac will still continue to be
traversed by a current of blood for the supply of the branches of the subclavian
dilated to much beyond their normal size, in consequence of the task of  supply-
ing  the right side of the  neck, face, head, and brain, being principally  thrown
upon them.  This current  through the proximal end of the subclavian, increased
as it would be by the whole of that blood which is destined to supply the  place
of that which should pass by the carotid, would place the sac in nearly the  same
condition as if the subclavian also had been ligatured, and would  consequently,
for the reason that has already been  given, be too powerful for us to expect a cure
to take place in the course of its stream.
   It now  remains for us  only to consider the simultaneous ligature  of both
vessels—an operation  that has been but once performed, and then under  such
circumstances as to preclude our reasoning upon it, the patient having died from
accidental  occlusion of the left carotid  and right vertebral arteries.  In reasoning
upon the simultaneous ligature of the two vessels, we must consider two points—
1st.   In what condition  do we place the sac ?  And, 2dly,  Is  the danger of the
patient much increased ?
   So far as the sac is concerned, it is impossible to place it in a better condition
for the deposit  of fibrinous matter; two-thirds of the blood flowing through it
being arrested, and that only traversing it which is destined for the supply of the
branches of the subclavian.  It is by no means improbable that even this stream
may yet be too large and forcible to  allow the process of occlusion to take place;
but yet it is impossible still further to diminish it, and if the aneurism be saccu-
lated, and  project from  one side of the artery, particularly if  to its  internal  or
mesial aspect, it is by  no means impossible that it might be sufficiently removed
from the stream to allow of consolidation  of its contents.
  Would it add to the danger  of the patient to ligature these two vessels simul-
taneously rather than separately ?  I think not: if the risk of a double operation
is to be incurred, I cannot think that it would be positively increased by the two
being performed at  once, instead of at separate  intervals.  The  whole  of the
vessels  that serve to maintain  the collateral circulation in  the head  and upper
extremity—the vertebral, inferior  thyroid, supra and posterior scapular and cer-
vical, being left uninterfered with.

                      ANEURISMS OF THE CAROTID.
  Aneurismal varix of  the carotid  artery and of  the jugular vein, as the result
of punctures and stabs in the neck, has been met with in a sufficient number  of
instances to establish the signs and treatment of such a condition; and an instance
is related by Mr. Macmurdo, in which a communication was established between
these vessels as the result of disease;  but I am not acquainted with any case  of
varicose aneurism  of these vessels having been recorded.   The signs of aneuris-
mal  varix in this situation  present nothing peculiar, and the treatment must be
entirely of a  hygienic  character, no operative interference  being likely to be
attended by any but a fatal result.  It is the more desirable  not to interfere  in
these cases, as the disease does not appear to shorten life.
  Spontaneous aneurism of the carotid is  not of very unfrequent occurrence;
in Dr. Crisp's table of 551  aneurisms, 25  were of the carotid, and it ranks  in
order of frequency between those of the abdominal aorta and of the subclavian. 
518                 ANEURISMS  OF  THE  CAROTID.
It occurs more frequently in the female than any other external aneurism : thus,
of the 25 cases alluded to, 12 were in women;  owing probably to it seldom being
the result of violence, but generally arising from disease  of the coats of  the
vessel.  This aneurism is also remarkable as occurring at earlier  ages than most
others.  Thus, Hodgson has seen it in a girl of ten; and Sykes, of Philadelphia,
in a woman of eighteen.  The right carotid is much more commonly  affected
than the left, and the  upper  portion of the vessel than the lower; indeed,  the
bifurcation is the most  common seat of aneurismal dilatation.   The  root of  the
right  carotid  not  uncommonly  is  dilated, but I have never  seen  nor  heard of a
case in which the left carotid/before emerging  from the chest, has been affected.
   A carotid aneurism in the early stage, presents itself as a small, ovoid, smooth
tumor, with distinct pulsation  and bruit, and well-circumscribed outline.  It is
commonly soft and compressible, diminishing in  size on  pressure, and  expand-
ing again with  the  usual aneurismal  dilatation.   As it  increases  in  size, it
becomes  more solid, occasions  shooting pains in the head and neck,  and by its
pressure on the pharynx, oesophagus, and larynx occasions difficulty in  deglutition
and respiration.   Sometimes the  salivary glands  are  much irritated.   After a
time,  the cerebral circulation becomes interfered with, giving rise  to giddiness,
impaired vision of the  corresponding eye, noises  in the ear,  and a tendency to
stupor.  These symptoms may each be owing to compression of the  jugular, or
to difficulty in the transmission of the blood through the tumor.   The size that
these  aneurisms may attain varies greatly;  usually they are  confined to the space
under the angle of the jaw, but not unfrequently they may occupy the  greater
part of the side of the  neck.   If  allowed to increase uninterfered with,  death
may happen, either by the rupture of the sac externally, or  into the pharynx, or
oesophagus; by asphyxia, from pressure on the larynx or recurrent nerve,  or by
starvation, from compression of the oesophagus.
   The diagnosis of carotid aneurism is  without doubt  more  difficult than that of
any other form of external aneurism; the best proof that this is so may,  I think,
be found in the fact  that out of thirty-nine recorded cases in which the carotid
artery has been  ligatured for  supposed aneurism of it or its branches, in  eight
instances no  such disease existed;  solid  cysts,  or  other tumors  of the  neck
having been mistaken for aneurism, and this by surgeons of great and acknow-
ledged repute.
   The diagnosis of aneurism of the lower part of the carotid from similar disease
                            of other arteries at the root of the neck, as of the
                            subclavian, vertebral, and brachio-cephalic,  and the
                            arch of the  aorta,  is surrounded by  difficulties
                            which can only be cleared up  by a careful stetho-
                            scopic examination of the part.  In some aneur-
                            isms of the arch of the aorta also, the sac rises up
                           into  the neck, so  as closely to simulate a  carotid
                           aneurism, as in the annexed  cut (Fig. 161), and
                           this greatly increases the difficulty of the diagnosis.
                           The  principal affections of the neck, however, with
                           which aneurism of the carotid may be confounded,
                           are  varix of the internal jugular, enlarged lym-
                           phatic glands, abscess, tumors,  cysts in the neck
                           and pulsating bronchocele.
                              From varix the diagnosis may readily be  made
                           by attention to the following circumstances:—that
                           in varix the  tumor is always soft;  does not pul-
                           sate expansively; diminishes in size during a deep
                           inspiration, and on  compressing the vein on its
                            distal side.
   Glandular  tumors of the neck are  often very difficult  to distinguish from
Fig. 161.
 
DIAGNOSIS  OF  CAROTID  ANEURISM.
519
aneurism, more particularly when the artery passes through and is embraced  by
the tumor, so that the whole mass distinctly moves at each pulsation.   In these
cases also there may be  an apparent diminution in the size  of  the  tumor  on
compression, by the artery within it being emptied, or by the growth receding
into some of the  cellular interspaces of the neck.  But in the gfeat majority of
instances attention to the globular, oval, and nodulated feel of glandular swellings,
the  possibility of raising them up and  pushing them away from the vessel,
which may best be done by feeling the carotid with the ends  of  the  fingers of
one hand, and then pressing upon the tumor with the other, will clear up  the
true nature of the case.
   From abscess of the neck the diagnosis must be made on  general principles;
the co-existence of ill-defined hardness and of enlargement of the glands, of  an
inflamed state  of the skin, the ready detection of fluctuation, and  the absence of
expansive pulsation in  the tumor,  will show that it is not aneurismal, however
similar its other characters may be.  It is also of importance to observe that  an
aneurism that  fluctuates is always forcibly distended with  strong  pulsation, and
can  be materially diminished  by pressure;  neither of which circumstances can
possibly occur in  abscess.  But if abscess  may be  mistaken  for aneurism,  the
converse also  holds good, and an  aneurism may, unless  care be  taken, be mis-
taken for abscess; a far more  fatal error.  And there is one variety of false
aneurism, that to which Mr. Liston has invited special attention, against which
the surgeon must be carefully on his guard, on account of the many points of
resemblance between it  and aneurism; I mean the case in which an  artery has
given way into the sac  of an  abscess.  In this case, fluctuation and pulsation
will exist, although not  perhaps of a distending kind.  An important  diagnostic
mark will be, however, that the outline of an aneurism is  distinctly defined and
limited, while  that of an abscess never is.   Aneurism of the internal carotid has
been found by Syme to  simulate very closely abscess of the tonsils.
   Tumors of various kinds, carcinomatous, fatty, and elastic, may occur in  the
neck, and cause some little embarrassment in the diagnosis from aneurism, thus
Lisfranc, O'Reilly, and  Kerr  of  Aberdeen, have recorded cases in  which  the
artery has been ligatured in such cases by mistake for aneurism.  The diagnosis
of such tumors as these must  be effected on  ordinary principles.  I have  in
several instances  met with a  small, hard, distinctly circumscribed tumor, lying
directly upon the carotid artery and apparently connected  with it, and receiving
pulsation from it, usually produced by a fit of  coughing or laughing.  This
tumor, with the true nature of which I am unacquainted, remains stationary,
and does not require any operative interference.
   The thyroid body is  not unfrequently the seat of pathological changes, that
have  been and may. be  mistaken for aneurism.  These consist chiefly in  a
limited, circumscribed enlargement of one of the lobes of the gland,  which  ex-
tends laterally over the  common carotid, and receives pulsation  from it.  The
most puzzling cases, however, and those in which mistakes may most easily  be
made, are instances  of  pulsating bronchocele, in which these tumors have  an
active and independent pulsation  or thrill.  In these  instances, however, there
are three points  that  will  almost  invariably enable the  surgeon to  effect the
diagnosis.  Thus, the tumor,  although principally confined to one lateral lobe,
always affects the isthmus more or less.  Then again, in bronchocele that portion
of the tumor  is  most  firmly  fixed  which stretches towards  the mesial line,
whilst in carotid aneurisms the firmest attachment is under the sterno-mastoid
muscle; and the third point of difference is, that on desiring the patient to make
an effort  at deglutition, the enlarged thyroid body moves with the pharynx and
trachea, and being raised from the neighborhood of the vessels, the pulsation  in
it ceases, whilst no effect  is produced  on  an aneurism.   Cysts in the  thyroid
body are of more common occurrence than  pulsating bronchoceles, and some- 
520
ANEURISMS  OF  THE  CAROTID.
times equally difficult of diagnosis.   Dupuytren has pointed out that when these
cysts are tapped, the pulsation often becomes stronger, and the fluid, which on
first flowing is of a serous character, may at last become pure arterial blood, so
that the surgeon may suspect that he has punctured an aneurismal tumor.
  Aneurisms of the carotid are usually of slow growth, and may sometimes exist
for  a considerable number of years without giving rise  to  any special incon-
venience ;  this is more particularly the case when they are seated at the bifurca-
tion of the artery.  When at the root they are  more likely to be attended by
injurious pressure-effects.
  Treatment.—Since the time that Sir A. Cooper first ligatured the carotid, in
1805, the only means on which the surgeon relies for the cure of aneurism of
this vessel is  deligation of the  artery at a distance from the sac.  When the
aneurism is so situated that a sufficient extent of healthy vessel  exists between
the sternum and the base of the tumor to admit of the application of  a ligature,
the Hunterian operation  may be  practised.  If,  however,  the  root or lower
portion  of the artery is so  involved that there is no room to apply the  ligature
between  the heart and the seat  of the disease, the distal operation may be
performed.
  Ligature of the Carotid.—When  the surgeon  can choose the  seat at
which  to  ligature the  artery, he usually selects that part of the vessel which
bisects the angle formed  by the  anterior edge of the sterno-mastoid and the
omohyoid muscles.  The  artery is  reached by making an incision about three
inches long over its course upon  the anterior edge of the  sterno-mastoid, which
is a sure guide to the artery.  After dividing the  integument, the subcutaneous
fascia and cellular tissue,  the sheath of the vessel  is exposed.  This must then
be  carefully opened, any  branches of theMescendens noni being avoided, and
the ligature passed from without  inwards, between the vein and artery.  In per-
forming this operation, subcutaneous vessels are  occasionally wounded, which
may bleed  pretty freely; if so, they should be ligatured.   When  the sheath is
opened, the jugular vein sometimes swells up considerably, so as to obscure the
artery, but by  being drawn aside with  a retractor, or compressed  by the assis-
tant's finger, all difficulty  from this source will cease.  The pneumogastric is not
seen, being drawn aside with the vein.   If the aneurism  have attained a very
considerable size, extending low in  the neck, and not leaving perhaps more than
one inch of clear space above the clavicle for the surgeon to operate in, the diffi-
culties are  necessarily very greatly increased, and  here the best plan  will be to
divide  the tendon of the  sterno-mastoid  muscle, so as to give additional space.
The external portions of the sterno-hyoid and sterno-thyroid muscles  may like-
wise be cut across  for the same purpose.   The jugular vein in this situation lies
considerably to the outside of the artery.
  After ligature of the carotid artery, the blood  is  so  freely conveyed to the
distal side of  the  vessel, by the free communications subsisting between the
arteries of  opposite sides within the cranium, that  a continuance and return of
pulsation in the sac is of common occurrence.  This condition, however, usually
disappears  after a time by the gradual consolidation of the tumor, and indeed
may generally be looked upon as  a favorable  sign,  being very seldom  associated
with those  cerebral symptoms that, as will immediately be explained,  commonly
prove fatal after this operation.   It is interesting to observe  that  the collateral
supply, after the ligature of the  common carotid, is not afforded  by any of the
branches of the corresponding vessel of the opposite side,  but by the subclavian
artery of the same side.  In a case related by Porter, in which the right carotid
had been  tied, the subclavian and vertebral  arteries on the same  side were
enlarged to at least double their natural diameters, and the  chief communica-
tions outside the  skull took place between the superior and inferior  thyroid
arteries, which were enlarged, whilst inside the cranium, the vertebral took the
place of the internal carotid. 
ligature  of the carotid  artery.
521
  Suppuration of the sac is not of very uncommon occurrence after the ligature
of the carotid for aneurism, sometimes even after so considerable an interval, as
eight months, as happened in a case related by Post.  In  the majority of these
instances the patient eventually does well, but death may result by the  tumor
pressing upon the pharynx and larynx, or by the occurrence of secondary hemor-
rhage, which may take place either from the part to which the  ligature is applied,
or from the suppurated sac.   In the first  instance it usually occurs about  the
period of the separation of the ligature, in the second it  may happen at a con-
siderably later  period, after  many weeks even.   Besides  these, which may be
looked upon as  the ordinary  accidents following the application of a ligature for
aneurism, deligation  of the carotid artery occasionally gives rise to serious and
even fatal disturbance of the circulation  within  the cranium.
  Many experiments have been made by Meyer, Jobert,  and others upon  the
lower animals, with the view of determining the effect produced on the brain by
the ligature of the carotid arteries;  but the deductions  from  these are of no
value whatever when applied to the human  subject, for the simple reason, which
appears to have been strangely overlooked, that in many of the lower animals on
which the observations were  made, as the dog and rabbit for  instance, the com-
mon carotid arteries are of secondary  importance so far as the cerebral circulation
is concerned, being destined  principally for the supply  of the external parts of
the head, the brain deriving  its chief supply from the vertebrals; whilst in other
animals, as  the horse, the brain derives nearly  the whole  of its blood from  the
carotids, and but a very small quantity from the vertebrals. Hence, in one case,
the carotids may be  ligatured without danger,  whilst in the other their deliga-
tion is inevitably fatal.   On turning to  the result of observation on the human
subject, we find, according to Dr. Xorris, that  the carotid artery has been liga-
tured in 149 instances, and that of these 32 were fatal, 18 of the deaths resulting
from cerebral disease. The proportionate frequency of deaths from this condition,
according to  the cause  that  led  to  ligature, may be seen by reference to  the
following table:—

table of  ligature of carotid followed  by fatal cerebral DISEASE.
CAUSE OF LIGATURE.	NUMBER OP CASES.	DEATn FROM CEREBRAL DISEASE.	DEATH FROM OTHER CAUSES.
Aneurism, Wound, .... Erectile and other tumors, Extirpation of tumors, Cerebral affections, Distal operation,	38 30 42 18 6 15	7 6 3 1 1	5 2 5 1 1
	149	18	14
  By this it will be seen that the most common cause of death after the ligature
of the carotid, is cerebral disease induced by the operation; and that this result
appears  to  have followed the Hunterian more frequently than the distal opera-
tion.  We  should  necessarily expect, that  in  those cases in which  both vessels
had been ligatured, there would have been a greater tendency to cerebral distur-
bance than in those in which one only had been deligated. It would,  however,
appear, as is shown by the annexed table, that of the ten instances in which the
operation has  been performed, death occurred but in one  case from this double
cause, and  in another, in which such disturbance took place, a fatal result did
not occur.
  After a  careful  examination of  this subject, I think  we are warranted in 
522
ANEURISM  OF  THE  CAROTID.
coming to  the following conclusions:  1st. That the  ligature of  one carotid
artery is followed in about one-fifth of  the cases by cerebral  disturbance, more
than one-half  of which are fatal.   2d.  That when both carotids  are ligatured
simultaneously, death has hitherto always resulted, as in the two cases in which
Mott and Langenbeck ligatured these vessels with an interval of but a few mi-
nutes between each operation.   3d.  That when the two carotids are ligatured,
with an interval of some days or weeks, the operation is  not  more frequently
followed by cerebral disturbance than when one only is tied.  4th. Pathological
investigation has shown that  if the vessels be gradually and successively oblite-
rated, the patient may live, although one carotid and one of the vertebral arteries
have been  occluded by disease and the other carotid ligatured, as in  a  case
related by Rossi.   And, lastly, as in a case recorded by Dr. Davy, an individual
may even live  for a considerable time, though both carotids  and both vertebrals
be occluded, the cerebral circulation being maintained through the medium of
the anastomoses of the intercostals and internal mammary arteries.
CASES  OF LIGATURE  OF BOTH CAROTIDS.
OPERATOR.	AGE.	DISEASE.	DATES OP LIGATURE.	RESULT.
1. Preston.		Epilepsy.	Right carotid tied Aug. 23. Left carotid, Nov. 14.	Recovered.
2. Preston.		Epilepsy.	Tied at interval of month.	Recovered.
3. Macgill.		Fungous tu-mor of both orbits.		Recovered.
4. Mussey.	20	Aneurism by anastomosis of scalp.	Left carotid, Sept. 20. Right carotid, Oct. 2.	Recovered.
5.Langenbeck		Hemorrhage from supe-rior thyroid.	Both at the same time.	Died next day.
6. Moller.	H	Erectile tu-mor.	Sept. 13, and Jan. 28.	Recovered.
7. Kuhl.	53	Aneurism by	Left carotid first. Right forty-	Recovered;
		anastomosis	one days after.	convulsions
		of scalp.		after each
8. Mott.		Disease of parotid.	Interval of fifteen minutes.	operation. Coma and death in a few hours.
9. Ellis.		Secondary hemorrhage following gunshot.	Interval of four and a half days.	Cured.
10. J. M. War-		Erectile tu-	Tied left, October 5. Right,	Cured.
ren.		mor of face.	Nov. 7.	
  The cerebral symptoms that arise from the ligature of one  or both carotids
may be such as depend upon a diminished supply of blood sent to the brain;
consisting of twitchings, tremblings, or  convulsive movements, syncope, or
giddiness  with paralysis, sometimes with complete hemiplegia of the side oppo-
site to that of the ligatured  vessel, troubled  vision, and  deafness.  In other
cases, again,  they appear to arise from increased pressure upon the brain, drow-
siness, stupor,  coma,  and apoplexy supervening; and to the  third order of
symptoms belong those that are of an inflammatory character, usually coming on
a few hours after the operation.
  The cause of these symptoms  is certainly the  disturbance  of the  cerebral
circulation, induced by the ligature of the carotid.   When a considerable  por- 
LIGATURE  OF THE CAROTID  ARTERY.
523
tion of the supply of blood to the brain is suddenly cut off, two sets of symptoms
may ensue, one immediate, the other remote.  The immediate symptoms are those
that generally result from functional  disturbance of the brain, consequent upon
too small a  supply  of arterial  blood.    They  consist of syncope, trembling,
twitches,  giddiness,  impairment of sight, and at last hemiplegia.  After  this
condition  has been maintained for a few days, the nutrition of the organ becomes
materially affected, and softening of the  cerebral substance takes place, giving
rise to a new and more serious set of  symptoms, indicative of this pathological
condition; such as convulsions, paralysis, and death.   In other cases congestion
may come on, either by the interference  with the return of blood  through the
jugular vein, or as a consequence of that venous turgidity that we so  commonly
observe after  the ligature of a main arterial trunk, or perhaps as the result of
apoplectic effusion into a softened portion of  the organ inducing coma.
   Inflammation of the brain may come on immediately after the  application of
the ligature, being apparently at once  induced by the disturbance of the circu-
lation.  In other cases it occurs  at a  later period, as  the result of alteration in
the structure of the organ.
   Besides the brain, it not uncommonly  happens that  the  lungs are secondarily
affected  after  ligature  of  the carotid.   To   this  condition  special  atten-
tion has been directed by Jobert and  Professor  Miller.'   The  lungs appear to
become greatly congested, and have a tendency to run into a low form of inflam-
mation. ^  The cause  of  this congestive   condition of the  lungs is  extremely
interesting.   It cannot be owing to the simple obstruction of the passage of the
blood through the carotid, causing a disturbance in the  balance of the circula-
tion, and thus a tendency to internal congestion; for  if this were  the cause, we
ought  to  meet with  it generally after the ligature  of the arteries of the  first
class.   Nor can it be  owing to any injury sustained by the eighth nerve during
the deligation of the  artery; as  in many of  the instances in which it is  stated
to have occurred, there was no evidence  of that nerve having  been exposed or
damaged,  and every reason to believe the contrary, from the known skill  of the
operators.  I am rather inclined to look  upon the unusually frequent occurrence
of  pulmonic congestions  after ligature of the carotid, as a secondary condition
consequent upon a  derangement in the functions of the brain and  medulla
oblongata, primarily induced by the disturbed state of the circulation  through
that organ.   For we know that any  cause  that depresses the activity  of the
nervous centres tends to diminish proportionately the freedom of the respiratory
movements, and  thus, by interfering  with the  due  performance of the  act of
respiration, disposes to congestion of the  lungs,  just  as we observe happens in
injuries of the head,  in apoplexy, and in the  operation of the sedative  poisons.
   It would appear from the detail of some of the recorded cases, as well as from
Jobert's experiments, that bloodletting is of  considerable service in the removal
of  this condition, and should consequently not be omitted.
   Ligature of the  Carotid on  the Distal Side of the Sac.—Aneurism  of the
carotid artery, occurring low in the neck, does not admit of the application of a
ligature on the cardiac side  of the tumor.  What, then, is to be done in such a
case as this;—should it be left  to the remote chance of a spontaneous cure, or
should it be subjected to surgical interference ?   The occurrence of spontaneous
cure in  carotid aneurism has never yet, I believe, been met with.  The surgeon,
therefore, must endeavor to  treat the disease  by ligature.  In this way two plans
of treatment are open to him—either to deligate the innominata, or to tie the
carotid on the distal side of the  tumor.   The first alternative may fairly  be  set
aside, for  not only are the cases  in which it is possible to find room between the
sternum and the sac  extremely rare, but even were such an instance  to. present
itself, no surgeon would, I think, be justified in undertaking an operation which
has never yet succeeded  in the most skilful hands; we are consequently reduced 
524
LIGATURE  OF THE CAROTID.
to the alternative of ligaturing the artery on the  distal  side of the  sac.   But
although this operation is the only alternative that presents itself,_ yet its appli-
cation  in  practice is  attended by serious  difficulties and perplexities; for the
surgeon must be able to  satisfy himself that it is actually an aneurism of the
root of the carotid with which he  has to do, and that it is not the trunk of the
innominata or the arch of the aorta that is  affected.  The  difficulty in  doing this
is far greater than would at first appear; for, on examining the details of eight
cases  in which the distal operation has been performed for  supposed carotid
aneurism, three  must be excluded;  as, after death, the tumor  was  found to
arise from the  aortic arch.   In the annexed table will  be  found the result of
four cases, in which the carotid artery  has  been  tied for aneurism  of its root on
the distal side of the sac.  I  have excluded a  fifth case, as there is reason to
believe that in  it the  artery was not ligatured, but a portion of the sheath  acci-
dentally tied instead—an accident, by the way, that  Sedillot has seen  happen,
and which Morris relates also to have occurred at  the Xew York Hospital;  and
which  I have known occur to  a most excellent surgeon in the case of ligature of
the femoral.
ANEURISMS OF ROOT OF  CAROTID TREATED  BY LIGATURE  ON DISTAL SIDE.
OPERATOR.	SEX.	AGE.	RESULT.	CAUSE OP DEATH.	REMARKS.
1. Wardrop.	f.	C3	Recovered.		Tumor diminished until fifth day, then inflamed, suppu-rated, and burst. The patient recovered and was alive three years after operation.
2. Lambert.	f.	49	Successful so	Died of	Tumor diminished after ope-
			far as aneu-	hemorrhage	ration, and became consoli-
			rism was	from upper	dated; sac filled with firm
			concerned.	portion of artery.	coagulum, and lower part of artery closed ; ulceration into artery, just above part liga-tured ; dilated where liga-tured.
3. Bush.	f.	36	Recovered.		Suffocation was imminent be-fore operation; tumor be-came rapidly diminished after ligature. Alive three years afterwards.
4. Colton de	f.	63	Recovered.		Tumor and pulsation dimi-
Noyou.					nished. Alive and well
					three years after.
  On analyzing the four cases  in  which  the trunk of the common carotid has
been ligatured on the distal side of an aneurism of the root of that vessel, there
are several points of interest that arrest our attention; thus we find that in every
case the tumor immediately on the ligature  being tightened, underwent a con-
siderable diminution in its bulk with corrugation of the integuments covering it,
and considerable subsidence in the force of its pulsations.  In one case, that of
Mr. Bush, respiration, which before the operation had been attended with great
difficulty became  easy; and in another, that of Mr.  Wardrop, inflammation of
the sac, unattended however by any bad consequence, took place.   It is not safe
to deduce any general conclusions from so small a number of cases as four.   But
yet the result of these is so uniform, that I have no hesitation  in stating it  as my 
DISTAL  LIGATURE  OF CAROTID.
525
opinion, that whether we regard the principle on which this operation is founded,
the amount of success that has hitherto attended it, the necessarily fatal  result
of these cases if left to themselves, or the absence of any other means that hold
out a reasonable hope of benefit, the surgeon is justified in resorting to the liga-
ture of the trunk of the  common carotid on the distal side of the sac, in cases of
aneurism, limited to the root of that vessel.
   Aneurism of Internal Carotid and its  Branches.—The internal carotid
artery may be the subject of aneurism before  or after it has passed through the
carotid canal and entered the  cranium.   The  symptoms of these two classes of
cases differ necessarily in  almost every respect, as likewise  do the termination
and the susceptibility of the case to surgical interference.
   When an aneurism affects the trunk of the internal carotid before its entrance
into the cranium, the symptoms presented by this disease do not materially differ
from those of aneurism  at the bifurcation, or  of the  upper part of  the common
carotid except in one important respect; which was I believe first pointed out by
Mr. Porter, of Dublin—viz., tendency to the extension of the tumor inwards to-
wards the pharynx, and to its  protrusion into that  cavity.   The reason of this
is obvious; when we consider the anatomical relations of the  internal carotid
artery, we at once see that its pharyngeal aspect is  that which, if one may so
term it,  is the most superficial,  between which and the  surface  the  smallest
amount of soft part intervenes—nothing lying between the vessel and the mucous
membrane except the thin, paper-like constrictor, some  lax  cellular  tissue, and a
few filaments of the superior  laryngeal nerve; whilst externally there  is inter-
posed between  it and  the integument,  the layers  of  the  cervical fascia, the
margin of the sterno-mastoid, the digastric and  three styloid muscles,  and the
styloid process.
   When dilatation, therefore, of the vessel takes place, it has a necessary tendency
to push forwards  that part of its covering  where it  meets with  least resistance,
and  this being to  the pharyngeal side, more  or less prominence will consequently
be found in this cavity.  In a case that occurred to Mr. Syme, this was espe-
cially well marked, the aneurism of the internal carotid simulating closely an
abscess of the tonsil.   In two cases related by Mr. Porter, in the iTth vol. of
the "Dublin Journal,"  this was one of the most marked features, the  "appear-
ances of the tumor (as  seen  by the mouth) were most  alarming;  the pulsation
could be distinctly seen, and the blood almost  felt under the mucous membrane;
it seemed ready to give  way, and burst into the mouth every moment."
   The treatment of these  cases does not differ from that of aneurisms connected
with the carotid arteries, and seated at the upper part of the neck; but we are
not in possession  of a sufficient number of facts to enable us to  determine with
any  degree of precision  what the result of surgical interference in them is likely
to be.   If we could give an opinion from the limited number of cases at present
before the profession, we  should feel disposed not  to entertain a very favorable
opinion of the result of the Hunterian operation, as applied to these cases.  This
is doubtless owing to the situation of the aneurism against the mucous membrane
of the mouth, being such that the surrounding tissues  do  not  exercise a suffi-
cient amount of pressure against  the sac after the ligature of the vessel to allow
of the efficient  deposition of kmelkted coagulum, and  consequent occlusion of
the artery leading into  it, which, in accordance with the  principles that  have
been kid down in speaking of the Hunterian operation,  is necessary.
   After the carotid artery has passed through  the carotid canal, and has entered
the cavity of the  cranium, it or its branches may occasionally be the subject of
aneurism; but as the consideration of these  intracranial aneurisms  does not fall
within the province of the surgeon, it need  not detain us. 
526
aneurism  of  the  subclavian.
                 ANEURISM  OF THE SUBCLAVIAN ARTERY.

   Aneurisms of the  subclavian occur  in  order of frequency between  those of
 the carotid and of the brachio-cephalic.   They  are most frequently met with on
 the right side, in the proportion of nearly three to one, and this would appear to
 be in a great measure dependent on their being occasioned by direct violence, or
 of repeated and prolonged exertion of the arm.   Thus they commonly  occur by
 falls, blows upon the shoulder, or excessive fatigue of this extremity.  From the
 fact of the aneurisms  arising  from external violence, we should expect to meet
 with them most frequently  in males, and this  we do in a remarkable manner.
 Of thirty-two cases, I find only two occurring in females, and in both  these in-
 stances the disease resulted from injury.  The disease may be seated in  any part
 of the vessel  on the right side, though most commonly it is not dilated until after
 it has got beyond the scaleni.   On the left side it never occurs  before its emer-
 gence from the thorax, and then, as on the right, aneurism most commonly hap-
 pens in the third part  of the course of the vessel.
   An aneurism in the  subclavian artery, is characterized by a pulsating com-
 pressible  tumor of an elongated or ovoid shape,  situated at the base of the poste-
 rior inferior triangle of the neck, immediately above the clavicle.  If it be  small,
 it will disappear behind this bone on  the shoulder being raised; as it increases
 in size, it fills up the whole of the  space between the clavicle and  the trapezius,
 often attaining a very  considerable  bulk.   In consequence of the pressure which
 it exercises on the brachial plexus of nerves, there is pain,  often  attended by
 numbness, and extending down the arm and fingers, usually with some weakness
 of these parts.  In some instances  there is spasmodic affection of the diaphragm,
 owing to irritation  of the phrenic  nerve.   The external jugular vein  is  com-
 monly distended and varicose, with oedema of the hand and arm, or even of the
 side of the  body.   The tumor does not increase rapidly in  size, owing to its
 being  tightly compressed by  the surrounding parts, and  as  the disease  never
 extends inwards, it does not interfere with the trachea or oesophagus.   In some
 cases it has been known to extend downwards and backwards so as  to implicate
 the pleura and summit of the  lung.
   The diagnosis of these aneurisms is  usually  easy, and presents no point of a
 special character.  As they increase in size they may become diffused, and burst
 either externally or into the pleural sac.  In some instances a spontaneous  cure
 has been observed.
   The treatment of subclavian aneurism is in the highest degree unsatisfactory.
 The attempts  at obtaining consolidation of the tumor by constitutional means, by
 galvano-puncture, or compression, have hitherto failed, except in some very rare
 instances.   Thus a case is reported by Mr.  Yeatman  of the  cure of subclavian
 aneurism  by Valsalva's plan,  in eighteen months; and  another of Dr.  Abeille,
 in which the tumor was consolidated by galvano-puncture, and this plan  perhaps
 may under certain circumstances deserve a trial, when we consider the  extreme
 want of success attending the  other means of cure.
  The ligature  of the brachio-cephalic,  and of the  subclavian itself, before,
between, and beyond the scaleni muscles, has been practised for the cure of this
form of aneurism; it has likewise been proposed to apply the distal operation to
the treatment of this disease,  and to amputate it at the shoulder-joint.
  When an aneurism is situated on the  right subclavian artery on the  tracheal
side of the scaleni, there is no way in which the flow of blood through it can be
arrested, except by the ligature of the brachio-cephalic artery.  When it is situ-
nted beyond the scaleni, or  even  between  these muscles, the  ligature of the
vessel has been  practised  in the first part of its course before it reaches  these
muscles.   For subclavian aneurisms on the left  side, in these situations, no ope-
ration conducted on the Hunterian principle would be practicable. 
LIGATURE OF THE BRACHIO-CEPHALIC.           527
CASES  OF LIGATURE OF BRACHIO-CEPHALIC.
	AGE			
OPERATOR.	AND SEX.	NATURE OF DISEASE.	RESULT.	REMARKS.
1. Mott.	m.	Subclavian	Died on 2Gth	Tied an inch below bifurcation
	57	aneurism.	day.	Ligature separated in four-teen days. Hemorrhage in twenty-five, stopped by pres-sure. Recurred in twenty-six.
2. Graefe.		Subclavian	Died on 67th	Ligature separated in fourteen
		aneurism.	day.	days. Died of hemorrhage.
3. Hall.		Subclavian	Died on 5th	Coats of artery were diseased
		aneurism.	day.	and gave way. Wound plugged without success.
4. Dupuytren.			Died.	Case referred to as occurring in the practice of Dupuytren.
5. Norman.			Died.	
6. Bland.	m.	Subclavian	Died on 18th	Hemorrhage came on on the
	31	aneurism.	day.	seventeenth and eighteenth days. Ligature applied to upper portion of artery.
7. LlZARS.		Subclavian	Died on 21st	Ligature separated on seven-
		aneurism.	day.	teenth day. Hemorrhage on nineteenth.
8. Hutin.	m.	Hemorrhage	Died in 12	Punctured wound in axilla for
	26	from axilla after ligature of subclavian.	hours.	which subclavian was tied ; secondary hemorrhage, and then b. c. ligatured.
9. Arendt.		Subclavian	Died on 8th	Inflammation of lung, pleura,
		aneurism.	day.	and aneurismal sac.
N. B.—The artery was cut down upon but not ligatured by Porter, Post, and Aston Key.
  Ligature of Brachio-cephalic.—Let us now proceed to examine the results
that have attended these operative procedures.  The brachio-cephalic artery, as
may be seen by  the accompanying table, has  been  ligatured nine times, and in
every instance with a fatal result.   In three other  instances, the operation has
been commenced, but abandoned owing to unforeseen difficulties, and this  by
three  of the most skilful operators  that their respective countries can boast of.
Although in reasoning on the propriety of performing an  operation,  it is not in
general worth while taking the difficulties that a  surgeon may encounter into
consideration, provided  the operation be at last practicable; yet, when we consi-
der the fact of the ligature of the brachio-cephalic having been attempted, and in
consequence of unforeseen and insurmountable difficulties left unconcluded  in so
large a proportion as one-fourth of the cases, and these in the hands of surgeons
who were as well able as any to accomplish whatever was in the power of opera-
tive surgery to do, we may well hesitate upon the difficulties  that beset the ope-
ration itself, before proceeding to the consideration of its results.   The difficul-
ties to which I allude, do not consist merely  in the position and anatomical  rela-
tions of the vessel, but  rather in the condition in which the  artery and adjacent
structures may be found after the vessel is exposed.  Thus, in Mr. Porter's  case,
the aneurism, which was a large  one, occupied  the whole  of the posterior  infe-
rior triangle of  the  neck, being  nearly six  inches  broad; as no pulsation was
traceable in the  vessels  beyond the aneurism, it was useless to attempt the  liga-
ture on the distal side.  On exposing the brachio-cephalic, that vessel was found
to be diseased, and it was not thought desirable to pass the ligature round it.  In
consequence of the exposure of the artery, however, the pulsation in the tumor
gradually diminished, and at last ceased entirely, its bulk also becoming less. 
528
ANEURISM  OF  THE  SUBCLAVIAN.
  In Mr. Key's case, in which it was impracticable to pass the ligature, it  was
found  after death that the brachio-cephalic  was  diseased, being dilated  im-
mediately after  its origin into an oblong tumor, which occupied  the  whole of
the artery.  It is remarkable that in this case, as  in Mr. Porter's, inflammation
seems to have taken place in the artery in consequence of the necessary handling
to which it was subjected, and  that  the pulsation  in the  sac  consequently
diminished.
  It would thus appear, that  even after the difficulties of the operation have
been  surmounted (and these, from the depth of the vessel, its proximity to  the
centre of the circulation, the  neighborhood of large  veins, which may become
turo-id, and a wound of which not only obscures the line of incision with venous
blood but induces a risk of the entrance  of air into the circulation, are of serious
magnitude), and the artery has been exposed, its coats may be found so diseased,
or its  calibre so increased, that it may be undesirable or impossible to pass a
ligature  round it.  The failure in deligating the  artery would, however, as we
shall immediately see, appear  to be less disastrous in its consequences than suc-
cess in that attempt; for of the three cases that have just  been referred to, in
which this attempt was made and did not succeed,  one was  cured of the disease,
the artery being obliterated by adhesive inflammation;  and  in  another, Mr.
Key's patient, an attempt to set up this action appears  to have been made,  the
tumor becoming solid and ceasing to  pulsate, whereas in every case in which
the vessel was ligatured, a fatal result speedily ensued.
  The results of the ligature of the vessel are in the highest degree discouraging;
for  of the nine cases in which it has  been  done, not one recovered.  Death
occurred from secondary hemorrhage in four cases, from inflammation of lungs or
pleura in two, and in three from causes that are not mentioned.
  In one case, that of Hall, the artery was transfixed by the aneurism  needle;
hemorrhage occurred at the time, which was arrested by plugging, and  did  not
recur, the patient dying from other causes.  In three cases, those of Mott, Bland,
and Lizars,  the hemorrhage came on shortly after the separation of the ligature;
but in Graefe's (the most successful)  it did not occur for fifty-one days after this,
the cicatrix in the artery having then probably given way under the influence of
some imprudent movement on  the  part  of the  patient.  With such results as
these, there can, I think, be but one opinion as to the propriety of such an opera-
tion being  again had  recourse  to.   As  its performance has hitherto  in  every
instance  entailed death, and, in all cases but one, a speedy death to the  patient,
it should without doubt be banished from surgical practice;  and I can  think of
no  circumstances that should induce a surgeon, in  the face  of the  consequences
that have hitherto invariably followed the application of a ligature to this artery,
again having recourse to such a procedure.
  Ligature of the Subclavian.—If the aneurism be situated on the right
subclavian artery, between or beyond the scaleni, that vessel has been ligatured
on the tracheal  side  of these. muscles;  on the left side  this  operation is  not
practicable, on account of the depth at which the artery is situated.  When we
consider  the anatomical relations of that portion of the right subclavian which
intervenes  between  the brachio-cephalic artery and the tracheal edge of  the
scalenus  anticus muscle, we are at once struck with the great difficulties of this
undertaking;  and when we reflect on the position in which the ligature will be
placed between the onward current of blood in  the brachio-cephalic on the  one
side, and the regurgitant stream conveyed by the vertebral, the thyroid axis, the
internal mammary and intercostal, into the  subclavian, immediately beyond  the
seat of deligation on the other side, we could scarcely, in accordance with those
principles on which the formation  of a coagulum within a ligatured vessel takes
place, anticipate any but the most disastrous results.
  In  reference to the mere difficulties of the operation, Mr. Fergusson  justly 
ligature  of the  subclavian.
529
characterizes it as the most  serious in surgery;  the proximity of the common
carotid  artery on  one side, the  internal jugular  vein  on the other, the vena
innominata below, the par vagum  and numerous small venous trunks in front, the
recurrent  laryngeal nerve and pleura behind, constitute  relations  of sufficient
importance to justify Mr. Fergusson's opinion.  But supposing these difficulties
overcome, and the  ligature applied, this must be situated, as has just been stated,
in such a  position, with a strong current  of blood flowing upon either side of it,
as to render the formation of an internal coagulum, and consequently occlusion
of the artery, impossible, and thus to lead inevitably to the occurrence of a fatal
hemorrhage on the separation of the ligature.  Besides the danger of secondary
hemorrhage from these causes, there would be the  additional risk  of the  coats of
the artery being diseased, as we commonly find them in  a more or  less  morbid
state in the  immediate  vicinity of aneurisms; and thus being rendered in-
susceptible of  healthy inflammation,  ulceration and sloughing  would take place
along the  track of  the ligature, thus causing the probability of a recurrence of
hemorrhage.   Thus, in Colles's case, it was  found on exposing the subclavian
artery, that the aneurism had extended in such a way towards the carotid, that
it was doubtful whether  any part of the affected vessel continued  sound.   On
exposing it fully, it was found  that only a space of the vessel three lines in length
remained free between the sac and the bifurcation of the brachio-cephalic, and it
was in this narrow space that the ligature was applied.
   The subclavian has been ligatured on the tracheal side of the scaleni  muscles
in seven  cases, all of which have proved fatal, six from hemorrhage, and  one
from inflammation of the pericardium and pleura.
   The cases are as follows :—
SURGEON.	SEX.	AGE.	DATE OF DEATH.	CAUSE OP DEATH.
Colles.	. m.	33	4 th day.	Hemorrhage.
Mott.	f.	21	18th day.	Hemorrhage.
Hatden.	f.	57	12th day.	Hemorrhage.
OReillt.	m.	39	13th day.	Hemorrhage.
Partridge.	m.	38	4th day.	Pericarditis and pleurisy.
Liston.*	m.		13th day.	Hemorrhage.
LlSTON.f	m.		36th day.	Hemorrhage.
Fig. 162.
  Thus it will be seen, that if this  operation is-bad in principle it is most
unfortunate in practice.  This table is, to my mind, conclusive as to the merits
of the  operation, the patient
having in  every case but one
been carried off by secondary he-
morrhage from the distal side of
the ligature, in consequence of
the close proximity of numerous
collateral branches (Fig. 162),
and in this exceptional case the
operation,  although performed
with the utmost  delicacy and
skill, proving fatal from pericar-
ditis and  pleurisy before the
period  at which secondary he-
morrhage might have been ex-
pected. Mr. Liston, in one case,
ligatured the root of the  common carotid,  as  well as that of the subclavian,

   * In this case the carotid was also tied, but the hemorrhage came from the subclavian (Fig. 163.)
   t Fig. 162.
                                     34
 
530
ANEURISM  OF  THE  SUBCLAVIAN.
hoping in this way to diminish the risk of the supervention of this fatal hemor-
rhage, by arresting the current  of blood  which, by sweeping into the carotid
past the mouth  of the  subclavian, necessarily washed away any coagulum that
would  otherwise  have  formed  in this  artery.   But  his  expectations  were
not realized, hemorrhage taking place as  usual, and from that  portion of the
artery which lay on the distal side of the  ligature (Fig.  163), the blood having
                                        been carried into this part of the vessel
                                        in a retrograde  course, through the
                                        connexion existing between  its vessels
                                        arising from it at  this point, and  those
                                        on the  opposite side of the head and
                                        neck, as illustrated by the annexed cut,
                                        taken from the preparation of the  case
                                        in the University College Museum.  In-
                                        deed this is the  great  danger to be
                                        apprehended after ligature of the sub-
                                        clavian  artery on  the tracheal side of
                                        the scaleni, depending as it does on the
                                        anatomical relations and connexions of
                                        the vessel, which no skill on the part of
                                        the operator can in any way lessen, and
                                        which, in my opinion, ought certainly
                                        to cause this operation to be banished
                                        from surgical practice.
   When an aneurism is  situated on the  subclavian artery, in the  posterior in-
ferior triangle  of the  neck, it is necessarily impossible to ligature that vessel
beyond the scaleni, as there would not be sufficient room for the exposure of the
artery, which, even if laid bare, would in all probability be found in too diseased.
a condition to bear the application  of a ligature.
   Thus it will be seen, that in  every case in which an aneurism  of the subcla-
vian artery has been subjected to operation, whether by ligature of the brachio-
cephalic or of the subclavian itself internal to the scaleni, the  result has been a
fatal one.   As this unfortunate termination to  every case that has  yet  been sub-
mitted to surgical interference is in no way to be attributed to want of skill on
the part of the operators,  who are,  without exception, men  greatly distinguished
for the possession of this very quality, but is solely dependent on certain anato-
mical peculiarities in  the  arrangement of these vessels, by which their  successful
ligature has been rendered impossible, a repetition of these  attempts, which may
hasten the patient's death, can  scarcely be considered  justifiable.   What then
are we to do ?  Are we to leave  patients laboring under  aneurism  of the  sub-
clavian artery to  inevitable death, without making an effort to save  them ? or
does surgery offer other modes  of  treatment  besides those just mentioned, by
which  we may hope to arrive at more successful results.
   Without mentioning galvano-puncture, which is certainly deserving  of further
trials in combination with appropriate constitutional  treatment, three  modes of
treatment present themselves :—
   (1.) Compression on the artery  where it passes over the first rib, and conse-
quently on the distal  side of the tumor.
   (2.) Ligature of it on the distal  side, above or below the clavicle.
   (3.) Amputation at the shoulder joint, and  the distal ligature of artery.
   1. Compression of the artery on the distal side of the sac could only be effected
where  it crosses  the  first rib,  and consequently would  only be applicable to
aneurisms of the  first part of this vessel.  This plan has never been tried, partly,
perhaps, on account of the difficulty in applying pressure in  this situation,  and
partly, probably,  on account of the want of success that has attended procedures
of this kind when applied to vessels in  other situations.
Fig. 163.
 
LIGATURE OF  THE  SUBCLAVIAN.
531
  The difficulty in applying  the compression might, I think, be overcome  by
the use of the instrument of which a representation is  given by Bourgery; and
the efficiency of the compression would be materially increased by the  employ-
ment of the  galvano-puncture  at  the same time, and in this way a coagulum
might  be formed in the sac.   Although much ought not to be  expected from
this mode of treatment, yet I think it might with propriety be tried in cases of
the kind that have been mentioned.
  2. Dupuytren ligatured the  axillary artery under the  pectoral muscles, for a
case of subclavian aneurism, two arterial branches being divided in the incisions
through the fat and cellular tissue, and the patient died on the ninth day.  This
is the only instance, to my knowledge, in which the distal operation has been
attempted for the cure of this  disease.  It could not be  expected  to  succeed;
for between the ligature  and  the sac are the large and numerous alar, acromial,
and thoracic branches of  the  axillary artery, which would  continue  to be fed by
a current sent through the tumor, and thus preclude the possibility of its contents
being sufficiently stationary for  ultimate contraction and cure to result.   Laugier
performed the distal operation in a supposed case of subclavian aneurism, which
afterwards  turned out to  be one of the brachio-cephalic artery.
   Ligature of the subclavian artery in the third  part of its  course,  on the distal
side of the tumor, has been  suggested, and may, perhaps, hold out some pros-
pect of success in cases of aneurism situated between or internal to the scaleni.
In  an  aneurismal sac  springing from the artery in this  situation, the principal
current of  blood would,  in all probability, be that which is  destined for the
supply of the upper extremity.  Some of the branches arising from the  artery
before it has passed beyond the scalenus  anticus would,  doubtless, be  more or
less compressed, and  thus  obliterated, by the tumor, or might be obstructed by
an  extension  of the  laminated fibrine over  their orifices.  If, therefore, the
supply to the  upper extremity  could  be cut off,  there might be  a  possibility of
those changes taking place within the sac which are necessary for the obliteration
of its cavity.   The principal obstacles to this  desirable result would necessarily
be the transversalis colli  and  humeri arteries;  which, being the two vessels that
are more particularly destined to carry on the circulation in the upper extremity
after the ligature of the  subclavian, would necessarily, if  not occluded, undergo
dilatation, and  thus continue to draw too large  a current of blood  through the
sac for stratification of its contents to take place; and if occluded, there  would
be danger of gangrene of the arm from insufficient vascular supply.   These diffi-
culties are  met by a plan of procedure, the suggestion of which has originated,
I believe, with Mr. Fergusson, but which has not, to my knowledge, been had
recourse to as yet.  It is the amputation of the  arm at the shoulder-joint, and
then the distal ligature of the  artery—a desperate undertaking truly, but for a
desperate disease it must be remembered, and  one that  has never yet,  under
ordinary surgical treatment, been cured.
  The artery might be ligatured before the amputation. " It  is known," says
Mr. Fergusson,  " that amputation  at  the shoulder-joint is generally a. very suc-
cessful operation;  so far as this wound  is concerned, then, there might be little
to apprehend, but the effect on  the tumor is not so  easily foretold.   Ligature  of
the axillary artery on the face  of  the stump  might here be reckoned like Bras-
dor's operation,—yet there  is a vast difference,  for in the latter case the same
amount of  blood which  previously passed towards  the upper extremity, would
still find its way down, and  probably part of it would  run through  the sac;
whereas,  were the member removed,  as the same quantity would no longer  be
required  in this direction, the tumor  might possibly be much more under the
control of pressure.  The value of such a suggestion remains yet to be tested,
however, and it would  be futile to  reason upon  it at present.  It might be a
judicious venture first to  tie  the axillary or subclavia% under the clavicle, and 
532           ANEURISM  OF  THE  AXILLARY  ARTERV.
then if it were found  that the  aneurism still increased,  amputation might be
performed, either immediately before or after the separation of the ligature."
   Were a case of  aneurism of the subclavian artery internal  to the  scaleni, to
present itself to me, the plan that I should  adopt would be, first  the employ-
ment of  pressure  on the vessel at the  distal  side of the tumor, if practicable;
should this not succeed, I would, if the disease were situated  between, or inter-
nal to the scaleni,  ligature the artery in the third part of its course, and did that
not succeed in  checking the increase  of the aneurism, perform amputation at
the  shoulder-joint as recommended by Mr. Fergusson.   Should the  aneurism
occupy the artery  after it has passed the scaleni, I would not attempt the liga-
ture of the artery below the clavicle, as it is an operation, the result of which
is not  very satisfactory, and would not prevent a  large current  through the sac
for the supply of the collateral circulation of the arm, but  at once have recourse
to amputation at the shoulder, and then ligature  the vessel, as near as possible
to the  sac.  It is  true that even in this case the  ligature would be  below the
branches that are  given off under  the  pectoral muscles, but as the arm would
be  removed, they could not undergo any increase of activity for  the supply of
the collateral circulation of the upper extremity.

                  ANEURISM OF THE AXILLARY ARTERY.
   This artery,  though less commonly  the seat of aneurism than other large
vessels, such as those of the ham, the groin, and the neck, yet is sufficiently fre-
quently diseased, owing partly to its situation; for its proximity to the shoulder-
joint causes it  to  be subjected  to  the  very varied, extensive and often forcible
movements, of  which that articulation is the seat;  and partly to the artery
being  deficient  in that support which would be  afforded  it by  an  investing
sheath, such  as is commonly met with in arteries of corresponding magnitude.
Amongst  the most frequent causes  of axillary aneurism, may be mentioned falls
upon the shoulder or  upon the outstretched hands,  and  in many cases the
efforts made  at reducing old standing  dislocations;  instances of which  are re-
corded by Pelletan, Faubert, Warren,  and  Gibson;  the  head of  the bone in
these cases having probably contracted adhesions to the artery, in consequence
of which  the vessel was torn during the efforts at reduction.   Axillary aneur-
ism, like  the  subclavian, occurs more  commonly on the right than on the left
side, and  is met with in special frequency amongst men;  of thirty-seven cases,
only three have occurred in women.
   In axillary aneurism, there are three  sets of symptoms, attention to which will
usually enable the surgeon  to  recognise the  disease; these are, the  existence
of a tumor in  the axilla, the pain that it occasions, and  the affections that it
gives rise to in a limb.
   The precise  situation at which an  aneurism of the axillary artery presents
externally, will depend upon whether it springs from that portion of the vessel
that lies above, beneath, or, below the pectoralis minor muscle.  If from above,
it will appear as a tumor seated  immediately below the clavicle and occupying
the  triangular space between the  upper margin of the lesser pectoral and that
bone; if it be  lower  down, it will raise the  anterior  fold  of the  axilla, being
prevented extending much out of this  space, by the dense fascia that stretches
across from one side to the other.  The tumor, which is at first soft and com-
pressible, has a whizzing bruit,  and its  pulsations, which  are  expansile, may be
arrested by pressure  upon the subclavian artery, where it passes over the first rib.
It usually increases with great rapidity, owing to  the  little resistance opposed
by the loose cellular tissue in this  situation, and most commonly extends  down-
wards and forwards, causing the  hollow of  the axilla to  disappear.   In  some
rare instances, however, the tumor has  been known to take a direction upwards
under the lesser pectoraL^and into the cellular  interval above  that  muscle, or 
  DIAGNOSIS  AND TREATMENT  OF  AXILLARY  ANEURISM.   533

even underneath the clavicle into the acromial angle between it and the  trape-
zius.  Such a course for the aneurism to take is fortunately rare, as it presents
serious inconvenience in the ligature of the subclavian, and there is more than
one instance on record, in which the sac has been punctured  in  the  attempt
to pass the needle round this vessel.  When the aneurism is seated high up, it
not unfrequently happens that the clavicle is'pushed upwards by the pressure
of the tumor  beneath it, a complication of considerable moment in reference
to the operation,  the difficulties of which  are  greatly increased  by it.   The
pressure of the tumor may give rise to  serious consequences upon neighboring
parts ; thus it may occasion a carious state of the first and second ribs, and the
compression of the brachial plexus  of  nerves will  occasion pain and numbness
in the upper extremity.   In some cases the brachial artery beyond the  tumor
would appear to  be obstructed, no  pulsation being perceptible  in  it; and the
compression of the axillary vein may occasion  oedema  of the hand and arm,
with some diminution in the temperature of the  limb, which, if the tumor attain
a very large size, may even amount to  symptoms indicative of impending gan-
grene.
  The diagnosis of axillary aneurism is usually readily made ; there being but
two diseases with which  it can  well be confounded, viz., chronic  enlargement
and suppuration in the glands of the axilla and  pulsating tumor of the bones in
this region.  From glandular or other abscess, the diagnosis is generally easy;
but I have seen some cases  in which pulsation being communicated  to their con-
tents by the subjacent artery, it  was somewhat difficult to distinguish the nature
of the tumor.  Here, however,  the history of the case and its speedy progress
to pointing will indicate its true  nature.  From  medullary tumor, or osteo-aneu-
rism of the head of the humerus, the diagnosis is not always so easy, and there
are at least two instances  on record in which  the subclavian artery has been
ligatured for disease  of this kind on the supposition of its being  an aneurism.
In these instances  it has, however,  generally been observed that the tumor first
made its appearance on the  forepart  of the shoulder and not in the usual situation
of axillary aneurism ; that  it was from the first,  firm, smooth, elastic, but nearly
incompressible; and that although  it presented  distinct  pulsation, there  was no
true bellows-sound, but rather a  thrilling bruit perceptible  in it.  The most im-
portant diagnostic mark,  perhaps, is the fact of  these tumors forming  a  promi-
nence in situations in which aneurisms of the axillary artery would not at first
show themselves, as  at the upper,  outer, or anterior part of the shoulder.  In
more advanced stages, when the substance of the bone has undergone absorption
and its shell has become thin and expanded by the outward pressure of the tumor,
there is often a dry, crackling, or rustling sound  perceived on pressure, which is
never met with in cases of aneurism.
  Treatment of Axillary Aneurism.—I am  not acquainted with any instance in
which an aneurism of the axillary artery, not arising from wound or injury, has
undergone  spontaneous  cure, or been  consolidated  by  constitutional treatment.
Xor is it probable that compression  can ever be made applicable to aneurisms in
this situation,  insomuch that the pressure brought to bear upon the subclavian
must necessarily at the same time influence the whole or  the greater part of the
brachial plexus of nerves, to such an extent as to be unendurable by the patient.
The ligature of the artery is  therefore the surgeon's sole resource in the treat-
ment  of these cases.,  The part of the vessel universally selected for the appli-
cation of the ligature  is, in  accordance  with  the Hunterian doctrines, that which
lies on the first rib beyond the scalenus anticus muscle;  this part presenting the
advantage of being sufficiently removed from the seat of disease to insure the
probability of \he  coats of the artery being in a  sound state, of being by  far the
most accessible, and when deligated,  of allowing the collateral circulation by
which the  vitality of the arm is to be  maintained to remain  uninjured.   Not- 
534
ANEURISM  OF  THE  SUBCLAVIAN.
withstanding these obvious advantages, presented by the ligature of the subcln-
vian over that of the  axillary artery; in other words, of performing  Hunter's
instead of Anel's operation for the cure of spontaneous axillary aneurism;  there
would  appear to be a tendency in the minds of some surgeons to advocate the
latter instead of the former of these  operations : and to substitute for one that
offers the advantages that have just been mentioned a procedure that is not only
much more difficult in its performance, and  that  interferes with  the collateral
circulation, but that is  practised upon a diseased part of the vessel, in dangerous
proximity to the sac.
  Ligature of  Subclavian in third part of its  course.—In  order to
apply a ligature  to that portion of the subclavian  artery which  intervenes be-
tween the acromial edge of the scalenus anticus and the lower border of the first
rib, the patient should be placed  in  the  recumbent position, the  arm depressed
as much as possible, and the head turned somewhat to the opposite side.  The
integuments of the lower part of the neck should then be put  on  the stretch by
beino; drawn downwards over  the clavicle, and an  incision about four inches in
length made upon the  bone through  the integument, the superficial fascia, and
the pktysma.   When tension  is taken off the part, this incision will be found to
traverse the base  of the inferior triangle  of  the neck; a vertical incision should
then be made at right  angles to, and  falling into the centre of  the first, and the
two flaps of integument and fascia should  then  be  turned up.   A quantity of
loose cellular  tissue will now be  exposed,  in which a venous plexus, and the
lower end of the  external  jugular vein will  commonly be found.    These vessels
should be carefully avoided, and the cellular  tissue dissected or scratched through
with the point of a knife and a blunt probe;  should any vein be wounded, a
double ligature must be passed underneath  it, or either end tied.   If the trans-
versalis colli or humeri arteries, as occasionally happens, should  inconveniently
traverse this place, they must be drawn out  of the way with a  blunt hook.  By
the combined  action of cutting and  scratching through the cellular tissue, the
external edge of  the scalenus anticus is reached, down which the finger is run
until the tubercle of the first rib is felt; this is the guide to the  artery, which will
be found immediately above and a little behind it, covered, however, and bound
down to the rib  by a dense fascia.   This  must now be very carefully opened
with the point of a knife, and  the needle  passed from before backwards.  In
doing this,  attention must be paid  to the  brachial  plexus, situated above and
behind the artery.
  There are several points in  connexion with this operation that deserve special
attention.    In the first place it is necessary that the shoulder should be depressed
as far as possible, so as to bring the superior margin of the clavicle down.  This
is a matter of much  importance; for if the  clavicle be thrust upwards by the
pressure  of a large aneurism, the surgeon  will have to  find the  artery at the
bottom of a deep  narrow wound, instead of on a comparatively plane surface.  A
case occurred to Sir A. Cooper, in which the attempt to ligature the subclavian
artery for a large aneurism of the axilla was forced to be abandoned,  in conse-
quence of the clavicle being thrust up to too great a height to enable him to
reach the vessel.   The extent of the difficulty occasioned by this elevation of the
clavicle must necessarily depend in a  great measure upon the height  at which
the subclavian artery happens in any particular case to be situated in the neck.
It is not uncommon to find it pulsating so  high in the neck, that  no amount of
elevation of the  clavicle by subjacent axillary aneurism could raise that bone
above the level of the  vessel.  In the majority of cases, however, in seventeen
out of twenty-five, as  shown by 31 r.  Quain  in his  Work on the Arteries, it is
either below the level of the bone, or but slightly raised above  it;  so that if the
clavicle were thrust upwards and forwards, the vessel would be buried in a deep
pit behind it.   Dupuytren was of opinion that the artery coursed high in persons
/ 
LIGATURE  OF THE  SUBCLAVIAN.
535
who were thin, with slender, long necks; whereas, in thick, short-necked persons,
with muscular shoulders, it was deeply seated.   I have often verified the truth
of this observation both in dissection and in examining  the pulsations of the
vessel during life.  In order  to obviate  the difficulty that has occasionally been
experienced  in reaching the artery when thus buried behind an elevated clavicle,
it has been proposed by Mr. Hargreave to saw through the bone.
   The most serious objection that can be raised against this practice is the fact
of the clavicle being sometimes a part of the wall of the aneurism;  but supposing
the surgeon could satisfy himself that this was not the case, I cannot see any ob-
jection to this procedure, provided any very  great  and insurmountable difficulty
presented itself in getting the ligature round the vessel without  it.
  In passing the needle round the subclavian, care must be taken that some of
the lower cords of the brachial plexus be not included in the noose, and indeed
the mistake has more  than once been committed of tying these nervous trunks
instead of the vessel.   Thus,  Mr. Liston, in the first successful  case of ligature
of the  subclavian in this  country, passed the thread  round the lower nervous
cord;  but immediately perceiving his error, turned  it  to  account by drawing
aside the included nerve, and thus more readily exposing the  artery.   Dupuy-
tren, in a case of aneurism of some years duration, succeeded, after an operation
that lasted one hour  and  forty-eight minutes, and which  he describes as  the
most tedious and difficult  he  ever attempted, in passing a ligature round  the
vessel, as he believed.  After  the  death of the patient,  which occurred from
hemorrhage on the fourth or fifth day, the fourth cervical nerve  alone was found
included in the noose.  In a case related by Porter, it is stated that the artery
communicated such distinct pulsation to  the inferior  nervous trunk, that there
was  no means of ascertaining whether it  was the  vessel or not, except by passing
the needle under it.
  In some cases, as has already been stated, the sac  passes upwards below the
clavicle into the inferior posterior triangle of the neck; when this  is the case,
the surgeon  incurs the risk of puncturing  it from  its close proximity to  the
artery, as it lies on the first rib.    This accident happened  to  Mr. Cusack  while
ligaturing the subclavian in the  third part of its course, for a diffused aneurism
of the  axillary  artery.  An  alarming gush of blood took place, which was
arrested by plugging the wound, but the hemorrhage recurred on the tenth day,
and the patient died.   In  a case related  by Mr. Travers, in which the  sac was
punctured by the  needle, which was being passed  round the artery, the blood,
which was arterial, did not flow  per  saltum, but in  a continuous  stream.   " The
hemorrhage," says Mr. Travers, " was more terrific and uncontrollable  than I
have ever witnessed,"  and  was not commanded by drawing the ligature tight.
It was so great that it  was  doubtful whether the patient would leave the theatre
alive, and  was only arrested by plugging the wound with sponge-tents.  The
patient died  of inflammation  of the pleura.   On  examination, the aneurismal
sac was found to have  a pouch-like enlargement  upwards, overlying the artery,
where  it had been punctured.
  If it be found that the sac  encroaches upon the neck, rising above the  clavi-
cle, or that the artery is  not sound in  the  third  part of  its  course, it may be
necessary to ligature it between  the  scaleni,  by dividing the outer half or two-
thirds of the scalenus  anticus.   This operation should not  be  considered as one
distinct from the ligature of the vessel in the third part of its  course, but rather
as an extension of that proceeding, if it be found, for the reasons just mentioned,
unadvisable to tie the  artery on  the first rib; in this way it has been practised
by Dupuytren and Liston.   In  its first  steps, as far  indeed as  the exposure of
the scalenus anticus, it is the same as that for the deligation of the vessel in the
third part of  its course.  When this muscle  has  been exposed,  a director  must
be pushed under it, upon which it is to be divided  to the extent of half or two- 
536
ANEURISM  OF  THE  AXILLARY  ARTERY.
 thirds its breadth, when it  retracts, exposing the vessel.   During  this  part of
 the operation, some danger may be incurred to the phrenic nerve, and the trans-
 versalis colli and humeri  arteries; but if ordinary care be taken, this will not
 be very great.   The phrenic nerve, as  I  have found by very frequent examina-
 tions on the dead body, lies altogether to  the tracheal side of the incision if that
 be not carried beyond one-half the breadth of the muscle;  and should it appear
 to be in the way, may readily be pushed inwards towards the mesial line, bein<r
 only loosely invested by cellular tissue.   I  have, however, seen one instance in
 which the right subclavian  artery was ligatured  for a spontaneous  cylindriform
 aneurism of the axilla, and the  patient died on  the eighth day of pneumonia •
 on examination after death, the edge of the scalenus was found cut,  and the
 phrenic nerve divided.   Had the  pneumonia in  this  case  anything to  do with
 the injury to  the nerve ?  I do  not think it improbable, as division  of one
 phrenic by paralysing to a certain  extent  the diaphragm, and so far interfering
 with the respiratory movements, must  necessarily have  a tendency to  induce
 congestion  of the lung, which  would  readily  run on to  inflammation of that
 organ.   I have likewise heard of one case in which incessant hiccough followed
 this operation, and after death the  phrenic  nerve was found reddened and
 inflamed, having probably in some way been interfered with during the exposure
 of the vessel.
   Another important point in reference to the ligature of the vessel in this part
 of its course is the frequency with which a  branch arises  from the subclavian
 artery between the scaleni.  When this peculiarity exists, there would probably
 be but a slender chance of the occlusion of the artery by ligature in this situa-
 tion. ^  The transversalis colli and humeri  arteries, though in some danger, whilst
 crossing over the scalenus anticus, may be avoided  by keeping the incision in
 the  muscle between and  parallel  to  these vessels.   One  principal danger in
 ligaturing the subclavian artery at any point above the first rib, certainly arises
 from interference with the fine cellular tissue which lies  between it  and the
 scalenus muscles, separating  it from the  pleura, and which is  continuous with
 the  cellular membrane  of the   anterior mediastinum,  being indeed  the deep
 portion of the _ ascending  layer  of  what Sir A.  Cooper  has described as the
 " thoracic fascia," and which tends to form the superior boundary of the chest,
 being continuous in the neck with  the deep cervical  fascia.  After the deeper
 layers of the cervical fascia have been opened, this  fine cellular  membrane pre-
 sents itself, and if inflammation  be excited in it,  the morbid action  will readily
 extend by mere continuity of tissue into the thorax by the anterior mediastinum,
 invading ultimately the pleura and pericardium.   Hence,  whenever  it is practi-
 cable, the surgeon should keep the point of the needle close to that  part of the
 artery which lies upon the first rib, as there is less risk here of opening into the
 deep cellular tissue of the  neck.
   The general result of the  ligature of  the  subclavian artery in  the third part
 of its course, for spontaneous aneurism in  the axilla, is by no means satisfactory.
 Thus, of 45 cases of aneurism of the axillary artery, not dependent upon  any
 external wound, in which the artery was ligatured above the clavicle, I find  23
 cures against 22 deaths.   This  result is so unfavorable, and so different,  indeed,
from what  I had anticipated, that I was led to analyze carefully the  causes of
 death.   I find them as follow :—

      Inflammation within the chest, &c,
      Suppuration of the sac,
      Hemorrhage, .
      Gangrene of hand and  arm.
      General gangrene, .
      Not stated, ....
.  9 cases.
  6  ';
.  2  >'
  1  "
  1  «
  3  "
22  " 
      ACCIDENTS AFTER LIGATURE  OF  THE  SUBCLAVIAN.    537

   Thus it will be seen that the two most frequent causes of a fatal result follow-
 ing the operation for axillary aneurisms, are not those that are usually met with
 after the ligature of the larger vessels.   It would, therefore, appear to be owing
 to some special condition, dependent either upon the application of a ligature to
 the subclavian artery in  the third part of its course, or upon the situation and
 nature of the disease for which that  operation is had recourse to; and the impor-
 tant point to be determined is, whether these conditions are the accidental  or the
 necessary consequences of the application of a ligature in this situation for the
 cure of an  aneurism in the axilla.
   The inflammation of the contents of the thorax proved fatal  in 9  out of 22
 cases, or 1  in 2 J, and is  the most frequent cause of death after, though not, I
 believe, the most frequent untoward complication of this operation.  It might at
 first be supposed  that in this respect the operations on the subclavian artery re-
 sembled other of the greater  operations, after which  pneumonia  is so common a
 sequela; but on closer examination it will be found that this is not the case, that
 the inflammation, when attacking the thorax or its contents after ligature of this
 artery for axillary aneurism, is  not  confined to  the  lungs, but  very  commonly
 affects the  pleura and pericardium as well as  or even in preference to  these
 organs.  It would, therefore, appear probable that it arose from causes that are
 essentially connected with this disease or operation.   These are referable  to three
 heads.
   1st. Inflammation of the deep cellular tissue at the root of the neck,  extend-
 ing  to  the  anterior mediastinum,  the pleura  and pericardium.   This would
 appear to have been the cause of the supervention of inflammation  in a patient
 of Mr. Key's, and has been especially adverted  to by that  excellent surgeon in
 the relation of the case of a patient on whom he  performed this operation.
   2d.  The sac may, by its pressure  inwards, encroach upon and give  rise  to in-
 flammation of that portion of the pleura that corresponds to its posterior aspect.
 This occurred in a case in which Mr. Mayo of Winchester operated, and is more
 liable to happen if suppuration  has  taken place  in the  sac; when this happens,
 adhesion may  occur between it and the pleura, or even the tissue  of the adjacent
 lung, and the  contents of the suppurated tumor be discharged into the  pleural
 cavity or air-tubes, and so coughed  up.  Of this curious mode of termination
 there are at least two cases on record, one by Mr. Bullen, in which the patient
 recovered;  the other by Dr. Gross, in which the patient died from the escape of
 the contents of the sac into the cavity of the pleura.
   3d. Division of the phrenic nerve would  necessarily, by interfering with the
 respiratory  movements, induce a tendency to congestion and inflammation of the
 tissue of the lungs;  and although such an accident must be  a very rare one in
 cases  of ligature of the subclavian for  axillary aneurism, yet it undoubtedly has
 occurred.
   Suppuration of the sac  is the most common, though not the most fatal accident
 after ligature of the subclavian  for  spontaneous  axillary aneurism.  It was the
 immediate cause of death  in 6 cases,  and occurred in 2 of the patients that died
 of inflammation of the chest; and took place in 6 cases  that recovered, in all 14
 cases  out of  45, nearly 1 in 3, a much  higher proportion  than is  generally
 observed in  cases of ligature for aneurism.
   What is it that occasions this greater frequency of suppuration of the sac in
 these than in aneurism in other  situations?  The only cause to which it  appears
 to be attributable is  the great laxity  of the cellular membrane in this  situation,
 which allows the tumor to increase so rapidly in size as to excite inflammatory
action in the surrounding  tissues, which may speedily run into suppuration.   So
long as the contents  of the tumor continue fluid, they will necessarily excite less
irritation on surrounding structures;  but when once they have become  solidified,
whether by the gradual deposition of laminated fibrine, during the  progress of the 
538
ANEURISM  OF  THE  AXILLARY ARTERY.
disease, or more suddenly, in consequence of those changes that take place in the
contents of an aneurismal sac after the ligature of the artery leading to it, the
indurated mass  acting like any other foreign body sets up inflammation in the
cellular tissue that is in immediate contact  with it, and thus disposes  it to run
into suppuration.  The more speedily the solidification  takes place, the more dis-
position will there  be to the occurrence of this accident, the neighboring parts
being unable to accommodate themselves  to the sudden extension and compres-
sion they are compelled to undergo.
   The period at which suppuration of the sac may be expected to occur in cases
of axillary aneurism, after the  ligature  of the  subclavian, must necessarily in a
great measure be dependent on the state of  the sac at the time of the operation.
If inflammatory action have been already set  up  around it, it may happen in a
few dajs after the artery has been  tied.  But if  this  morbid action have  not
already commenced, the period at which suppuration may most probably be ex-
pected is between the first and second month.  The period at which suppuration
and rupture of the sac take place does not influence the probable termination of
the case to any material extent; as in the cases that proved fatal death occurred
at various  periods between the seventh  day and the  second month;  in Aston
Key's case, on the ninth day, in Mayo's on the twelfth, in Belardini and Graefe's,
at the end of the first month, in Bigaud's, at the sixth week, in B. Cooper's, in
the second month.   The recoveries, likewise, took place at all periods  after the
ligature of the vessel, between a few days, as  in  Porter's, and six weeks, as in
Halton's case.
   An axillary aneurism that has suppurated may either burst externally or into
the lungs  or pleura, or both.   It is most usual for it  to burst externally; the
tumor enlarging, with much pain and tension,  a part of the skin covering it be-
comes inflamed, fluctuation can here be  felt, and if an incision be not made into
it, it will  give way, discharging  most usually a  quantity  of dark-colored pus,
mixed up with more or less  broken-down  and disintegrated coagulum and fibri-
nous deposit, and perhaps sooner  or later  followed by a stream of arterial blood.
   Occasionally, but more rarely, the sac extending backwards becomes adherent
to the pleura, and may give way into that cavity, or by pressing upon, may be-
come incorporated with the lungs.   Of this remarkable termination two instances
are recorded, in one  of which recovery took place.
   The first case of the kind is one in which Mr. Bullen ligatured the subclavian
artery for axillary aneurism.  Eighteen days after the operation the tumor began
to increase, and to take on the  symptoms that are indicative of suppuration.  On
the twenty-sixth day six or eight ounces of bloody  pus were expectorated during
a paroxysm of coughing, and the  tumor suddenly diminished to one-half its size;
it was now punctured, and five ounces of the same  kind of matter let out with
great relief.  When the patient coughed, air passed into and distended the  *c
through an aperture between  the  first and second  ribs,  near their sternal extre-
mities, through which the contents of the  tumor had escaped into the lung. The
discharge from the external aperture greatly decreased, the cough lessened, and
_nally, three months after the operation, the patient was quite well.
  Dr. Grosse tied the subclavian  artery for axillary aneurism  on  the 18th of
February.   After  the performance of the operation the contents of the tumor
solidified, and its volume progressively diminished.  On the 15th of March,  the
patient suffered from fever, and slight tenderness  on the apex of the tumor was
perceptible.  On the 16th, he was suddenly seized with intense pain in the chest,
which  was particularly severe  at the base of the  right lung, and extended up
towards the axilla.   The respiration  throughout the right lung was bronchial,
and there was dulness on percussion over the lower ribs; the aneurismal tumor
had suddenly disappeared at  the  time of  the attack.   On the 18th, the patient
experienced a sensation, as if a fluid was  passing from  the pleuritic cavity into 
      ACCIDENTS  AFTER  LIGATURE  OF  THE  SUBCLAVIAN.    539

that of the aneurismal tumor;  and, upon auscultating, a  plashing  sound was
heard at every inspiration, the noise resembling that produced  by shaking water
in a closed vessel.  On the 20th, he died.  Upon dissection  the aneurism was
found to communicate by an aperture, one inch and three-quarters in length, by
an inch and a half in width, with the pleural cavity; this opening was situated
between the first  and second ribs, and was obviously the result of ulceration and
absorption, caused by the pressure of the tumor.   Both ribs were denuded of
their periosteum.  The right side of the chest contained nearly three quarts of
bloody serum, intermixed with laminated clots and flakes of lymph;  the former
of which had evidently been lodged originally in the aneurismal sac (Xorris, in
American Journal, 1^45, p. 19).  Besides these cases, a somewhat  similar one
has been  recorded by Mr.  Xeret, of Xancy.   A patient was admitted into the
hospital, laboring under hemoptysis, and on examination was found  to have an
aneurism  of the left subclavian  artery as large as a chesnut.  He died shortly
after admission, and on  examination  the aneurism was found to communicate
with a large cavity in the upper part of the lung.
   The cause of death in Dr. Grosse's case was probably the fact of the sac open-
ing and discharging its contents  into the pleural cavity.   This does  not appear
to have occurred in  Mr. Bullen's, in which a  communication was  established
directly with the  lung, the contents of the abscess finding exit through the air-
tubes, as is the case, occasionally, in hepatic abscess, adhesion having previously
taken place between the opposed surfaces of the pleura.
   The principal danger, and the most frequent cause of death after  the suppu-
ration of the sac,  is the supervention of profuse arterial hemorrhage.   This may
either occur from the distal extremity of the artery opening into the sac, or from
one of the large branches which  serve to support the collateral circulation round
the shoulder, such as the subscapular or posterior circumflex, coming off either
immediately above or below the sac, or from the sac itself.   When  hemorrhage
does not take place after the suppuration of the sac, it must be from the fortunate
circumstance of the occlusion of the main trunk, where it opens into the tumor.
It can scarcely be from the occlusion of the principal collateral branches, as there
would, in this event, be a difficulty in the preservation of the vitality of the limb.
It is easy  to  understand, that if the sac  spring from  the axillary, at a little
distance above the orifices of the subscapular and circumflex arteries, all that
portion of the main trunk which  intervenes between the tumor and these vessels
might be  occluded, and  thus hemorrhage be  prevented  on suppuration  taking
place;  whilst the collateral circulation would take place uninterruptedly through
these vessels.   If this  portion of the artery have not been  occcluded by inflam-
matory action, the safety of the  patient must depend upon the accident of  a
coagulum or piece of laminated fibrine being fixed or entangled in the mouth of
the sac.  This may prevent for a time the escape of arterial blood, which, on such
a plug  being loosened, may break forth with impetuosity, and either at once, or
by its recurrence  at intervals, carry off the patient.
  Another danger may be  superadded  in  these  cases on the suppuration of the
sac and the supervention of hemorrhage, namely, the occurrence of inflammation
of the pleura, lung, and pericardium, from the extension inwards of  the morbid
action going on in the sac.
   Secondary hemorrhage does not  frequently occur in cases of ligature  of the
subclavian artery in the third part of its course,  except as a consequence of sup-
puration of the sac.  I am only acquainted with two cases in which it proved
fatal from the hemorrhage  taking place from  this artery at the  part ligatured.
One of these happened  to Liston, and the preparation is preserved in the Museum
of the College of Surgeons (Xo.  1695).  In this case, it may be seen  that the
artery was  diseased at  the point ligatured, and that  the bleeding occurred, as
usual, from the distal side of the ligature. 
540           ANEURISM  OF  THE  AXILLARY  ARTERY.
   Gangrene of the  hand and  arm is but seldom met with as a sequela of the
 operation we are considering.   This  is  doubtless owing to the freedom of the
 anastomosing circulation  between the  branches of the transversalis  colli and
 humeri, and those of the subscapular, circumflex, and thoracic acromial arteries;
 as well as between the superior thoracic and  the branches of the first and second
 intercostals and internal  mammary, by which the vitality of the limb is readily
 maintained.   The principal risk from  gangrene would doubtless arise from  the
 subscapular artery being in any way occluded or implicated in  the disease, as it
 is on the anastomosis of this vessel that the limb  is mainly dependent for its
 supply of blood.  But, at all events, this danger is small, the only case in which
 it appears to have given rise to a fatal termination being one in  which Mr. Colles
 tied the artery;  gangrene of the limb  coming on after much constitutional dis-
 turbance of a low type, with rapid, weak pulse, thirst, sweats, restlessness, and
 delirium.  In Blizard's case there was  sloughing of the sac, and pericarditis, the
 gangrene being confined to two fingers; and  in Brodie's case, it occurred in both
 the lower as well as in the upper extremity, and must, therefore, have proceeded
 from some constitutional cause, altogether independent of the mere arrest of cir-
 culation through the subclavian.
   The case of  an axillary aneurism becoming inflamed, and  threatening to run
 into suppuration before the surgeon has  had an opportunity of ligaturing the
 subclavian artery, is one that is full of important practical considerations, and
 one  that admits of little delay, for if the sac rupture, or be opened, fatal hemor-
 rhage is the necessary and inevitable  result.  It would obviously be impossible,
 in a case of spontaneous  aneurism, with any fair chance of success,  to lay open
 the  tumor, turn  out the  coagula, and  ligature the vessel above and below the
 mouth of the sac; the coats of the artery being not only diseased, but still further
 softened by inflammation  and supervening suppuration, would not be in a condi-
 tion  to hold a  ligature.   There are two other courses open, viz., the ligature of
 the vessel, or amputation  at the shoulder-joint, and in  the selection of one or
 other of these, the surgeon must be guided by the progress the disease has made,
 the condition of the limb as to circulation and  temperature, and whether the
 contents of the tumor are  solid or fluid.
   If the tumor be of moderate size, and circumscribed, the arm of a good tem-
 perature, and not very edematous, the ligature of the artery  may hold out a
 reasonable  chance of success.  It is true  that this is  but a chance; for  as the
 blood will, immediately after the  noose is tied, be carried by the supra and poste-
 rior  scapular arteries into  the subscapular and circumflex, and by them into the
 axillary at no great distance from the mouth of the sac, or enter, perhaps, directly
 into  the mouth of the latter if the profunda or circumflex should chance to take
 their origin from the dilated portion of the vessel, the only safeguard  against the
 supervention of hemorrhage  as soon as  the sac has burst or been opened or has
 discharged its contents, will be the occlusion  by inflammatory action of that por-
 tion  of the artery that intervenes between these two collateral  branches and  its
 mouth, or the accidental entanglement in the  latter of a mass of laminated fibrine.
 Yet  under the circumstances, as to the condition of tumor and limb that have
just  been mentioned, it would be but right for the surgeon to give the patient a
 chance of preserving his limb.
   Should, however, hemorrhage occur on or  after the discharge of the contents
 of the sac,  the  subclavian  having previously been ligatured, what should be done?
 If the bleeding be moderate, an attempt should be made to arrest it by plugging
 the wound, and by the application of a compress and bandage.   If it recur, or
 is so profuse as  to threaten the life of  the patient,  what  course  should the
 surgeon then pursue ?   Two lines of procedure are open to him ; either cutting
 through the pectoral muscles so as to lay the sac open fully, and attempting to
 include the bleeding orifice between two ligatures, or amputation at the shoulder-
joint. 
LIGATURE  OF THE AXILLARY  ARTERY.
541
  If a surgeon were to undertake the first of these  alternatives  in  a  case of
spontaneous aneurism,  of which alone we are now  speaking, he would, in  all
probability, find the part in such a condition as would prevent the possibility of
his completing the  operation he  had commenced.   After laying open a large
sloughing cavity, extending under the pectoral muscles, perhaps as  high as the
clavicle, and clearing out the broken-down coagula and grumous blood it contains,
in what  state would he find the  artery ?   Certainly, the probability would  be
strongly against its being in such  a  condition as to bear a ligature, even if it
could be included in one.   Its coats, in the immediate vicinity of the sac, could
not,  in  accordance  with what we know  to be  almost universally the case in
spontaneous aneurisms of large size or old  standing, be expected to be in anything
like a sound, firm state, and would almost certainly give way under the pressure
of the noose; or the vessel might have undergone fusiform dilatation, as is very
common in this situation, before giving rise to the circumscribed false aneurism,
in which case it would be impossible to surround it  by a ligature; or, again, the
subscapular or circumflex arteries might arise  directly  from,  and pour their
recurrent blood into, the sac or the dilated  artery, and  lying, as they would, in
the midst of inflamed and sloughing tissues, no attempt at including them in a
ligature could be successfully made.   Under such  circumstances as these, the
danger of  the patient  would be  considerably increased, by the irritation and
inflammation that would  be  occasioned  by laying  open and  searching for the
bleeding vessel in the sac of  an inflamed,  suppurating, and sloughing aneurism,
and much valuable time would be  lost in what must be  a fruitless operation; at
the close of which it would, in all  probability, become necessary to have recourse
to disarticulation at the  shoulder-joint, and thus remove the whole disease at
once.  I should, therefore, be disposed to have recourse to disarticulation at the
shoulder-joint, at once, in all cases of profuse recurrent hemorrhage,  following
sloughing of the sac of an axillary aneurism, which could not be arrested by direct
pressure on the bleeding orifice, after the  subclavian has been tied.
  There  is another form of axillary aneurism, that requires immediate amputation
at the shoulder-joint, whether the subclavian artery have  previously been ligatured
or not;  it is in  the case of  diffuse aneurism of the armpit,  with threatened
gangrene of the limb.
  Ligature of  the  Axillary Artery.—Should ligature  of the axillary
artery at any time be required, the vessel may be secured in two  ways, in the
space that intervenes between the  lower margin of the  clavicle and the  fold of
the axilla.
  The first is by an incision, either straight or somewhat semilunar, parallel to
and immediately below  the inferior border of the clavicle ; this must be  carried
through the pectoral muscle, and when this is divided, some loose cellular tissue,
in' which the thoracica suprema artery  ramifies, is exposed.   This  must  be
scratched through cautiously, until the fascia covering the vessels is reached.
On opening this, which must be done in the most careful  manner, by making a
small aperture in it and then passing a grooved  director under it, the  vein first
comes into view.  This must  be drawn downwards, when  the artery will  be
found immediately above and behind it in the deep hollow formed by the clavicle
above and the edge of the lesser pectoral below.  This  operation is an exceed-
ingly difficult one, on account of the depth and narrowness of the wound and the
muscular character of its walls, as well as from the embarrassment occasioned by
the numerous venous  and arterial branches  which ramify across the space in
which the artery lies.   After the vessels have been  exposed, the passage of the
ligature round them  will be greatly facilitated by bringing the  arm to the side of
the body, so as to take off all tension in the wound.
  The safer and simpler operation consists in making an incision from the centre
of the clavicle directly downwards, in the  course of  the vessels, to the middle of 
542      ANEURISM  OF  THE  ARM,  FOREARM,  AND  HAND.

the anterior fold of the  axilla.   In this way the skin, superficial fascia, and
pectoralis major must be successively divided.  The lesser  pectoral will then be
exposed, and  the  artery  may either be  ligatured below this,  without further
division of muscular substance, or  if it be thought desirable to deligate it under
this, the muscle must be  cautiously cut  through.   When  this  is  done a very
distinct and firm fascia will  come into view; this, being  pushed  up, must be
carefully opened, when the artery  and vein will  be seen lying _ parallel to one
another,  the artery not being overlapped by the vein, as it is higher  up.   The
vein havino- been drawn inwards, the aneurismal needle must be  carried from
above downwards between it and the artery.  The great advantage of this opera-
tion is, that the wound is open and free, and that, consequently, the artery can
be more  readily reached in any part of its course.  The disadvantage is the great
division  of muscular  substance  that it  entails.    This, however, need not leave
any permanent weakness  of the limb,  as by proper position ready and direct
union may be  effected between the parts.

              ANEURISM OF  THE ARM, FOREARM, AND  HAND.
   Spontaneous aneurism  rarely occurs  below the axilla, but yet it may occa-
sionally be met with at  any part of the  upper extremities.  Thus  Palletta,
Flajani,  Pelletan, and others, relate cases of spontaneous aneurism  at the bend of
the arm; and Liston states that he once tied the brachial artery in an old  ship-
carpenter, who, whilst at work, felt as if  something had snapt in his arm.   Mr.
Pilcher has recorded a case of aneurism under the ball of the right thumb, which
was produced by repeated though slight blows with the handle of a hammer used
by the patient, a working goldsmith, in his trade; the radial  and  ulnar arteries
were tied immediately above the wrist, and the disease thus  cured.  Aneurism
has also been met with in this situation after attempted reduction of the thumb.
Spontaneous aneurism in the forearm is of extremely rare occurrence.  I am only
acquainted with one, that recorded by Mr. Todd, as occurring in a woman twenty-
eight years of age,  which had existed for several years  before the  brachial was
ligatured, when pulsation  in  the  tumor ceased, though it continued solid and
hard for some months after the operation, and in  1849, a man was admitted into
University College  Hospital, for a tumor that presented  all the  characters of
aneurism, and that  was  situated in the  upper third of the ulnar  artery of the
right forearm.  The brachial was  ligatured by Mr. Arnott, when  pulsation and
bruit ceased in the tumor, though some enlargement of the arm continued for
some time afterwards.
   Bare as spontaneous aneurisms  are in  these situations, the traumatic forms of
the disease  are, as has already been stated (p. 174),  of frequent occurrence, and
may require the ligature of the  brachial, or of either of the arteries of the fore-
arm.
   Ligature of the Brachial Artery.—The brachial artery may be ligatured
in the middle of the  arm, which is considered the seat of election of this ope-
ration, by making an incision about three inches long,  parallel to  the inner side
of the biceps;  the fascia, which is exposed, must be opened carefully to a corre-
sponding extent, when the median nerve will commonly be seen crossing the
wound;  this must be drawn downwards  with a blunt hook, when the artery, ac-
companied by its two veins, will  be exposed;  these vessels  must then be sepa-
rated from one another, and the ligature passed and tied in the usual way.  In
performing  this operation, the  principal point to attend to is to cut down upon
the inner edge of the biceps, which will be the sure guide  to  the artery.  If the
surgeon keep too low, he may fall upon the ulnar nerve and the inferior profunda
artery, which  might possibly be mistaken for the brachial; but by taking care
to expose the  lower fibres of the biceps  in  his early incision, he will avoid this
error. 
aneurism by anastomosis, and nevus.         543
   In the upper part of the arm, the  brachial artery, where the axillary termi-
nates in it, will be found lying immediately behind, and covered by its vein.  On
drawing this to the inner side, the artery will be seen, the plexus of nerves being
somewhat above and behind it.   In ligaturing  the artery in this situation, care
must be taken to divide the integuments, which are extremely thin, with great
caution;  when by rotating the  arm outwards and bepding the elbow, the artery
will be thrown  forward and rendered  less tense, so that a ligature can easily be
passed round it.
   At the bend of  the arm, the brachial artery may be reached by making an
incision about two inches in length in a direction downwards and inwards, about
half an inch internal  to the edge of the tendon of the biceps.   After carrying
it through the skin  and fascia, the vessel will be found accompanied by its veins,
in the triangular space bounded  externally by the biceps tendon, and internally
by the pronator teres.   In performing this operation, the  veins at the bend of
the arm,  with the filaments of the internal cutaneous nerve, must be divided to
some extent, though they should be spared as much as  possible.  The artery
will be found about half an inch to the inner side of the tendon, accompanied
by the median nerve, which is to its ulnar side.
   The radial and ulnar arteries should never, I think, be ligatured (except in
cases of direct wound) above the middle third of the arm; any attempt at deli-
gating them at the upper part  of the forearm will  not only be  attended with
great difficulty,  but  with  the  danger of crippling the muscles in this situation,
and thus  impairing the  after-movements of the arm, and may always have the
ligature of the brachial substituted for it.
   The radial artery may  be  ligatured near the wrist, by making an incision
about two inches in length, half an inch  to  the outside of  the  tendon of the
flexor carpi radialis; when, after the division of the superficial and deep fascia,
the artery, accompanied  by its two veins, will be exposed, and may be  tied in
the usual  way.  The ulnar artery above the wrist may be readily ligatured by
making an incision about two inches in length, a little above and one-third of an
inch to the radial side of the pisiform bone, parallel to the tendon of the flexor
carpi ulnans.  After dividing the fascia covering it,  the artery, with its two ac-
companying veins, will be found to the radial side of the ulnar nerve.
                        CHAPTER  XXXIX.

            ANEUBISM BY ANASTOMOSIS, AND  NEVUS.

   Aneurism by anastomosis is a disease of the arteries in which the vessels be-
come excessively elongated, tortuous, and serpentine; sometimes they assume a
varicose condition, being dilated into small  sinuses, and  are always very thin-
walled, resembling rather veins than arteries in structure.   This kind of dilata
tion of the vessels  will give rise to pulsating tumors, often of considerable size
and of  a very active and dangerous character.  They may be situated in almost
any tissue  or organ of the body, but are most commonly  met with in the sub-
mucous and subcutaneous cellular tissue, and  most frequently occur in the upper
part of the body, especially about the scalp, orbit, lips, and face; but theY have
been met with in other situations, such as the tongue, and even in internal organs,
as the liver, and I have seen very active growths of this kind on the nates and
toot.   In some caSes aneurism by anastomosis occurs in bones, in which it forms
a special disease, and is not uncommonly associated with encephaloid.   Indeed 
544         ANEURISM  BY  ANASTOMOSIS,  AND NEVUS.

there is certainly a great tendency for aneurism by anastomosis and encephaloid
to run into one another, the limits between them not being very clearly defined,
especially when occurring in connexion with osseous tissue.   It will  generally be
found that the  arteries leading to, though at a considerable distance  from the
aneurism by anastomosis, are tortuous, enlarged, with thin and  expanded coats,
and pulsate actively; in fact constituting that condition that goes by the name of
cirsoid dilatation of  the vessels.
   Aneurism  by anastomosis  forms tumors of  varying magnitude  and irregular
shape; they are usually of a  bluish  color, have a spongy feel, are  readily com-
pressible, not  circumscribed, and with large tortuous vessels running into and
from them on different sides.   Their temperature is generally above that of the
neighboring parts; and a  vibratory or purring thrill, amounting in many cases
to distinct pulsation, may be felt in them.   This pulsation or thrill is synchronous
with the heart's beat, may be  arrested by compressing the tumor or arteries
leading to it, and returns with an expansive beat on  the removal of the pressure.
The  bruit is often loud and harsh, but at other times of a soft and blowing cha-
racter.  These growths rarely occur  in infancy, but generally make their appear-
ance, in young adults, though they may be met with at  all periods of life, and
often as the consequence of an injury of some kind.
   It  is of importance to  effect the  diagnosis between ordinary aneurism and
that  by anastomosis.   In many cases  the  situation  of the tumor at a distance
from any large trunk, as on the scalp, the outside of the thigh, or the gluteal
region, will determine this.   Then again the outline of the growth is less dis-
tinct than in true aneurism;  and tortuous  vessels will be felt leading to it from
different directions.  The  swelling also is  doughy, and very compressible; but
when the pressure is removed, the blood enters it with a whizz and  thrill, not
with the distinct pulsating stroke that is found in aneurism.   The pulsation, not
so forcible as in aneurism, is more heaving and expansive.   The bruit is louder,
more superficial, sometimes having a cooing note.  By pressure  on  the arteries
leading to the  tumor,  these  signs  are usually not  entirely arrested, though
diminished in force,  the blood entering it  from the  neighboring parts, and in a
less direct way.
   The treatment of  aneurism by anastomosis  must  depend upon the  size and
situation of the growth.   When it  is so placed that it  can  be  ligatured or
excised, as on the lip, or when of small size,  about the neck, face, or scalp, it
should be removed in one or other of these ways.   I always prefer, in cases of
nevus, the ligature applied, as will immediately be described as being the safest,
and  upon the whole the  readiest mode  of getting rid of such a tumor.  If
excision be  practised,  it is necessary to  be very careful  to cut widely of the
disease; if it be cut into, fearful  hemorrhage may ensue, which  can only be
arrested by pressure, and which in several  instances  has proved fatal.
   If  the disease be very large and extended, as is commonly seen on the  scalp,
or when deeply seated, as on the orbit, neither ligature or excision of the tumor
can be practised, and it becomes necessary to starve  it by cutting off its  supply
of blood.  This*"may be done either by ligaturing the principal branches leading
to it,  or the main trunk of the limb, or part.   The simple  ligature  of the arte-
rial branches leading to the tumor has never, I believe, been followed by success,
at least in ten  recorded instances  in which it has  been had  recourse  to, the
disease has not in one instance been  cured.  It has, however, been  successfully
conjoined  by Dr. Gibson in two cases of aneurism by anastomosis of the  scalp,
with incisions made round  the tumor at intervals between  the  principal feeding
arteries, which at the same time were tied.
   The main trunk leading to  the tumor has been  ligatured in a  considerable
number of cases.  The brachial and  femoral arteries have  been tied for disease
of this kind  situated on the  extremities,  and in some instances with success; 
NEVUS.
545
 but the carotid is the vessel that has been most frequently deligated, in conse-
 quence of the tumor being so commonly situated on the scalp and  in  the  orbit.
 This operation has  been done  in twenty recorded cases, and in five  instances
 both the  carotids were ligatured at intervals  of several weeks.   In all of those
 cases  in  which the  double operation  was performed, the  patients ultimately
 recovered.   In  some of the  cases  in  which  one carotid alone was tied,  the
 disease being seated upon the scalp, was not cured, and it was afterwards found
 necessary to have recourse to ligature of the tumor, to excision,  and to  other
 means of removal; indeed, when seated upon the scalp, this disease appears to
 be more intractable than in any other  part of the body, owing probably to  the
 freedom  of the arterial supply from the numerous vessels  that ramify in this
 region.   Here, however, much  benefit might be derived after  ligature of  the
 carotid, by adopting the plan suggested by  Dr. Gibson of tying the feeding
 arteries, and  making incisions between them down to  the bone.   The ligature
 of the carotid has answered best for diseases  of  this kind in  the  orbit; of six
 instances in which the artery has been tied for aneurism  by  anastomosis in this
 situation, a cure was accomplished in five.

                                   NEVUS.
   This  disease,  under  which  those various affections are included, termed
 mother's marks, erectile tumors,  and vascular growths, constitutes  an  important
 and interesting  section of surgical affections.  It appears to consist essentially
 in an  excessive development of  the  vascular tissue of a part, and differs greatly
 as to  nature, cause, and treatment;  according as the  arterial, the capillary, or
 the venous  elements of the tissue predominate.   The predominance of  the
 arterial tissue we have already considered,  under the head of aneurism by anas-
 tomosis, it now remains  for us to describe the capillary and venous nevi.
   Capillary nevi appear as slightly elevated but flat spots on the  skin, of a
 bright red or purplish tint,  and having occasionally granular or papilkted eleva-
 tions,  with some  larger vessels ramifying on  their surface.   They often spread
 superficially  to a considerable  extent;  they  are usually  situated  on  the face,
 head,  neck, or arms, but  occasionally, though more rarely, on the back,  the
 nates,  the organs of generation, and the lower extremities;  they are, I believe,
 always congenital, though often at birth of a  very small size, not larger than  a
 pin's head, from which they may spread in the course of a few weeks or months
 to patches an inch or two in diameter.  In many cases no inconvenience results
 from this disease  except the deformity it entails, but  occasionally, more  espe-
 cially when the growth is at all prominent, there  is a great disposition to ulcera-
 tion of an unhealthy and hemorrhagic character.   When bleeding occurs, it is
 usually in a trickling stream, and without any degree of force.
   Venous nevi are of a  dark purple or reddish  color, usually very prominent,
 and  often forming distinct tumors  of considerable size, which  may  either be
 smooth and ovoid, or else  somewhat lobukted.   On compressing  a growth of
 this  kind, it subsides to a certain extent, feeling doughy, soft, and inelastic, and
 on the removal of the pressure fills up again.   In some  cases, when consolidated
 by inflammation, or containing cysts, it cannot be lessened in bulk by pressure.
 These  nevi  are  usually  about the size of  half a walnut, but  sometimes much
 larger.  I have removed them from the nates  and the back fully as large as  an
 orange.  They less frequently occur upon the head and face  than the  capillary
 form of the disease; most of the  instances that I have seen have been met with
in the lower  part of the body, about  the  nates, back, lower  extremities, and
organs of  generation.
   Subcutaneous nevi are occasionally met with, of a mixed  character, forming
soft, doughy,  and compressible  tumors,  which  may  be  recognised  by being
capable of diminution by pressure, on the removal of which they slowly fill out
                                    35 
546         ANEURISM  BY  ANASTOMOSIS,  AND NEVUS.

again to as large a size as before; they also become distended when the child
screams or  struggles, and  are usually of an  oval  shape, smooth,  and uniform.
The  skin covering the tumor is often unaffected; at other times it is  implicated
in an oval patch on the most prominent part of the growth, and occasionally the
surrounding veins are bluish and enlarged.
   In structure, the capillary nevi appear to be composed of  a congeries of small
tortuous vessels, of a capillary character; the venous nevi  appear made up of
thin  tortuous veins, dilated into sinuses and  small pouches.  In the midst of these
masses, cysts are not uncommonly found, sometimes containing clear,  at other
times, a dark, sanguinolent fluid.  These cysts are  probably venous sinuses,  the
openings into which have become occluded.
   The treatment of nevi may be conducted on three principles.   By  means  cal-
culated to excite adhesive inflammation in them, and so to produce plugging and
obliteration of the vascular  tissue of which they are composed;  by agents that
destroy the growth; or by its removal with the knife or ligature.   Each of these
different plans of treatment  is peculiarly applicable  when  the  disease  assumes
certain forms, and affects certain situations.
   When the disease is of small size, and occurs in  such situations that its  de-
struction by caustics, or removal by knife or ligature, would be attended by serious
deformity, as when it is seated about  the eyelids,  upon the  tip of the  nose, at
the inner angle between the eye and the nose, or about the corners of the mouth,
it is  best to endeavor to procure its obliteration, by exciting the adhesive inflam-
mation in it.  This may be done in various ways.    The most  convenient plan
consists, perhaps, in passing a number of fine silk  threads  across  the tumor in
different directions, and leaving  them in for a week or two at a time ;  until they
have  produced sufficient inflammation along their tracks:  then withdrawing
them, and passing them into other parts of the tumor.   In this way its  consoli-
dation may gradually be effected.  Another very useful plan is to  break up  the
substance  of the growth subcutaneously, by means of a cataract needle, and in the
intervals between the  different introductions  of  this  instrument  to keep  up
pressure upon it.   In other cases again, passing acupuncture needles into it, and
then heating them by means of a spirit-lamp, or injecting astringent solutions
into  it, will induce the requisite amount of inflammation.   In all these different
ways the surgeon may succeed in curing the disease.
   When the nevus is small, very superficial, of the capillary character, with  an
exceedingly thin covering of cuticle, and so situated, as upon the arm, neck, or
cheek, that a moderate amount of scarring is of little consequence, it  may most
conveniently be removed by the free application of  nitric acid.  This  should be
well  rubbed on by means of a piece of stick,  and  after the separation of  the
slough produced by it,  its applications must be repeated as often as  there is any
appearance of the granulations springing up, which will occasionally happen at
one  angle  of the wound,  and  is indicative  of a recurrence of  the vascular
growth.
   When the nevus is of large size, constituting a more or less distinct tumor,
and is of a somewhat venous character, it may occasionally be excised.  In doing
this, however, care should be taken to cut wide of the disease, and no operation
with the knife should be undertaken unless the growth be either  so situated, as
upon the lip, that the parts may readily be brought or compressed together, or
upon the  nates or thigh, and of a very indolent and venous character.  As a
general rule, it is far safer  and more convenient, to  extirpate the growth with
the ligature, and this, indeed, is  the  mode of treatment that is most generally
applicable to tumors of this kind in whatever  situations  they may occur, as it
effectually removes them without risk of hemorrhage, and leaves a sore  that
very readily cicatrizes.
   The ligature requires to be applied in  different ways, according to the  size  and 
TREATMENT OF  NEVI.
547
C->g_ '•- --- -"] ;"v:;":;;
situation of the tumor.  In all cases, the best material for this purpose is  firm,
round, compressed whip-cord.   This should be tied as tightly as  possible, and
knotted securely,  so that there may be no  chance of any part of the tumor
escaping complete and immediate strangulation.  It is well, if possible, not to
include in the noose any healthy skin, but always to  snip across with  a pair of
scissors that portion of integument which intervenes between the cords that are
tied together;  at the same time care must be taken to pass  the  ligatures well
beyond the limits of the disease.
   When the tumor is small, an ordinary double ligature may be passed across its
base, by means of a common suture needle,  and the noose being cut and the
thread tied on either side, strangulation will  be effected.  When of larger size,
and of round shape, the most convenient plan of strangulating the tumor is that
recommended by Liston.  It consists in passing, by means of long nevus-needles,
fixed in wooden  handles, and having the eye near their points, a double whip-
cord  ligature, in opposite  directions across  the  tumor; then cutting through
cither noose, and tying together
the contiguous ends of the liga-                   ri---164-
ture  until  the  whole of  the
growth  is encircled  and stran-
gled by them.  In doing this, a
few  precautions  are  necessary;
thus,the first nevus-needle should
be passed across  the  tumor un-
armed (Fig. 164 a), and used to
raise up the growth  somewhat
from subjacent parts.  The second
needle,  armed (Fig. 164  b), as
represented   in   the   annexed
wood-cut, carrying the whip cord
ligature by means  of a piece of
suture  silk,  should  be  passed
across the tumor in  the  oppo-
site direction to,  but underneath
the first needle;  the needle (b) being withdrawn, the ligature is carried across,
and  the first one  having been armed in the same way, carries its noose through
the  tumor as it is drawn out.  The two nooses
having then been cut, an assistant must seize, but
not  draw upon, six of the ligature  ends;  the sur-
geon then having divided the intervening bridge of
skin, ties pretty  tightly, in a  reef-knot,  the two
ends that are left hanging out; as  soon as he has
done this, he proceeds to  the next  two, and  so on
until he gets to the last (Fig. 165).   When  he
ties these, he must do so with all his force,  espe-
cially if the  tumor  is large,  as by drawing on
them he tightens all  the other nooses, and  drags
the  knots  towards  the centre of the  growth,
which is thus effectually strangled.   He then cuts  off the tails of the ligature.
After the tumor has sloughed away, which happens in a few days, if properly and
tightly strangled, the sore is treated on ordinary principles.  If the nevus is alto-
gether  subcutaneous,  the skin covering it should  not be sacrificed, but  being
divided by a crucial incision, may be turned down in  four flaps, and the ligature
then tied as directed.  In some situations, as upon the anterior fontanelle, it may
be dangerous to  pass the  threads across the base of the tumor, lest the  mem-
branes of the  brain which  lay immediately  beneath it be wounded.   This diffi-
Fi<r. 165.
 
548         ANEURISM  BY ANASTOMOSIS,  AND  NEVUS.
culty I  have readily overcome by making a puncture on one side of the tumor,
and then pushing an eyed-probe conveying the whip-cord across its base through
the  soft spongy tissues  of which it is  composed, and cutting down upon its
point, where it projects on the opposite  side of the tumor, drawing it through;
the second threads are tied in the same way, and the mass firmly strangulated.
Although I have seen convulsions follow the ligature  of nevi in this situation, I
have never met with a fatal result.
   In some cases, the  nevus is so flat and elongated that the application of the
quadruple ligature, as above described, cannot include the whole of it.   Under
these circumstances, I have found the ligature about  to be described eminently
useful, having successfully employed it in a great number of instances.  Its great
advantage is, that while it completely and very readily strangles the tumor, it
does not inclose an undue quantity of integument, and thus does not produce a
larger cicatrix than is necessary for the eradication of the disease.  It is applied
in the following way: A long triangular needle is threaded on the middle of a
whipcord about three yards in length; one-half of this is stained black with ink,
the other half is left uncolored.   The needle is inserted through a  fold of the
sound skin,  about a quarter of an inch from one  end of the tumor, and trans-
versely  to the axis of the same.   It is then carried through, until a double tail,
at least  six inches in length,  is left hanging from the  point at which it entered;
                                                    it is next carried across
                                                    the  base  of the tumor,
                                                    entering and passing out
                                                    beyond its  lateral limits,
                                                    so as to  leave a series of
                                                    double loops  about nine
                                                    inches in length on each
                                                    side (Fig. 166 a). Every
                                                    one  of these loops should
                                                    be  made about   three-
                                                    quarters of an inch apart,
                                                    including that space of
                                                    the  tumor, and the last
                                                    loop should  be brought
out through a fold of healthy integument beyond the  tumor.   In  this  way we
have a series of double loops, one white,  and the other black, on each side (Fig.
166 a).   All the white loops  should now be cut on one side,  and the  black loops
the other, leaving hanging ends of thread of corresponding colors.
   The tumor may now  be strangulated  by  drawing  down and knotting firmly
each pair of white threads on one  side, and each pair of black ones on the other.
In this way  the tumor is  divided into segments, each of which is strangulated,
by a noose and  a knot:  by black  nooses  and white knots  on one side, by white
nooses and black knots on the other (Fig. 166 b).
   The cicatrix resulting from the removal of a nevus is usually firm and healthy,
but in some instances, I have seen it degenerate into a hard warty mass requiring
subsequent excision.   The ligature may be used successfully at  all ages.   I have
repeatedly tied  large nevi in infants a month or two  old, without meeting with
any accident.
   It has been proposed by Mr. Curling to ligature the nevus subcutaneously, by
passing  a thread around its base, under the skin, and then tightening it.  This
may succeed when the growth is of small size, and is useful when  so situated
that a  cicatrix is objectionable.  Mr. Startin has very ingeniously proposed a
plan, which I have advantageously adopted in some cases, of elastic subcutaneous
strangulation, by fixing a vulcanized India-rubber  ring,  put upon the stretch, on
to the noose of the ligature, and then keeping up steady traction upon it.   The
 
DISEASES  OF  THE  NERVOUS  SYSTEM.
549
annexed cut (Fig. 167) represents a nevus with two ligatures (a, a) passed  sub-
cutaneously round  it, in opposite directions, and attached  to India-rubber rings
(b, 6), to which tapes are tied by which the traction is made.

                                  Fig. 1C7.
                        HEMORRHAGIC DIATHESIS.
  In connexion with diseases of the arteries, it may be stated, that in some con-
stitutions it is  found, though very rarely, that there is a great tendency to very
troublesome, indeed almost  uncontrollable  bleeding, from  trivial wounds; life
being put in jeopardy, or even lost, by the hemorrhage resulting from the extrac-
tion of a tooth, the opening  of an abscess, lancing the  gums, or  some equally
slight unimportant surgical  procedure.   The blood in these cases does not flow
in a jet, but continues to trickle  in an oozing stream, apparently  from the capil-
laries of the part.  This disposition is  usually congenital,  and  in many cases
hereditary, in other instances it appears to result from the acquirement of a scor-
butic condition. It is uncertain whether the hemorrhage is owing to the blood being
deficient in  fibrine, or to the smaller vessels being not sufficiently contractile.   In
such cases as these, care must be taken not to make any surgical  wounds if they
can possibly be avoided;  though it is a remarkable fact, that this condition seems
only to have been met with after trivial  injuries of the  kind  above mentioned,
and not to have  been encountered in any  really serious surgical case.  In the
treatment of the diathesis little can be done.   It has been proposed to administer
saline hydragogue purgatives, with a view of inspissating the blood.   I should,
however, imagine that the improvement  of the general  health,  by attention to
exercise, &c, would be the best  means of increasing the plasticity of this fluid.
In the event of actual bleeding occurring in such cases as these, the employment
of pressure, or  the application of the actual cautery, will constitute the best means
of arresting the hemorrhage.
                           CHAPTER  XL.

               DISEASES OF THE NERVOUS SYSTEM.

  Inflammation of the nerves, or neutritis, is not of very unfrequent occurrence,
being usually the result of rheumatic inflammation, of wounds, or strains.  When
rheumatic, it principally affects the nerves of the face and of the lower extremity.
The symptoms consist of tenderness on pressure along the  course of the nerve,
with severe continuous pains,  ramifying  down its trunk  and branches, with
occasional violent exacerbations, especially on moving or touching the part, and
at night; there is usually swelling along the course  of the trunk, and some con-
stitutional pyrexia.   When  chronic, this condition may readily  be confounded
with neuralgia, of which indeed it constitutes one variety.   On  examination after
death, in these cases, the sheath of the nerve will be found injected and swollen, 
550            DISEASES  OF  THE  NERVOUS  SYSTEM.

and the nervous tissue softened.   The treatment consists in the employment of
antiphlogistic means; cupping or the application of leeches, according to situa-
tion, poppy or belladonna fomentations, and local emollients.  When rheumatic,
the acetous extract of colchicum is the best remedy that can be administered;
when of a more chronic and nocturnal character, the iodide of potass, cither alone
or in combination with sarsaparilla, may advantageously be  given.

                                NEURALGIA.
   In this disease, pain in the course of a nerve or greatly  increased superficial
sensibility, is the characteristic symptom.   It is  of all degrees of severity, some-
times moderate, at others unendurable, even by those who  possess  the greatest
fortitude; when severe, it usually comes on suddenly, with a kind of shock, and
continues of a  Sharp  darting or tearing  character, coursing along the trunk or
ramifications of the affected nerve, the distribution of which  may often be dis-
tinctly indicated by the direction  the pain takes.   It is often accompanied by
other sensations, such as a tickling, smarting, or creeping feeling on the affected
surface; in some instances relieved by pressure, in others  increased  by the
slightest touch, or movement of the part.   Occasionally there is spasm in the
muscles, supplied by the affected nerve; in others, heat and redness of the sur-
face, with increased secretion from  the neighboring organs, as a,flow of saliva or
tears, when the nerves of the eye or jaw are implicated.   The duration of an
attack may vary from a few moments to many days  or months, the pain being
most  commonly intermittent or remittent,  often  irregularly so, but in  some
instances the periodicity is well marked.
   This disease  may affect almost any part of the body; it is most commonly seated
distinctly in the trunk and branches of a nerve.   The divisions of the fifth pair
are especially liable to be affected;  it may extend to the whole of the branches
of this nerve on one side of the head and face, or more commonly it is confined
to one of its principal divisions, such as the infra-orbital, which is especially
liable to be affected by it; in many instances it is seated in the temporal  and
dental.   Xot unfrequently some of the terminal twigs merely, of one of these
nerves,  become  the  seat  of intense  pain.  Thus,  occasionally,  the affection is
found limited to a patch on the cheek, brow, or temple;  from which it scarcely
ever shifts.   The  posterior branches of the dorsal spinal nerves, and the inter-
costals, are also very commonly affected, though  not  to the  same extent as the
fifth pair.  In other cases the whole of an  organ, or part, becomes the  seat of
neuralgia, though no  one  nerve may appear to be distinctly implicated.  Thus,
the testes, the breast, the uterine organs, or one  of the larger joints, as the hip
or knee, is occasionally the  seat of severe suffering of this  kind.   An extreme
degree of cutaneous sensibility is a  marked feature in the  affection, in some cases
the patient wincing and suffering severely whenever the skin is pinched or touched,
however lightly.
   The causes of this  very painful disease are  very various; in  many instances ,
they appear to  be purely of a nervous character; depressing  influences of all
kinds  being especially likely to produce it.   Thus, debilitating diseases, mental
depression, and particularly exposure to malaria, are common occasioning causes;
those forms of the disease  that arise from malarial influences, or from exposure
to simple cold and wet, usually assume a very intermitting or periodical character,
and are commonly seated in the nerves of the head.   The  hysterical tempera-
ment  very frequently disposes to the spinal and articular  forms of neuralgia.
Various sources of peripheral irritation, as loaded bowels, the irritation of worms,
and carious teeth, may be  recognised as producing some of the more obscure
varieties of the  disease.
   Xeuralgia may also arise from any compression exercised upon the trunk of
a nerve, and thus indeed some of the more intractable forms of the affection have 
TREATMENT  OF  NEURALGIA.
551
their origin.   Thus, the pressure of a tumor of any kind, or of a piece of dead
bone, may give rise to the most intense pain in the part supplied by the irritated
nerve; and it is not improbable that in  many of the cases of neuralgia in the
branches of the fifth, pain may be owing to periosteal inflammation,  or other
disease of the osseous canals,  through which these nerves pass.
  The diagnosis of neuralgia, though usually effected without any difficulty, is
in some cases a little embarrassing, as the pain may occasionally simulate that of
organic disease  or inflammation of a part.   From  organic disease of the part
that is the seat of suffering, such as the hip, the knee, the testis, or the breast,
this disease may usually be distinguished  by the co-existence of cutaneous sensi-
bility,  the existence of the hysterical temperament, and the absence of the other
signs that would  accompany lesion  of  structure in the  part affected.  From
inflammation, the diagnosis is usually sufficiently easy by attending to the inter-
mittent character of the neuralgic pain, its occurrence in hysterical temperaments,
and in the absence of the constitutional  symptoms of inflammation.  But occa-
sionally, when local inflammatory  irritation is conjoined  with  neuralgia, the
diagnosis  is truly difficult.   Here  the presence of cutaneous sensibility and the
relief of the pain by firm pressure will  indicate neuralgia; whereas, in inflam-
mation there is no tenderness of surface, but the suffering is aggravated by deep
pressure.
  The treatment of neuralgia must have reference to the cause of the disease, and
will be successful or not according as this may be more or less readily removed.
So  long as the conditions that primarily occasion the disease subsist, the pain is
likely to continue; and if these conditions are irremovable, the disease may be
looked upon  as necessarily incurable, though the  suffering may be alleviated by
appropriate means.   When  arising from any central neiwous affection, there
may be the fear of the  ultimate occurrence  of disease of a more  serious type,
such as epilepsy, insanity, &c.
  When occurring in the hysterical temperament, the administration of the more
stimulating and stronger preparations of iron,  such as  the sulphate, the sesqui-
chloride, or the  mistura  ferri comp., either alone or in  combination with qui-
nine, with attention to the state of the bowels and of the uterine functions, and
a general  tonic regimen calculated to brace and improve the general health,
such as sea-bathing, the cold douche, or sponging, will be found  to be of essen-
tial service.  In  some  of these cases the  combination  of  zinc, especially the
valerianate with the fetid gums, will remove the disease when iron  does not
influence  it much.   At the same time, the application or inunction of belladonna
or aconite plasters and  liniments  may be of  service.   When the neuralgia is
distinctly  periodical, quinine in full  doses, or the liquor  arsenicalis, as recom-
mended by  Dr.  Hunt,  will  usually effect a  speedy cure.  When  rheumatic,
occurring  in  debilitated subjects, and attended by distinct  nocturnal exacerba-
tions of pain, no remedy exercises  so great an impression upon it  as the iodide
of potassium, especially when administered in combination with quinine.
  In the more severe and protracted forms of the disease, relief may be occa-
sionally obtained by attention to the state of the liver and  digestive organs, by
a course of some of the more purgative  mineral waters, and by the occasional
exhibition of aloetics or croton oil, followed by the  administration of  tonic
remedies.   In many cases, all these means, however, are unfortunately unavail-
ing, and the sufferer is doomed to an existence of constant pain,  except when
the disease appears to cease of itself, or has its intensity blunted  by the admi-
nistration  of the more  powerful sedatives, such as morphia internally, or aco-
nite or atropine externally.   In these distressing cases, the  sufferer  is ready
to grasp at any means of relief that is held out to him, and section of the affected
nerve  is not unfrequently recommended as a last chance of the removal of the
disease.   It  is clear,  however, that such an  operation,  though occasionally pro-
ductive of temporary relief,  cannot in many cases be expected to benefit the 
552
DISEASES  OF  THE  NERVOUS  SYSTEM.
patient materially.   For by it the cause of the neuralgia is not removed, and it
can consequently only be of  service when the pain is peripheral,  occasioned
by some local irritation existing between the part cut and the terminal branches
of the nerve.  If dependent  on any central cause, or  on  local irritation exist-
ing higher up than the point divided, it must eventually be  useless.  Thus, if
the source of irritation  exist in the dental branches  of the infra-orbital, the
division of this trunk might  be useful;  but if the pain be occasioned by any
pressure to which this nerve  may be subjected in its passage through  its canal
by a carious  state of the bones, or by disease  of the  periosteum, it would be
unavailing; though  it is a remarkable fact that  it  not unfrequently happens
after these operations that there is a temporary cessation in the pain for a few
weeks  or months.   In some  of these cases, however,  the  pain shifts its seat
from the branch operated on to another  division of the same  trunk.   Thus,
if the  infra-orbital be divided,  the submental becomes the seat  of pain;  or
thus may ascend, as it were, to the point at which the nerve was divided.   Thus,
in amputation for neuralgia of the knee, the pain may return to the stump, and
again when this is removed a  second time or even  third time.
  The nerves on which this operation has been  most frequently performed are
the infra-orbital  and the submental.  Should it ever be  thought necessary to do
it, it would be proper not only to divide the nerve but  to excise a portion of it,
otherwise reunion will speedily take place, and the continuity of the nerve being
re-established the operation will  fail.  The procedure simply consists in cutting
down on the  trunk where it  escapes from  the foramen, isolating and dissecting
out a portion of it; in doing this, no  great difficulty  can be experienced by
any one possessing moderate anatomical knowledge.

                                NEUROMA.
  By neuroma is meant a tumor connected with a nerve.  These growths have
been well described by Mr. B. W. Smith, in a recent Monograph on the subject,
in which, indeed, the principal  part of our knowledge  of this subject is con-
tained.   These tumors  vary in size from a millet-seed  to  that of a  melon, are
usually solid,  and composed of fibrous tissue, but when  they attain a large bulk
                 cavities may form in them, containing a yellowish  or brown-
     Fig. 168.       ish serous-looking fluid, apparently owing to the disintegration
                 of the central portions of the mass.   In shape they are usually
                 oval or oblong, their long axis corresponding to the course of
                 the  nerve  (Fig.  168);  they grow slowly, and  are movable
                 transversely, but  not in the direction  of the nervous trunk on
                 which they are  seated;  they have no appearance of malig-
                 nancy, and  however large they become never contract  adhe-
                 sions to the  integument nor involve its  structure.   These
                 tumors commonly only affect the nerves of the spinal system, but
                 Berard has  met with one case of the disease on  a  ganglionic
                 nerve.
                    Most commonly the tumors are single, and then are usually
                 attended with  very severe lancinating  or neuralgic pain, which
                 extends, however, only to the parts  below the tumor, and is
                 commonly of a paroxysmal character.   This  pain is evidently
                 owing to the stretching of the nervous twigs as they pass along
                 the convexity of the growth.  When single and painful, these
                 tumors commonly go by the name of the painful subcutaneous
                 tubercle, and  are  then usually met with about the size of a
                 cherry-stone or small marble, commonly seated upon the limbs,
                 and most frequently in connexion with  the  nerves of the
                 lower extremity;  but they may be situated upon the arm, the
trunk, or even on the scrotum and cheek, where, however, they are not so com-
 
TETANUS.
553
monly met with.  Wherever they occur they are acutely and intolerably painful
on being touched, and are usually tender as well.
  In structure, the painful subcutaneous tubercle resembles exactly the ordinary
neuromatous tumor, being composed of a white or grayish fibrous mass developed
in the neurilemma, and having nervous filaments stretched  through or over it.
The nervous trunk above  and below the  tumor is normal; it is only where it
comes in contact with it, and is exposed to its pressure, that it undergoes the
change  indicated.   It is a very  remarkable  fact, that  though  neuromatous
tumors when single, or when but two  or  three exist, are  most acutely painful,
yet, that when they are generally  diffused over the body they lose  their sensi-
bility and are unattended by any inconvenience, except such as arises from their
numbers and bulk.  The number of these masses thus formed is often amazingly
great.   Thus,  in  one  of Mr.  Smith's  cases, he counted in the  two lower  ex-
tremities alone more than 250 of these tumors, besides those in other parts of
the body.  In another  case related by Mr. Smith, there were upwards of 200
small neuromata scattered over  the sides of the  chest and abdomen, 450 on
the right lower extremity, and upwards of 300 on the left, altogether probably
not less than 2000 of these growths in  "this  unprecedented case."
   Traumatic neuromata may arise from the wound, or  partial division of nerves,
and occasion the most intense agony.   Sometimes growths of this description, of
a fusiform shape, and varying  from a cherry-stone  to a pigeon's egg in size, are
met with in stumps after amputations;  in many instances  unattended by incon-
venience, but occasionally giving rise to a very severe degree of pain.
   The treatment of painful neuromata, whether of an idiopathic, or traumatic
character, or existing in stumps,  consists in  their  excision.  After removal, the
part supplied by the nerve, which  is usually necessarily divided,  becomes para-
lysed  for a time, but may  eventually regain  its  sensibility.  In  some cases,
however, by cautious dissection, the tumor may be removed from the nerve that
is in contact with it, without cutting this across.   This has been done by Vel-
peau in the  case of a neuroma of the sciatic nerve.   When  these  tumors are
numerous, they should not be interfered with,  and if unattended by pain,  they
need not be excised unless their  bulk prove inconvenient.

                                 TETANUS.
   Tetanus is a disease  consisting  essentially in an excited state of the spinal
cord and the medulla oblongata, in fact of the whole true  spinal system, giving
rise to painful  and continued spasms of the voluntary muscles and the diaphragm,
alternating with incomplete relaxation, and  usually terminating fatally.   This,
which is one of the most serious and  distressing diseases to which the nervous
system is liable, is, in the great majority of instances, the consequence of some
wound that implicates or irritates  a portion of the peripheral nervous system;
the local irritation so produced, being  propagated  to, and exciting  the nervous
centres, the excitation  of which  becomes persistent,  and  continues after  the
local cause has been removed, inducing  reflex  muscular movements in various
parts of the body.   The irritation of the nervous system, however, that induces
tetanus, may arise from other sources besides surgical wounds; thus, for instance,
the presence of worms in the intestinal  canal, exposure to cold and wet, and
even the uterine irritation following abortion, have been known  to  occasion it.
These causes, however, rarely give rise to it in this country, and we must con-
sequently regard it as a  disease chiefly arising from  traumatic lesion of some
kind.
  Tetanus may be occasioned by injuries that do not give rise to breach of
surface;  thus I have known it occur in a child who was suddenly thrown down
upon its back by another at play;  and Dr. Beid mentions  a case produced by
the stroke of a whip.  But certainly in the great majority of cases, it is directly 
554             DISEASES OF  THE  NERVOUS  SYSTEM.

occasioned by a wound of some kind; and  then it will generally bo found that
a nervous twig has been lacerated or  divided; thus in  a case of  tetanus follow-
ing a wound of the knee, in a  patient, who died in University College Hospital,
a small branch of the internal  cutaneous nerve was found to have been injured;
and, in another patient who died of tetanus about sixteen days after treading on
a rusty nail, a black speck was found in  the internal plantar nerve, where it had
been wounded by the nail.
  The kind of wound, as well  as  its situation, doubtless influences materially
the occurrence  of the disease.  Though  it  certainly more frequently follows
punctured, torn, and lacerated, than clean-cut, wounds, yet  it occasionally com-
plicates these, even when  the result of surgical  operations; thus, it has been
known to  follow the removal  of the breast, amputations,  the ligature  of  the
larger arteries, and  the operation for  hernia.  It is the common belief, both in
the profession and out of it, that wounds of the hands and feet, and more espe-
cially of the  ball  of the  thumb  and of the great toe, are more  likely to be
followed by tetanus than those in other situations.   I think there can be little
doubt of the general  truth of  this opinion; though it  is not improbable that
tetanus may occur  more  frequently after injuries of  those regions, simply
because punctured and lacerated wounds are far more common here  than else-
where.  It cannot well be supposed to be owing to the tendons and fascia that
abound here, as it  is seldom,  if ever, met with after  operations for tenotomy,
which are so commonly practised on the  feet.
  Tetanus is especially apt to occur in feeble and debilitated individuals, and,
indeed, may be looked upon  as a disease of debility; hence any  condition that
lowers the tone of the nervous system is especially likely to  occasion it.  Thus,
in unhealthy tropical climates,  as in some of the West  India Islands,  and
amongst the marshes of Cayenne, it  occurs with  peculiar  frequency, the most
trifling scratches or punctures being followed by the disease.   The exposure
also of the wounded on the field of battle to cold, wet, and night  air, is espe-
cially  liable  to occasion  it.   Thus,  after the battle of Bautzen, where the
wounded were left on the  field  during the night, exposed to severe  cold, Larrey
found on the following morning that  more than one hundred were  affected by
tetanus.   It may occur at all ages, but I believe is most frequently met with at
the early and advanced periods of life.  I have at least most commonly seen it
either in very young or in old people; most frequently, certainly, in the young.
In this country it rarely occurs amongst infants, but in hot climates it is said
not unfrequently to be met with shortly after birth, from the  irritation occasioned
by the ligature of the umbilical cord.
  Tetanus may occur at any period after the infliction of the wound that occa-
sions  it.    In hot climates   especially it may occur very  speedily; thus, Dr.
Bobinson  relates the case of  a  negro  servant in the West Indies,  who scratched
his finger with a broken plate,  and died  of  tetanus in a quarter of an hour.  It
is very seldom, however, in  temperate climates, that it occurs before the fourth
or fifth day.   Larrey, who  had great experience of this disease  during Napo-
leon's campaigns in Egypt,  met with it  most frequently between the  fifth and
fifteenth days after  the infliction of the wound.  According  to the experience of
the surgeons  of the Peninsular  War, under whose observation  many hundred
cases occurred, the disease  does not  show itself after  the  twenty-second day;
but though this may be the general  rule,  Sir G.  Blane  has  related a case in
which it occurred as late  as  a  montii after  the infliction of the  wound.  It is
stated that it may occur after the cicatrization of  a wound  is  completed;  when
this happens the disease must  rather be  looked upon  as being of an idiopathic
character, accidentally occurring in a person who has been recently injured.
   Tetanus may be acute or  chronic, being in some instances fatal in the course
of a few hours, but  usually lasting for two or three days.   If the  patient  sur- 
SYMPTOMS  OF  TETANUS.
555
vive this time, the disease will commonly run on to the eighth or tenth day, and
occasionally even for a longer period than  this.   Thus, S. Cooper  mentions a
case in which it continued in a soldier for five weeks after amputation.  As a
general rule, the  more acute the case, the more dangerous  is the disease.   In
chronic cases there is more hope of the  patient's recovery.
   Symptoms.—The  invasion of the disease is often preceded by a general un-
easiness on the part of the  patient, a sensation of fear, or a sense of impending
mischief.  Abernethy was of opinion that tetanus was usually ushered in by a dis-
turbed state of the digestive organs, the stools being offensive, and indicative of
much gastric irritation.  When the disease sets in gradually, it may be somewhat
difficult of recognition in its early stages; if it comes on suddenly, its nature is
immediately evident.   It is a remarkable fact that the cramps do  not begin in
the  parts injured; but,  wherever  this  may be situated, they  are  always  first
noticed in the muscles supplied by the portio dura of the seventh; and through-
out, it is principally these and the  muscles of  respiration that are affected.   The
first symptoms  usually consist in the patient  being unable to  open his mouth
widely, to take food or drink, the  muscles about the temples, jaw, and neck,
feeling stiff and rigid; this condition has given to the disease the popular term
of lock-jaw.  As the affection advances, the countenance assumes a peculiar  ex-
pression of pain and  anguish, the  features are fixed  or convulsed from time to
time, and the angles of the mouth  drawn up,  constituting1 the appearance called
the " risus sardonicus."  When fairly set in, the disease is marked by spasms of
the voluntary muscles of the most violent character, with much pain, and partial
remissions.  The pain is of that kind that attends ordinary cramp in the muscles,
as of the legs, and is usually very severe.   The spasms  are often of a jerking
character, the patient being suddenly thrown up, or twisted on one side; the breath
being drawn with a loud sobbing catch from spasm of the diaphragm, and from the
same cause there is  usually violent pain  experienced  in  the epigastric  region,
darting across the spine.   The muscles of the  trunk are usually affected, next in
order of frequency to those of the head  and  neck, the  body being bent back-
wards so as to form a complete arch; more rarely it is drawn forwards, and still
less frequently to one side.   In  some cases the body becomes perfectly rigid, like
a piece of wood, the belly being drawn in, and the chest expanded.   It is  said
that in severe cases the spasms  have been of so violent a character that muscles
have been ruptured, teeth  broken,  and the tongue lacerated.  In the numerous
cases of tetanus that I have unfortunately witnessed, it has never fallen to  my
lot to see any effects of this kind  produced, the  spasms, indeed, not in general
being of a very violent, though of  a continuous and very painful character.
  The intellectual faculties are not disturbed in these cases,  and the mind  con-
tinues clear to the last. In most instances there is a good deal of heat of surface,
and quickness of pulse, not from any febrile disturbance, for this disease is un-
attended by symptoms of pyrexia, but apparently simply from the violence of the
muscular contractions.  The prolongation of life appears to depend greatly upon
the intensity of the convulsive movements : the more severe these are, the sooner
does death result.   The fatal termination occurs not so much from any great
physical lesion, or disturbance of important parts, as from exhaustion, consequent
on the frequency of  the tetanic spasms.
  The  morbid appearances found  after  death  throw little light on the nature of
this affection; it is quite clear, however, from  these, that the disease is not of an
inflammatory character; indeed, the only morbid condition that is usually found,
is a degree of congestion of the brain and spinal cord, with some bloody fluid in
the ventricles and in the subarachnoid  space.   Nothing in any way of a special
character  has been  revealed by these  investigations, which, as yet, have  not
elucidated the true nature of tetanus, any more than that of many other nervous
diseases,  such as  hysteria, chorea, &c. 
556
DISEASES  OF  THE  NERVOUS  SYSTEM.
              The treatment of tetanus is of a local and of a constitutional character.   The
           local treatment has for its object the removal of the irritation that has induced
           the tetanic  condition.  It is true that when  once tetanic excitement has been
           set up in the cord, it has a tendency to continue, and  cannot be removed by the
           mere abstraction or cessation of the local irritation that gave rise to it in the first
           instance.  It is, however, only reasonable  to  suppose  that other treatment will
           succeed  best if local irritation be removed,  and, indeed, so long as this continues
           to keep up the centric nervous disturbance, no general means can be expected to
           succeed; as they will have not only to combat already existing disease, but also
           to overcome the continuous excitement  maintained  by the local disturbance.
           Hence, it is of use  to get the wound into as  healthy a state as possible, and to
           see that it is clean, free from foreign bodies, and not inflamed.   In order effect-
           ually to remove all local disturbance, amputation has  been had recourse to, but
           though this may have succeeded in checking  some of the more chronic forms of
           the disease, yet, other and milder local  means have sufficed equally well, and in
           the majority of cases it has had  no effect,  and hence  so severe an operation can
           scarcely be recommended  for adoption.  The division  of the  injured nerve, if
           there be one that has been punctured  or lacerated,  has occasionally proved  suc-
           cessful.  Thus, in a case of tetanus following injury of the supra-orbital nerve,
           Larrey cut this across, and the patient was  cured.   In a midshipman, in whom
*           tetanus came on the day after the sole  of  the foot had been wounded by tread-
           ing on a rusty nail, Murray  divided the posterior tibial nerve, and  thus cured
           the patient.  In those cases in which no special nerve appears  to have been in-
           jured,  Liston's  recommendation  of making a A  shaped  incision down to the
           bone, and above the part,  so as to insulate  it completely, may be advantageously
           followed. After the nerve has been divided, or the part properly insulated, some
           solution  of atropine may be applied to it, so as still  further to lessen local irrita-
           tion.
              In the constitutional treatment of the disease, it is  necessary to bear in mind
           that tetanus is an affection of debility, the violence  of the spasmodic paroxysms
           giving an  appearance  of  false  strength to the patient, and that  the principal
           source of danger and  death is from fatigue induced by the energy of the mus-
           cular movements, and the consequent want of rest.  The means adopted should,
           therefore, have for their object the removal of irritation and the support of the
           patient's strength, to enable him to hold up against  the disease.
              The first thing to be done is to clear the bowels well out with a dose of calo-
           mel and scammony, or a  drop of croton  oil, aided, if necessary,  by turpentine
           enemata.  The patient should then be kept perfectly quiet in a room by him-
           self, a screen or muslin curtains, as recommended by Dr. Marshall  Hall, being
           drawn round  the bed, noise or movement of any  kind increasing  the spasms
           greatly.  With  the view of allaying the spinal irritation, the most effectual means
           consists perhaps in the plan recommended by Dr. Todd, of applying an ox's gut or
           gullet  filled with ice along the whole length of the spine.  This is a powerful de-
           pressing agent, and unless care be taken, may lower the heart's action too much
           or indeed completely extinguish it.  It may,  however, be applied with safety for
           six, eight,  or ten hours, the condition of the patient being looked to in the mean-
           while.   Sedative or antispasmodic agents are seldom of  much service.  I have  seen
           many drugs of this kind employed, without producing any material effect in lessen-
           ing the violence of the convulsions. In some cases, however, the inhalation of ether
           and chloroform materially lessens their severity, and gives the patient temporary
           ease; and there are instances on record from  which it would appear that these agents
           have  occasionally effected a  cure."  Mr. IMiller  speaks highly of the cannabis
             [» See Ranking's Abstract, Nos. 17 and 18, and also the Medical Examiner for November, 1853, in which
           Dr. Betton, of Germantown, Pa., reports a case of tetanus,  resulting from a wound of the  foot by a nail.
           A mixture of chloric ether and chloroform was freely administered, and the patient recovered. Dr. Betton
           gays, " To the anaesthetic alone I attribute his recovery, and its influence appeared almost miraculous. May
           it not be equally valuable in hydrophobia?''—Ed.] 
PERIOSTITIS.
557
indica pushed to narcotism, 3 grains of the extract, or 30 minims of the tinc-
ture beino- given every half hour or hour.  In one case, at Dr. Garrod's sug-
gestion, I tried  atropine  endermically on a blistered surface, and gave conium
internally in large doses,  and although the patient, an old man, eventually died
exhausted, yet these agents appeared to exercise a marked influence in diminish-
ing the violence of the spasms, and I should be induced  to attach much impor-
tance to their administration.   Dr. Elliotson has spoken highly of the  prepara-
tions of iron, especially of the carbonate, in these cases.   At the same time that
such measures as these are had recourse to, it must not be forgotten that the dis-
ease  is one of great exhaustion, and that the patient will die worn out, unless he
be supplied with plenty of  nourishment.  Beef-tea and  wine should, therefore,
be administered by the  mouth, and nutritious enemata by the rectum, and in
this way the powers of life  may be supported until the violence of the disease
expends itself.
   DISEASES OF  THE  ORGANS  OF  LOCOMOTION.


                          CHAPTER  XLI.

                    DISEASES  OF  BONES.

                              PERIOSTITIS.

  Inflammation of the periosteum is of common occurrence as the result of
injuries, as a consequence of syphilis  and  rheumatism, or as a natural process
dependent on disease of the subjacent bone.  It often affects  the  membrane
covering  the  shaft of a bone, and  very commonly attacks the articular end,
becoming associated with inflammation of the contiguous joint.   When  acute,
the membrane becomes thickened, soft, and vascular, and loosens from the sub-
jacent bone.  When chronically inflamed, the periosteum becomes thickened by
the deposit of plastic matter within and  beneath it, and the subjacent bone usually
participates in the changes, undergoing hypertrophy and induration.  In some
cases, but rarely, suppuration and death of the layer of bone immediately subja-
cent to the affected membrane take place.
  The symptoms of periostitis consist of a hard but somewhat puffy swelling, not
distinctly circumscribed, and attended by much pain in the part,  especially at
night, with tenderness on pressure.
  In the treatment of the acute form of the affection, the free application of
leeches, with  hot fomentations, and  the exhibition of calomel  and opium, will
arrest the  disease, and give relief to the patient.   In  the more chronic form, the
continued administration of the  iodide of potass will  take  down the swelling,
remove the nocturnal pains, and  materially improve the local  condition  of the
part.  Added  to this, the occasional application of leeches and repeated blistering
will be of essential service.  In some instances I have seen advantage derived by
the subcutaneous section of the thickened periosteum, by means of a tenotome
slid under the skin.

                                OSTEITIS.
  Inflammation of bone may arise from the  same constitutional causes  as  the
preceding disease, but most commonly  occurs  as the result of injury, either acci- 
558
DISEASES  OF  BONES.
dental or inflicted by the surgeon in an operation.   When  a portion of bone is
inflamed, the periosteum  and medullary  membrane  participate  in the morbid
action, and together with the affected osseous structure, becomes highly vascular;
at the same time  the inflamed bone becomes expanded and softened,  partly in
consequence of changes induced in its organic constituents,  and partly  in conse-
quence  of  the  cancellated  structure becoming more cellular from interstitial
absorption;  the cells becoming filled with a sero-sanguineous fluid.  The com-
pact structure of inflamed  bone undergoes a peculiar kind of laminated expansion,
so that a section of it presents an appearance of concentric parallel layers.  AVhen
the  inflammation  is chronic, the  bone  is  likewise  expanded,  but instead of
becoming looser in its texture and softened, as in the acute form of the disease,
it becomes very dense, indurated, and compact;  looking and cutting more  like
ivory than ordinary bone.
   The symptoms  of osteitis consist of enlargement of the  affected bone, with
deep-seated pain and great tenderness in the limb; the pain, as in periostitis, is
greatly increased at  night, and when the  disease is chronic, is much influenced
by the state of  the weather.
   In the treatment of the acute  cases, our principal  reliance must be  on local
leeching, with  calomel and opium; in the  more chronic form • of  the affection,
when the bone has become thickened and enlarged, nothing of a curative kind
can be adopted, and  the only remedy consists in  the  administration of  iodide of
potass for the relief of the  pain, with perhaps the occasional application of leeches.
After a time when all morbid action  ceases, the hypertrophied  bone  does not
give rise to any very serious inconvenience, except such perhaps as may be occa-
sioned by its bulk.
   Osteitis is principally of importance to the  surgeon from its connexion with
other more serious diseases of bones, in which  it  not unfrequently terminates.
These conditions are suppuration of the bone, its ulceration, caries, and  necrosis.
                         SUPPURATION OF BONE.

   Suppuration  of  bone may occur in two forms, the acute and the chronic. The
acute form of suppuration  is almost invariably of a diffused character. It usually
arises as the result of injury inflicted on bones in  operations, as for instance in
amputations, or the excision of joints, but sometimes occurs in connexion with
compound fractures.  In it, the medullary membrane is primarily affected, the
inflammation rapidly extending through the whole of the medullary canal andad-
   Fisr. 169.     joining cancellous structure, which speedily becomes filled with pus.
             Mr.  Stanley observes that the medullary membrane in this disease
             becomes vascular like the  conjunctiva in chemosis, and is often
             black and gangrenous. This purulent infiltration of the interior of
             the bone, is  very apt to give rise to phlebitis and pyemia, and hence
             becomes  a most formidable affection, the pus finding its  way into
             the veins of the bone, and from thence into the general current of
             the  circulation.  When the diploe of the skull is affected, the
             sinuses and cerebral veins may be found after death highly inflamed
             and  filled with pus.  In a case  in which I lately excised the elbow-
             joint, the patient died of pyemia, and after death the interior of the
             humerus was found to be filled with pus, and  the axillary vein in
             a state of suppuration (Fig.  169).
               The invasion of this disease, after an operation, is indicated by
             great and deep-seated pain, with much swelling, tension, oedema,
             and  general redness of the limb  or stump.   The wound becomes
             sloughy, all  discharge from it ceasing, rigors occur, and the symp-
             toms of pyemia speedily set in. The treatment must be directed to
             the constitutional condition induced by the affection.
   The more chronic form  of suppuration of bone usually assumes a circumscribed 
SUPPURATION  OF  BONE.
559
Fig. 170.
Abscess in the head of the
       Tibia.
character, and leads to the  formation of abscess.   These abscesses are usually
met with in the cancellated structure, and occur with especial frequency in the
head and lower end of the tibia.   In some instances they are tolerably rapid in
their formation, but in the majority of cases  are excessively chronic.   When of
a more acute  character, they  are  probably  the result of the softening  of the
tubercle previously deposited in the bone; and forming in  the  cancellous struc-
ture are very apt to  undermine  the contiguous cartilage of incrustation  and
eventually to burst into the neighboring joint (Fig. 170).
When of  a more  chronic character, they are usually of
very small size, and are deeply seated  in the substance
of the head, or in the medullary canal of the bone ;  the
osseous substance  covering them having long been the seat
of chronic inflammation,  becomes  greatly thickened and
indurated.   Most commonly  the quantity  of pus con-
tained in these abscesses is extremely small, and it is
often mixed with cheesy or tuberculous  matter, or con-
tains  portions of necrosed  bone  intermingled with  it.
In some cases, however,  Mr. Stanley has observed that
abscesses of the bone  are large, containing a considerable
quantity of fluid.
   The symptoms  of chronic abscess  of bone are  usually
of  the  following character.   The patient, after  the
receipt of an  injury, perhaps, has noticed  that  at  one
spot the affected bone has become swollen  and painful;
the skin covering it preserving its natural color  in  the
majority of cases, but in some instances becoming red,
glazed, and cedematous; the pain, which is of a lancinating and aching character,
is usually remittent, often ceasing for days, weeks, or months, and then  returning
under the  influence of very trivial causes, with  its  original
severity.   It is  especially troublesome  at  night, and is  always
associated with a  degree  of tenderness of the part; and indeed in
the intervals of its accession, it will be found on  careful  examina-
tion that there  is  always one tender spot  in  the  enlarged and
indurated Joone.   The persistence of these signs will usually  point
to the existence of a  small circumscribed abscess under the thick-
ened wall of the bone.  But it must be borne in mind that the  same
local symptoms may be induced by the presence of a small portion
of dead bone confined within  an impervious casing, or even that
they may arise from the  simple pressure  of  hypertrophied osseous
structure.   For   all practical  purposes the  diagnosis is of  little
consequence, as the treatment is  the same, whether the pain and
other symptoms  arise from the confinement  of a few drops of pus,
the inclusion  of necrosed bone, or the pressure of the  hyper-
trophied tissue.
   The proper treatment  of circumscribed abscess of bone has been
pointed out by Brodie.   It consists in trephining the bone with  an
instrument having a small crown of this size, so as to make an aperture
for the exit of the pus (Fig. 171,1).  So soon as vent has been given
to this, which is often cheesy and occasionally very offensive in  its
character, the patient will experience great  and permanent relief.
In performing this operation, there are several points that deserve
special attention.   The bone must be exposed by a T or V shaped
incision, made over the spot which has been found to be uniformly
tender on pressure;  and to this the trephine should be applied.
The trephine should have a small and deep crown of this size and shape (Fig.
171), and  it is well always to be provided with two instruments of the same
-—-M 
560
DISEASES  OF  BONES.
shape and  size that will exactly fit the  same hole, lest one become disabled by
the density and hardness of the osseous case that has to be perforated, as I have
seen happen. When the trephine has penetrated to a sufficient depth, the button
of bone may be removed by means of an elevator; but care should be taken not
to perforate  the  whole thickness  of the bone.   The  diseased  cavity will very
commonly at once be opened in this way, a small quantity of pus escaping, which
may however readily be overlooked, as it is carried  away in streaks with the
blood, which flows freely from the cut bone.   Should  no  pus escape, perhaps a
portion of  dead bone  or some  dark gritty masses  of disorganized osseous tissue
are exposed;  if so, they  must  be removed with a  gouge.   But if neither of
these conditions are found, the  surgeon must  not be  disappointed,  but pierce
the neighboring osseous tissue in different  directions by means of a perforator,
when perhaps the abscess will  be opened;  should it not  be so, the patient
will still in all probability be materially benefited by the removal of the circle of
bone, and the consequent relief to the compression of the osseous tissue.   After
the operation, the cavity left must be dressed from the  bottom with wet lint,
and a poultice be afterwards applied; it will gradually fill up  with fibrous tissue,
leaving the limb unimpared in utility and strength.

                                  CARIES.
   By caries some surgeons mean a  kind of ulceration  of bone ;  others, again, a
species of disintegration of the osseous  tissue; and  Stanley includes  under this
term the various changes consequent on the  chronic suppuration of the cancellous
structure.   But caries, I think, properly means a disease  of the bone, charac-
terized by increased vascularity, softening, and ultimate disintegration of the osseous
tissue.  It appears to consist in a breaking  down of the organized portion of the
bone, in consequence of which the earthy matters  become eliminated in a granu-
lar, molecular, and almost diffluent form in the pus formed by the inflammation
of the surrounding more healthy structures.
   On examining a portion of carious bone, it will be found to be  porous and
fragile, of  a gray, brown, or blackish color; in parts  broken down in softened
masses, and at others  hollowed out into  cells, which  contain a reddish-brown and
oily fluid.  The process of wasting which  goes on  in the bone, appears to be
partly the  result  of ulceration,  and partly  of disintegration  of its tissue.  In
many cases, small masses  of dead  bone lie loose  and  detached in the carious
cavity.  Around  this  carious portion, the  bone, as  well as the medullary and
periosteal membranes, is usually extremely vascular; and, in many cases, hard-
ened compact masses  of osseous tissue will be found deposited around, or even
forming the exterior wall  of the carious cavity.   These changes are most com-
monly met with in the cancellous structure, but the compact tissue may likewise
be affected.  As  it so frequently occurs in  the cancellated tissue, it is commonly
met with in the heads of bones; and here the disease is  extremely dangerous,
being apt to undermine and destroy the contiguous articular  cartilage, and thus
implicate the joint  This caries of the  articular ends of bones is consequently a
most serious  affection, and is  a very frequent cause of incurable joint-disease,
such as suppuration and destruction of cartilage, followed perhaps by anchylosis.
Any bone may be affected by  caries, but it  is perhaps more frequently met with
in the short and cancellous bones.
   Caries occurring in strumous constitutions, and affecting the short bones, as
those of the  tarsus, or the cancellated heads of the  long bones, as  the tibia,
usually, if not always, commences in the centre of the bone, which becomes soft-
ened  and  disintegrated, in many cases without any external cause, but appa-
rently simply from the cessation of vitality in those parts of the osseous structure
which are farthest from the periosteum, and which do not, like the deeper struc-
tures of a long bone, receive  a supply  of blood from an internal or medullary 
             SYMPTOMS AND  TREATMENT OF  CARIES.           561

membrane.  In these cases, the inflammation of the soft investing parts is con-
secutive to the disease in the bone.
  The symptoms  indicative of the occurrence of caries are of a very equivocal
character, and are not unfrequently, in the early stages, mistaken for those of ordi-
nary phlegmonous abscess or  rheumatism.   They consist of pain in the  bone,
with a good deal of redness and swelling in the soft tissues covering it; abscess
at last forms, often of considerable size, and on letting out the pus, the character
of the disease  will be recognised,  as the bare and rough bone may be felt with a
probe, which sinks into depressions upon its surface, which, though rough, yields
readily to the  pressure of the instrument.   The cavity  of the abscess  gradually
contracts, leaving fistulous openings, which  discharge  a fetid pus, usually dark
and sanious, intermixed with granules  of bone, and containing a superabundance
of the phosphates.   The fistulous openings are generally surrounded or concealed
by high spongy  granulations, and  the  neighboring skin is duskily inflamed.
Caries usually occurs in constitutions  that have been  debilitated  by struma or
syphilis,  often  without any other  apparent cause.  In  syphilitic constitutions it
is apt, however, to affect the surface of the bone, disintegrating and eroding this
in a remarkable manner.   This condition has been described by Stanley as true
ulceration of bone, and he regards it  as  distinct  from caries, and analogous to
ulcers of the soft  parts.   Here the disease does not penetrate deeply, but leaves
the surface rough and porous, with a good deal of inflammation in the soft parts
around the affected bone.   He states, that it only occurs in adults, and in males,
and is very chronic in its  character;  it is  met with primarily in the bones of the
spine, but  also occurs  on the articular  surfaces in advanced stages  of  joint-
disease.
  The treatment of caries must be conducted in reference to the constitutional
cause that occasions it, the removal of which is the first and most essential ele-
ment  in effecting a cure.   If  it arise from syphilis, this must be eradicated;  if
from  struma, the  general  health must be improved.   By the removal of causes
such as these, the disease  will often cease  spontaneously, and even undergo cure,
more  especially in young  subjects.  Hence,  it is well  not to be  in too great a
hurry to  interfere,  by operative means, in the caries of the small  bones of chil-
dren.   I have often seen cases, especially of caries of the bones of the hands and
feet, in which an  operation for the removal of carious bone was apparently indis-
pensable, get well spontaneously by change of air, and attention  to the general
health of the child; the disintegrated  particles of the diseased bone being  elimi-
nated piecemeal.
  In  the first  stage of caries,  which is inflammatory, measures should be taken
by means of appropriate local and constitutional antiphlogistics to subdue  the
activity and limit the extension of the disease; and when this  has fallen  into a
chronic stage,  constitutional alteratives should be employed.  Amongst  these,
cod-liver oil, the iodides, and change of air, more especially to the sea-side, when
the patient is young, should hold  the first place.
  When, however, the  disease has fallen into  a chronic condition and nature
seems unable to eliminate the carious  bone,  all reparative  action having ceased,
or being inefficient for the restoration  of  the integrity of the part, an operation
becomes necessary.   When the operative procedure has reference to the diseased
part itself, it is impossible to be too careful in  delaying it until the acute  stage
of the disease has passed, and the inflammation in  the bone and surrounding
tissues has subsided into a chronic state.   Unless this be done, the excited action
set up by the  operation will infallibly give fresh impetus to the disease, which
will make more rapid progress, and may perhaps terminate in diffuse suppuration
of the bone.
  The operations  practised upon  carious  bones are of three kinds; consisting
either in simple removal of the diseased portion of bone;—in the excision of the
                                     36 
562
DISEASES  OF  BONES.
carious  articular end;—or, in  the amputation of  the whole  of the bone
affected.
  The removal of the carious portion of bone is best effected by means of the
gouge.  This instrument is especially useful in those cases in which  short, thick
bones, or the articular ends of the long bones, are affected, without the neigh-
boring joints being implicated.   In applying the gouge,  the diseased portion of
bone should be exposed by a crucial incision; and if necessary, its cavity opened
by a small trephine.  The  gouge, fixed in a  short,  round handle is  then freely
applied, and the diseased tissues scooped and cut out.  In order to  do  this effi-
ciently it is desirable to be furnished with instruments  of  different shapes and
sizes, so that there may be no difficulty in hollowing or cutting away every portion
of bone that is implicated.   I have found  the gouge-forceps (Fig. 177) a very
useful addition to the gouge in clearing away angular fragments and projections
of bone, and removing the  whole of the diseased  structures.
  In removing the carious bone with these  instruments, the  surgeon  may be
sometimes at a  loss to know when he has  cut away enough.  In this  he may
generally be guided by the  difference of texture between the diseased and healthy
bone; the former cutting soft and gritty, readily  yielding before the instrument,
whilst the latter is hard and resistant; so that when all  the disease  is removed
the walls of the cavity left  will be felt to be compact and smooth.  In some cases
it is true that the healthy bone may have been softened by inflammation; should
there be any doubt as  to the condition of  what has been gouged out, it may be
solved by putting  the detritus into water, when, if carious, it will either wash
white or black:  whereas, if healthy, but inflamed, it  will preserve its red tint.
The cavity that is left should be lightly dressed from the bottom, and allowed to
heal by granulation, when  it will  gradually fill up  by fibrous material deposited
in it.
  When the caries affects the articular ends of the bones, as those that enter
into the formation of the elbow or shoulder-joints,  it may be so situated as not
to  admit of removal in  the way just indicated,  but to  require excision of the
diseased articulation : these operations we shall consider in a subsequent  chapter.
When the  caries involves  a bone  so extensively that neither of the preceding
plans can successfully be put into operation, it becomes  necessary to remove the
disease either by the resection of the whole of the  bone, if it be of small size,
or by the amputation of the limb, if of greater magnitude  or if it  affect the neigh-
boring joints extensively.  Thus, for instance, resection  of  the os calcis may be
required for caries of that bone, whilst  if the whole of the tarsus  is affected,
amputation is the only resource.

                                 NECROSIS.

  The transition from caries to necrosis is  easy;  caries may be  regarded as the
■granular disintegration or molecular death of the osseous tissue, conjoined with
suppuration of the surrounding  healthy parts ; whilst necrosis must be looked
upon as the death of the osseous tissue as a whole, a condition indeed closely re-
sembling that  of gangrene  of the soft parts.   Whilst  caries, however, chiefly
affects the cancellous structures, necrosis  is  met with in the compact  tissue of
bone, and far more frequently occurs in the shafts  than  in  the articular ends of
the long bones.   It is, however, occasionally found in the cancellous structure;
thus in the head of the tibia, or in the os calcis, small masses of necrosed bone
are not unfrequently found lying in the midst of carious  or suppurating cavities.
The different bones are affected by necrosis, with varying degrees of frequency.
The tibia, at its anterior part is  most frequently diseased; the femur in  its lower
third is also very commonly affected.  The lower end of the humerus is not so
often necrosed; but not uncommonly the phalanges of the fingers from whit-
low,—the cranium, from syphilis,—the lower jaw, from  the emanations evolved 
NECROSIS.
•
563
in the manufacture  of phosphorus matches,—and the clavicle and ulna, from
injury or constitutional causes, are found affected by necrosis.
  The causes of necrosis are of very various character.  We have just seen that
it is predisposed to by the structure of particular parts of bone, and is more fre-
quent in some bones than in others:—amongst the more  constitutional causes,
we  may rank in the first line those cachectic conditions of the system that result
from  scrofula  and syphilis, and  those debilitated  states of constitution  that so
frequently follow upon typhus fever;  in these various states, the bone may sud-
denly lose its vitality, more especially if the limb be subjected to slight accident,
as concussion,  or to exposure to some degree of cold.  In some  cases the disease
results from the vitality of the bone being destroyed by the extension of inflam-
mation to it from the neighboring tissues, as in some cases  of whitlow, or by the
bone becoming exposed by a neighboring abscess.
  Traumatic causes frequently give rise to  necrosis.   Thus the denudation of a
bone by its periosteum being stripped off, may lead to its death; but though the
bone thus injured, often loses  its vitality, yet, if the  membrane be replaced, its
life may be preserved ; or even when exposed, adhesions may take place between
it and the neighboring soft parts, or granulations be thrown out by its  surface,
which eventually form another periosteum.  Necrosis frequently occurs as the
result of the detachment  and denudation  of a portion of bone in cases of bad
compound fracture;  so also the application of certain irritants, as the fumes of
phosphorus, may occasion this disease, and hence  it has occasionally been found
that in lucifer-match  manufactories, necrosis of the lower jaw is of frequent occur-
rence as a consequence of the acrid fumes that are eliminated getting access to
the bone through carious teeth, or being applied to the exposed alveoli.
  In  whatever way it originates, the necrosis may affect the outer laminae of the
bone  only, when it  may be denominated peripheral; or  the  innermost layers
that surround the medullary canal may perish, and then it may be termed central;
or the whole thickness of  a shaft, or of the substance of a short bone, may lose
its vitality.  The portion of bone that is necrosed, called the sequestrum, presents
peculiar characters, by which its  nature may at once be recognised.   Thus, it is
of a dirty yellowish-white color, and has a dull opaque look, and after exposure
to the air, it gradually becomes of a deep-brown or black tint.   The margins are
ragged, and more or less  spicukted, and the free surface  tolerably smooth, but
its  attached surface  is very irregular, rough, and  uneven,  presenting an eroded
or worm-eaten appearance.  When the sequestrum forms in the cancellous struc-
ture, it is usually of  a blackish-gray color, irregular but somewhat ovoid in shape,
as if  the bony matter had been partially dissolved away, and here is frequently
conjoined with caries of the surrounding bone.
  The symptoms of  necrosis are divisible into two distinct periods.   In  the first
the bone dies  and undergoes  separation, and an attempt  is  made  by nature  at
the expulsion of that portion of  it which has  lost  its vitality.  In the second
period the reparative processes for the restoration of the proper length and shape
of the shaft are carried on :  the  particular character of the symptoms depends
however not only on  the stage, but also in a great measure on the seat and extent
of the necrosis.   In  all  cases it is ushered  in by symptoms of local inflammation
of a more or less intense and painful character;  the  skin becoming glazed, cede-
matous, and of a purplish-red tint; abscess, often of  large size, and discharging
great  quantities of fetid or bloody pus, forms in the limb, and burrows widely,
in proportion to the  extent of the necrosis, amongst its cellular planes.   If  the
suppuration be not so extensive as to jeopardize life, as occasionally happens when
the thigh is the seat of disease, the patient sinking into rapid hectic, the suppu-
rating cavity will gradually contract, leaving fistulous  and sinuous tracts,  often of
great  length and extent, leading to rough and bare bone, discharging a fetid and
ichorous pus,  and having their orifices  surrounded  by protuberant and glazed 
564                      DISEASES  OF  BONES.

granulations.   All these symptoms of inflammation, abscess, and wide-spread sup.
puration, have for their ultimate objects the separation  and elimination of the
dead bone, and the proper formation of  new bone, as a substitute for that which
has died.
   In the peripheral necrosis of the shafts of the long bones, as of the femur or
tibia, the inflammatory symptoms just indicated are well marked, and the disease
usually runs a rapid course up to the period of the formation and  discharge of
the abscess.   In  the case of central  necrosis the pain is usually more severe than
in the former case, and is peculiarly deep-seated and throbbing,  being especially
intense at night.   The limb becomes very cedematous, red, and glazed; the bone
enlarges greatly,  and abscess at last forms, which  spreads widely in  the planes of
cellular tissue, undermining the  muscles, and producing  general destruction of
the limb, the tissues of which become rigid and condensed, having sinuses leading
down through them.  On introducing a probe into these channels, the instrument
passes through apertures in the bony case, termed cloacae (Fig. 172), at the bot-
tom of which the dead  bone will  be  felt  rough  and bare.  Though this is the
general condition that occurs in the central necrosis, it occasionally, but rarely,
happens, that a small portion of  some of the internal lamellae  of the bone dies,
and being included in a greatly thickened case of new bone, gives rise to symp-
toms of osteitis, but not to those  characterizing necrosis.
   When the whole thickness of  a shaft  dies the symptoms are always of a very
acute kind, the extent and gravity of the inflammatory and suppurative condition
being proportioned to that of the amount of bone that loses its vitality.   It is a
remarkable fact, however, that the  articular ends usually escape, though these some-
times even become affected and the joints involved.  "When the short cancellated
bones or the articular ends of long bones, become the seat of necrosis, it com-
monly happens that the disease is far more  chronic than in the cases described;
abscess forming,  which at first  may not reveal its true nature,  or being preceded
by continual pain, may  be looked upon as a disease  of a rheumatic  character.
Suppuration at last occurs, sometimes rapidly opening into the neighboring joint,
and disorganizing it with extreme constitutional disturbance, but more commonly
it runs a very chronic course.   On passing the probe down the fistulous openings
that lead through the indurated and thickened soft parts, an aperture may usually
be felt in the bone, at the bottom of which lies a necrosed mass not larger than
a hazel-nut,  surrounded by carious bone.
   The process of the separation of the dead bone, and of the formation of anew
osseous tissue to supply the place of that which is necrosed, is one  of the most
interesting phenomena that the surgeon can study.  The  separation of the dead
bone, or  its exfoliation, is precisely similar  to the mode  in which  a slough in
soft parts separates, the time required being the only difference.   Inflammatory
action  is set up so as to form a  true line  of demarcation and of separation in the
substance of the  bone  that is  still living, and that is immediately contiguous to
that which  has  lost its vitality.  In this  way a groove is gradually deepened
around the edge of the sequestrum,  by the  absoption or rather disintegration of
the earthy matter of the living bone, which is carried off by the pus formed in
the course of this  process; pus  that, according  to B. Cooper,  contains 1\  per
cent of phosphate of lime.   Along  this gradually deepening line of separation,
plastic matter is thrown out, from  which granulations are formed which constitute
a barrier as it were between the living and  dead bone, and extending  into the
under  surface  of the  sequestrum,  become so  implanted  in  the  hollows and
depressures which are there found, that this may continue to be  firmly attached
to the  subjacent living bone after all osseous connexion between them has ceased.
This process of exfoliation may often be beautifully seen in the separation of the
outer  table  of the skull in cases of necrosis  of that bone.  When occurring 
PATHOLOGY OF  NECROSIS.
565
between  the  shaft and articular ends  of  a long bone, the  process is precisely
similar, though the line of separation is not quite so regular.
  When once the dead bone has been detached by the formation of this line of
separation, nature adopts steps  for  its ultimate removal from the body,  there
being no evidence that it  ever, under  any  circumstances, undergoes absorption.
Mieseher has shown that the detachment of small scales of bone may take  place
by the disintegration of their substance by  a process of "insensible exfoliation,"
as he terms it.   This process is  a purely mechanical or physical one, and pro-
bably goes on in all dead bone that is in contact with pus, just as we see it take
place in the ivory pegs used in the treatment of ununited fracture.  It is this
disintegration of  the surface of the dead, together with  the absorption of the
margin of the living bone, in the formation of the line of separation, that explains
the fact that the sequestrum will always be found to be of much smaller size than
the cavity in which it is  lodged.  The ultimate expulsion  of  the loosened or
exfoliated sequestrum is  effected  by the  growth of the granulations  below it
pushing  it off the surface, or  out of the cavity in which  it lies.  When  the
necrosed bone is peripheral, it will be readily thrown off in this  way, although it
may for a time be fixed and entangled by the mere pressure and extension of the
granulations.   When the sequestrum is invaginated within old or new bone, the
process of elimination is necessarily very tardy, and may be difficult or impossible
without surgical  aid.   The time  required for  the exfoliation
and separation of dead bone varies greatly.   When superficial   ..-,,._ Jfl,.,,,^^.
and small in size, a few weeks may suffice; but when affecting
the  long bones, or especially those  of the ilium,  the  process
may be extended over several years, and may terminate in the
death of the  patient from exhaustion  before  it  is  concluded;
the constitution being harassed and worn out by hectic induced
by profuse suppuration.  Or the  disease may fall into a  chronic
state, the limb becoming rigid, with much condensation of tis-
sues, with fistulous  apertures leading down  to exposed but
attached  bone, and thus being a source of constant annoyance
and suffering to the patient.
   The reparative process adopted  by nature for the restoration
of the integrity of the bone, a portion of which has  necrosed,
varies according to the  extent of the loss of substance.   When
the outer lamellae alone are necrosed new bone is deposited by
the surrounding periosteum, and the depression that has formed
on the surface of the old bone is filled up by a kind of cicatri-
cial fibrous tissue, which  ultimately ossifies.  If the whole of
the inner lamellae of the shaft die, constituting central necrosis,
the  outer  layers  of  bone  become  greatly consolidated  and
thickened by osseous  matter deposited from the periosteum, in
which, in the majority of cases, the  circular or oval  apertures
termed cloacae, form for the ultimate extrusion of the sequestrum
(Fig. 172). In  some cases, however,  no cloacae form, the dead
bone continuing  to be incased  in the thickened outer  layers.
When the whole of a shaft dies,  the reproduction takes place from various sources,
principally perhaps from the periosteum, and the  medullary membrane, if that
is left, which become inflamed, vascular, and detached  from  the necrosed  bone;
the periosteum indeed takes the principal share in the reproduction, and has been
considered by some pathologists as the true organ of reproduction  of new  bone.
Then again the soft tissues of the limb generally, if thick, as in the thigh, con-
tribute to the formation of plastic matter, which gradually ossifies, and  so  tends
to strengthen the new case; and, lastly, the articular ends of the old  bone  still
preserving  their vitality, throw out sufficient osseous matter to consolidate  them- 
566
DISEASES  OF  BONES.
Fisr. 173.
w
 selves firmly to the new shaft that is formed.  Thus it will be seen that the new
 bone is formed by the vascular  and healthy tissues generally that surround the
 seat of disease, though in  this reparative  action the periosteum and medullary
 membrane take the chief share.
   The new  bone which  is deposited on  those parts of the surface of the shaft
               from  which  scales of  the  old  osseous  tissue have  been sepa-
               rated, or that envelopes the sequestrum when  the whole thickness
               of the shaft  necroses, is at first rough, porous, and  cancellated
               and very vascular; after a time it  gradually becomes more com-
               pact and harder, at the  same time that it assimilates in bulk and
               shape to the bone, whose place it takes.   When the new bone is
               deposited around the sequestra so as to envelope these in a kind
               of case, apertures of an oval  or circular form, cloaca3, are formed
               in it;  these serve for the escape of  the discharges, and it is even-
               tually through these that the dead bone  is extruded; they are
               said to correspond with points at which destruction of the peri-
               osteum has taken place.   The case of new bone, which necessa-
               rily exceeds in circumference the  old bone, as this  is included
               within it, gradually contracts both in texture  and in size, becom-
               ing firmer and smaller after the removal of the sequestrum; and
               the  cloacae closing  so soon as  all  dead bone has been extruded, it
               eventually acquires the  proper size and shape of the  bone; the
               medullary  canal even becoming lined by a  proper membrane
               forming in it.
                 The new  case usually forms with a  rapidity that  keeps pace
               with the death and separation of  the  old bone.   But in some
               instances, when the whole of a shaft is necrosed, it is not  com-
               pleted, or has not become attached to the articular ends before
               these are separated from the shaft (Fig.  173.)  In other cases
               again, though complete,  it has not sufficient strength to resist the
               contraction of the muscles  of  the limb; under these circum-
               stances, it  may  spontaneously fracture, as happened  in  a case
               of necrosis of the  thigh lately under my care in the Hospital, or
              become  shortened  or bent.   In other instances again  new bone
               does not form; but  as the sequestrum separates, the limb becomes
shortened, loose,  deformed, and useless.
 _  In the treatment of necrosis, the indications to be accomplished are sufficiently
simple, though the mode  in which they have  to  be carried  out often requires
much patience and skill on the part of the surgeon.
   The first point to be attended to is to remove any constitutional or local cause
that has occasioned or keeps up the disease.  Unless this be done, it is clear that
the whole of the rest of the treatment  must be  ineffectual.  Thus, for instance,
if  the death of the bone  appear  to result from  scrofula or syphilis, those con-
ditions must be corrected.  So, again, if it arise in the lower jaw, from the fumes
of phosphorus, the  patient must necessarily be removed from their influence; or,
if it be threatened in  consequence of denudation of bone, the best mode of pre-
vention will be to lay down the flaps of integument, and so cover the exposed
surface.
  After the cause has, in  this way, been removed or counteracted, the separation
ot  the sequestrum should be left,  as much as possible, to the  unaided efforts of
nature.   The less the surgeon interferes with this  part of the process the better,
for as has been justly observed by Wederaeyer, the boundaries of the necrosis
are only known to nature, and the surgeon will most probably either  not reach,
or  pass altogether beyond them.   Here  much patience will be required for many
weeks or months, and the utmost that the surgeon can do is to  attend to the state
I 
OPERATIONS  FOR  NECROSIS.
567
of the patient's health, treating him carefully upon general principles, removing
inflammatory mischief, by appropriate antiphlogistic means, opening abscesses as
they form in the limb, and at a later period, supporting the patient's strength by
good  diet, tonics, and general treatment, calculated to bear him up against the
depressing and wasting influence of continued suppuration, and of the irritation
induced by the disease.
   So soon as the sequestrum has been detached from the adjacent or underlying
bone, by the proper extension of the granulating line of separation, the surgeon
must proceed  to  its removal.  In  most cases it is sufficiently easy, when the
necrosis is superficial, to ascertain that this separation has taken place, as the flat
end of a probe may be pushed under the edge of the detached lamina.   When,
however, the  sequestrum  is  deeply seated,  it is not always so easy to ascertain
that the separation has occurred, though in  the majority of cases,  the introduc-
tion of a  probe through one  of the fistulous openings leading to  the necrosed
bone, and firm pressure exercised upon this,  will enable the surgeon to detect that
degree of mobility which is characteristic  of its being loose.  In other cases,
however, the sequestrum, though completely removed from all osseous connexions,
still continues to be fixed by the pressure of  the surrounding granulations, and
by the extension of its spiculae into the corresponding cavities of the new osseous
case.  This especially happens when the necrosis is central and invaginated, and
the  cloacae  leading to it of such small  size that  but a  limited portion of it is
exposed.  Here a more careful examination  will be required, and its looseness
may sometimes be determined by pressing upon it with a probe in a kind of jerk-
ing  manner, or by  introducing  two probes  through different  cloacae, at some
distance from one another, and  alternately  bearing upon the exposed bone with
one or other of them. Then again, if the sound elicited by striking the end of the
probe against  the sequestrum is a peculiarly  hollow one, the detachment of the
bone may be suspected.   The duration  of the disease, also, will probably throw
some light upon the probable state  of things inside the new case.
   So soon as the separation of the sequestrum has  been ascertained, the surgeon
must adopt measures for its removal.   If the necrosis  is peripheral,  all that is
necessary is to make an incision down  to it through the  soft parts, and then to
remove it with a  pair of forceps, or to tilt it off the bed of granulations on which
it is lying by introducing the end of an elevator beneath its edge.
   When the necrosis is central,  the sequestrum being imbedded in  the new case,
or covered in by old bone, the operative procedures for its removal are of a more
complicated character.  The  difficulties here  consist in  the depth from the sur-
face, and  the obstacle offered by its passage through  the  soft parts in some
cases, and in  others, in the length and magnitude  of the sequestrum in propor-
tion to the small  size of the cloacae, and the manner in which it lies, in a parallel
direction  to these openings.   In cutting down upon the bone,  the surgeon must
be guided by the direction, or the course of the fistulous tracks that  lead to the
principal apertures in the new case, the incisions being carried in the axis of the
limb, and carefully directed away from large'bloodvessels and nerves.  In many
instances, however, the hemorrhage is  somewhat  abundant, in consequence of
the injected state of the tissues furnishing  a  copious supply of blood, and their
rigid condition  preventing  retraction  of the vessels.   This,  however, may  be
arrested by the pressure of an assistant's fingers, and will soon gradually cease
of itself.   The bone having been freely exposed, it will sometimes  be found
that the  cloacae are of sufficient size  to  admit of the ready  extraction  of the
sequestrum.   But in the majority of  cases,  this  cannot be done  at  once, and
the  apertures must be enlarged, either with the gouge or the trephine, accord-
ing to the density of the new case,  and amount of room required.   Occasionally,
when two cloacae are close to one another, the intervening  bridge  of bone  may
very conveniently be removed by  means of  cutting pliers, of different shapes, 
568                      DISEASES  OF  BONES.
as in Figs. 174 and 175, or by means of a Hey's or a straight narrow saw (Fig.
176, and space thus given for  the extraction of the sequestrum.   Very conve-
Fig. 174.                          Fig. 175.
nient pliers, for  this purpose, are those represented in Fig. 177.   They are
made by Mr. Coxeter, with gouge-ends, and hence may be termed gouge-forceps.

                                   Fig. 176.
   I have found them extremely serviceable in many operations upon the bones.
 Care, however should be taken not to remove more of the new case than is abso-
 lutely necessary, as  the aperture  so made in it will  not be filled up  again by
 osseous matter, but will be closed by fibrous tissue, and thus the ultimate sound-
 ness of the limb might be endangered.   For the extraction of the sequestrum
 the most convenient instrument is a pair of strong necrosis  forceps, well  rough-
 ened at their extremity.  Occasionally the  sequestrum is so shaped and placed
 that it cannot be seized with this instrument; under these circumstances, it will
 be useful to  drive  a screw-probe  (Fig. 48) into  it, by which it may either be
 extracted, or so fixed as to admit of seizure, and removed  by the forceps.  In
 some cases, additional and convenient purchase may be  ffiven to the dead bone,
 by fixing a bone-forceps, such as represented in Fig. 178 firmly into it.   If the
 sequestrum is too large to be removed entire through the cloacae, it may perhaps
 best be extracted piecemeal, having been previously divided by passing the points
 of  narrow, but strong,  cutting pliers into the interior of the bone.   After the
 removal of the  sequestra,  a smooth,  hollow cavity will be left in  the new case,
 from the bottom and sides  of  which blood usually wells up freely,  issuing abun-
 dantly from the vascular bone, and  from the granulating membrane  lining its
 interior.   Should  this  hemorrhage  be  at all troublesome, pressure will  always
 efficiently arrest it.   Lint  must then be  lightly introduced  into the  bottom of
 the wound, and the part elevated; a good' deal  of inflammation  is frequently
 set up after these operations, but that must be combated on  general principles.
   If the sequestrum have been a long one, and involve  the greater part of the
 shaft of the bone, it may happen that the new case has not sufficient strength to
maintain the  limb of its proper length and shape, and that it will bend or'break 
AMPUTATION AND  RESECTION IN NECROSIS.        569
under the action of the forces and weight to which it is subjected.  In order to
prevent this  accident, it will be necessary to  put it up in light splints, or in a
starch  bandage.   After the removal of the dead bone, the fistulae will speedily
close, and the limb eventually regain its normal size and shape.
Fig. 177.
   If the necrosed  bone be so situated  that it cannot be removed, occupying
too great an extent and continuing to be firmly fixed, and if, at the same time,
the patient's health have been worn down by constant discharge, and symptoms of
hectic come on; or, if the limb have generally been  greatly disorganized by the
morbid processes going on in it, amputation must be had recourse  to as a  last
resource.  It is especially in the  lower third  of the  femur that these severe
forms of necrosis occur, necessitating amputation of the limb.  As an idiopathic
disease necrosis of the tibia is rarely met with requiring this operation, but when
it is the result of bad  compound fractures, or of other serious injuries  of that
description,  the removal of  the limb may become imperative.   It  occasionally
happens that amputation is required for a very acute  form of necrosis:  this form
of the disease I have chiefly met with in  young people, from the ages of  sixteen
to twenty, of a strumous habit of  body;  the affection, having come on  without
any obvious cause, being situated in the  lower part of  the thigh, involving per-
haps one-half of the  bone, and attended with the formation of such immense
abscesses, and so abundant a discharge of pus, that in the course of three or four
weeks, life may be endangered  by the profuseness of the suppuration, and  the
removal of the limb become necessary.
   Amputation may also be required in necrosis for hemorrhage from the sinuses
and abscesses, the bleeding being either the result of general oozing from their
walls, or arising from the laceration of a large arterial trunk by the point of a
rugged sequestrum.   In other cases, again, removal of the limb may  be rendered
imperative by the implication and suppuration of a neighboring joint.
   Besection of the whole of the necrosed bone may,  in some cases,  be advanta-
geously performed.  Thus, in the case of necrosis of  the ungual phalanx occur-
ing from whitlow, where, by  the removal  of the dead  bone, the end of the finger
 
570
STRUCTURAL CHANGES IN BONE.
may be preserved, so also in necrosis of some of the metatarsal and tarsal bones,
resection may be advantageously practised.   When the ilium  and pelvic bones
are affected, it is seldom that any operative measure can be had recourse to with
advantage.  In some cases, however, if the disease be limited to a portion of the
crest of the ilium, or to the tuber ischii, the dead bone may be  removed.   In
these cases  it is, however, seldom advisable to operate, as  it  not uncommonly
happens  that  disease of a similar kind exists elsewhere, about the sacrum or
spine, that will eventually destroy the  patient.   In a  case in which I removed a
portion of the crista ilii for necrosis that was apparently confined to that bone, it
was found, on the patient dying some weeks afterwards of erysipelas,  that the
lumbar vertebrae were also diseased.
   Necrosis of the flat bones, such as the scapula and bones of  the pelvis, is an
excessively tedious process, there being but  very little tendency to the formation
of the line of separation, and the detachment of the sequestrum,  which will
continue bare, rough, and adherent for many  years.   Should it  be  so situated
that it can be removed, it must be excised, even though not detached;  but, un-
fortunately, in these bones, it often happens that the necrosed portion is so deeply
placed that it cannot be safely excised : here we must leave the patient to the
chance of the bone being at length so  loosened as to admit of extraction.
                          CHAPTER  XLII.

                 STBUCTUBAL CHANGES  IN  BONE.

  The bones are liable to various structural  changes, by which their size, shape,
and consistence are modified, or in consequence of which they become the seat
of tumors of various kinds.
  Hypertrophy of bone usually results from inflammation of the osseous tissue,
but in some cases it may occur apparently without having been preceded by any
signs  indicative of this condition; it then  resembles in character  some of the
forms of exostosis that will presently be mentioned.  Atrophy of bone sometimes
occurs as a natural result, in old age.  In other  cases, again, it happens as a con-
sequence of fracture, the nutritious artery of the bone, asdias been pointed out
by Mr. Curling, having been torn across, and one of the fragments  consequently
receiving insufficient vascular  supply.  Atrophy of bone also commonly occurs
from  disuse, as is the case in old dislocations.  In  cases  of hypertrophy, the
bone  is  not only enlarged  in  circumference, and  also perhaps  in length, but
indurated, becoming specifically  heavier.  In atrophy, on the other hand, it is
thinner,  lighter, and  more porous than usual, the compact structure disappearing,
and the cancellous being expanded.
  Rickets is a disease of early life, usually being met with in scrofulous children,
and never occurring after the age of puberty.   In it the structure of the bones is
changed, the earthy matter being deficient and  the organic material in excess, so
that the bone continues to be  soft, flexible, and  cartilaginous in structure, at an
age when its tissue ought to have undergone proper consolidation.   It appears to
be atrophied, and the  cancellous structure to  be expanded  into cells of varying
magnitude, which contain a brownish-red serous fluid.   In consequence of the
change of structure and the loss of firmness in the bones in this disease, consider-
able distortion of the  body takes place.  The head early appears  large and ex-
panded ; indeed,  Killian states that the rickets always first appear in the head,
the forhead being especially protuberant; according to Mr. Stanley, this arises 
RICKETS — MOLLITIES  OSSIUM.
571
 not  from enlargement of the cranial bones, but  in  consequence of  the want of
 development of those of the face;  the head thus appearing large from its  dispro-
 portion to the small face.  The shape of the limbs is  much changed and distorted,
 in consequence of their yielding to the pressure of the superincumbent weight;
 the pelvis becoming contracted, and  the thighs and  legs bent either forwards or
 outwards.   The joints are usually swollen, the articular ends of the bones appear-
 ing enlarged.   In early life the chest will be observed to be deformed in a pecu-
 liar  manner, being  narrowed  above, where the  upper ribs  are contracted and
 pressed  in,  but expanded  below,  apparently from the weight of the abdominal
 viscera, which are often tumefied and in these cases  drag on  the lower ribs.  As
 puberty advances,  lateral  curvature of the  spine commonly takes place.   In
 ricketty children there  is a general delicacy of appearance,  and often a  strumous
 habit of body, though according to Bokitansky, they are not usually  tuberculous.
 If they live, however, to  past the age of puberty, they may eventually become
 sufficiently powerful in frame.
   The treatment of rickets must be conducted  on  the same general principles
 that guide us in .cases of scrofula; pure air, good food, and plenty of it, regular
 exercise, and the administration of tonics, especially the preparations  of iron, with
 scrupulous attention to the general habits of life of  the child, will generally im-
 prove  his condition to the utmost limits compatible with the powers of his con-
 stitution, and by improving the nutrition of the system tend  to the more healthy
 deposition of osseous matter.   In some  cases  the administration of lime-water
 with milk seems to be of service in  supplying those elements that  are required
 by the system.   It is of much importance in preventing deformity in these cases
 not to allow the child to walk or stand much, but to let it take exercise in don-
 key-panniers or hand-chairs, and to support those limbs that have a special ten-
 dency to become excurvated,  with properly constructed steel  supports, which will
 be found of much  use, provided  they are not too heavy, or interfere with the
 action of the muscles.  Methodical  friction  should also be  employed, so as to
 stimulate the muscles;  as these become more vigorous, their osseous  attachments
 have a tendency to become stronger.
   Mollifies  and Fragilitas Ossium.   Osteomalacia.—A very rare but most  de-
 structive and dangerous disease of the bones, characterized by softening and fra-
 gility of the osseous structure, is  occasionally met with.   This  affection  has of
 late  years been studied with  much  attention  by Curling, Solly, Stanley, and
 Maclntyre,  and it is principally from the labors  of these gentlemen that we are
 acquainted with its true pathology.
  In this disease the bones are bent, their epiphyses swollen,  and  their shafts
 broken in various parts of the body.   Occasionally, though very rarely, only one
 is fractured; but in other cases, as in Tyrrell's  there may be  as many as twenty-
 two fractures; or, as in  Arnott's thirty-one.   These fractures are unattended  by
 any attempt at  the formation of callus.   The body becomes  singularly and dis-
 tressingly distorted.   On examining the bones after death they  will  be found to
 be light, soft, and somewhat gritty;  bending, and at the same time readily snap-
 ping across; occasionally they are  expanded and thickened.   This happens espe-
 cially with the skull, which becomes  often considerably increased in substance.
 On cutting  the bones,  which are soft, and yield, something like cartilage, the
 knife usually encounters a kind of gritty sensation.   On making a section°of the
 bones they appear of a deep reddish-brown, or maroon color, and will be seen to
 contain cavities of various  sizes, small or large, but always of a circular or oval
 shape,  and generally filled with an oily red and  grumous fluid; though sometimes
 they contain clear serum.   On examining this red grumous matter under the
microscope, Solly remarks that, as it shows a cell-development, it is  probably an
adventitious morbid product, and not simply fatty matter altered by  the effusion
of blood into it; and Dalrymple  has shown that this material   is  composed of 
572
STRUCTURAL CHANGES IN BONE.
granular matter, nucleated cells, and a few caudate corpuscles ;  he therefore be-
lieves it to be a disease essentially malignant in  its nature, but differing from
other malignant affections; for " instead of progressively reproducing and deve-
loping themselves  without limitation, the new and morbid formations which re-
place the original and sound structure seem to  have been at an early stage of their
existence removed by absorption  and carried  out  of the system"  (Maclntyre).
The bone itself has been found by Solly on microscopical examination to have its
laminated structure absorbed, the osseous corpuscles diminished in number, and
the Haversian canals enormously distended.
   In chemical  composition the diseased  bone has  been found by Dr. Leeson to
be composed of 1875 animal matter, 29 17 phosphate and carbonate of lime, and
52-08 of water in every hundred parts.
   The cause of the complaint seems altogether unknown; it would appear that
in many cases it is connected with a rheumatic tendency, as in every case re-
corded, the affection  has been preceded or accompanied  by severe pains,  or dis-
tinct rheumatic attacks.   It most commonly,  though not invariably, occurs in
females, a fact pointed out by Killian, and exclusively attacks adults, commenc-
ing even at very advanced ages.
   One of the most important points connected with this affection is the condition
of the urine in it.  In all cases that have been recorded,  this excretion has been
seen to contain large  quantities of earthy matter.   Solly pointed out that this is
the phosphate of lime, which has been absorbed from the bone, and thrown out
by the kidneys  in  the urine; and sometimes the elimination of  these matters is
so abundant that it forms, as in one of the cases which he relates, a solid calculus
clogging up the interior  of the kidney.  In  Dr.  Maclntyre's  case, the  earthy
matters of the  bone  appear to have been,  in the first instance,  absorbed, and
carried off from the  kidney by the urine, but  afterwards an animal matter of a
peculiar and apparently previously undescribed character, was discharged in great
abundance.   He says, that on adding nitric acid to the urine "a slight yellowish
opacity was  the first  announcement of a change going on in the  mixture; this
gradually deepened in tint, with increasing consistency of the fluid, till the whole
congealed into  a bright and  somewhat resplendent mass, presenting very much
the appearance of a  heap of nitrate  of  urea scales, blocking up  the tube.   It
further resembled that substance in  liquefying on the application of heat, and
again concreting on cooling, but  no crystalline arrangement could be perceived,
the sparkling appearance being evidently due  to numerous air-bubbles entangled
in the mass.  Perfect redissolution took  place when the  tube was held for a few
minutes in the  flame of a spirit-lamp, or plunged into hot water at 160 or 170°,
the  ordinary coagulating point of albumen; and the fluidity thus acquired per-
sisted under ebullition, however prolonged."   (Med. Chirurg. Trans, vol. xxxiii.
p. 29.)
   The symptoms of this disease are, in the early stages, of an extremely obscure
and insidious character.  The patient complains, in the first instance, of pains of
a wandering character about the limbs and trunk;  these assume  usually a rheu-
matic character, though they have been observed to be of a much more  severe,
persistent and intractable nature, than in any form of that affection.   The patient
becomes debilitated, unfitted for exertion, and  emaciates.  Spontaneous fracture
now occurs in some bones under the influence of the most trivial causes;  others
become bent, and  the body consequently greatly misshapen and distorted, occa-
sionally in the most wonderful manner.    The  urine will be observed  to present
some of the abnormal characters above described, and death eventually  results
from general exhaustion.
   The diagnosis of this affection has to be  made in the early stages from rheu-
matism.   This is not so easy, and, indeed, is at first impossible; but after  a time,
when the peculiar phosphatic condition of the urine, and the fragility or distor- 
TUBERCLE IN BONE.
573
tions of the osseous system manifest themselves, the true nature of the affection
reveals itself.   From rickets the diagnosis may usually be pretty readily made, by
observing that whilst rickets is a disease of childhood, osteomalacia is an affection
peculiar "to adult or advanced life.   The  occurrence of severe pains, and  the
greater amount of distortion, with the tendency to spontaneous fracture, which is
observed in this disease, is never noticed in ricketty children.
   With regard to treatment, but little can be done; the administration of tonics,
and a general supporting plan of treatment, may arrest for a time the progress
of this  terrible  affection;  but when once  it is declared, it usually  progresses
from bad to worse,  and at last destroys the patient.  Opiates may be employed to
allay the pain, and in Dr. Maclntyre's case some temporary advantage appeared
to result from the administration of  alum.   But no remedy has appeared to exer-
cise any decided or continuous advantage in this complaint, which there is reason
to believe,  with  Solly, is of a  truly malignant character.
   Tubercle of Bone.—The deposit of tuberculous  matter in bone,  plays an  im-
portant part in many diseases  of this tissue in children  and young people of a
scrofulous habit of body, being a common cause of some of the most intractable
forms of chronic osteitis, circumscribed abscess, caries, and necrosis.   As tubercle
is almost invariably deposited  in the cancellous  structure, it is  a frequent cause
of those forms of inflammation of the articular extremities of long bones, that
terminate in the destruction of the contiguous joint.  In the short bones, as those
of the tarsus, it  commonly leads to caries and necrosis, and forming, as it often
does, in the bodies  of the vertebrae,  it very frequently gives rise to some of the
most destructive diseases of the spine, attended by the formation of large lumbar
and iliac abscesses.   When once tubercle has been deposited in  a  bone, it inva-
riably sets up a low form of inflammation  in  the surrounding osseous  tissue,
which rapidly runs into a carious condition, with the formation of  curdy pus, in
which masses  of half disintegrated  tubercle may be seen.  If  this  destructive
action takes place  with  great rapidity, portions of the  bone will  be found to
necrose in  small masses, which lie at the bottom of these tuberculous and carious
cavities, as may commonly be  observed in  some forms of strumous caries of the
os calcis and  head of the tibia.   When the tuberculous  deposit has  been very
extensive, and is of a more acute character, it may cause  inflammation and  dis-
integration of the whole  of the articular  end of a long bone,  with  separation
of the epiphysis.   These  destructive changes may take place with great rapidity;
I have seen them happen in a lad, whose thigh I amputated for acute tuberculous
infiltration  of the lower end of the femur, in less than a month from the first
occurrence of the complaint,  the patient at the time of the operation,  being
nearly exhausted by hectic, induced by the abundant discharge from the diseased
bone, and from immense abscesses in his thigh.
   When on the contrary the tuberculous matter is  deposited in small quantity
in an otherwise healthy bone,  it may, as it undergoes softening, dispose  to  the
occurrence of circumscribed abscess, at the same  time that chronic thickening
and condensation of the surrounding bone  takes place.  It is in consequence of
this condensation of the  peripheral  portion of the bone by the deposit of fresh
layers of osseous tissue under  and by the inflamed periosteum, and the difficulty
that the tuberculous abscess necessarily experiences in traversing these hypertro-
phied osseous structures, that  it is so apt, when deposited in the  vicinity of a
joint, to work its  way eventually into the cavity of the articulation ;  as on this
surface  no fresh deposit or condensation of  osseous tissue can take place, and,
consequently, no additional obstacle offered to the onward progress of the tubercle,
or rather of the curdy pus into which it has become transformed.
   The presence of tubercle in osseous  tissue thus  not only gives  rise to destruc-
tive changes in the  bones  and  adjacent articulations, but will occasion  inflamma-
tion and extensive suppuration in  the neighboring soft parts.   Indeed some of 
574
STRUCTURAL  CHANGES  IN  BONE.
the largest chronic abscesses that form in the body, those connected with diseased
dorsal or lumbar vertebrae, owe their origin in a majority of cases  to the deposit
and disintegration of tubercle in the bones.  AVhen once tubercle in  bone has
given rise to caries and perforation of the osseous  tissue covering it, together
with abscess and sinuses  of the  soft parts,  these conditions will continue in  a
permanent manner;  the fistulous tracks leading down to the bone and the cavi-
ties in it, remaining open  so long as any tuberculous matter is  left at the bottom
of them ; and in this way the patient may eventually be exhausted by the copious
and continuous  discharge from those osseous vomicae.   In some favorable cases,
as the result of  natural  processes, and  in  others, by those operations that the
surgeon practises for  caries, the whole of the tuberculous matter may be disinte-
grated, and thus eventually eliminated or  scooped out by the gouge,  and then
the fistulous track, whether in soft part or in bone, having no longer this kind of
foreign body lying at its bottom, will gradually close;  not by the contraction of
its osseous walls, which  is of course impossible, but by the deposition of a fibrous
tissue by which the cavity is occluded.
   Nekton has pointed special attention to the pathology of tubercle of bone, and to
the important part that it plays in the diseases of the osseous structure.  He describes
two forms of tubercle in this situation ; the first, which is the most common, is
the encysted variety, which occurs in  the  form of  small masses, of an  opaque
white or yellowish color, contained in the cyst, which is soft, vascular and spongy,
apparently of a  cellular  structure.   The other form, in  which tubercle  occurs,
according to Nekton, is  as an infiltration into the cancellous structure  of bones.
This  may be in  the form of semi-transparent granulations of  a grayish or rosy
tint, opalescent  and slightly transparent; occasionally these granulations are firm,
so as almost to resemble  cartilaginous deposits in the interior of the bone.  The
osseous structure, in the midst of which this kind of tuberculous matter is depo-
sited, does not appear at first to undergo any material alteration.  The other form
of tubercle is that in which it is infiltrated as opaque  puriform matter of a pale
yellow  color,  soft, and  without  vascularity.  The  osseous tissue, under  the
influence of this disease, often becomes, as Nekton observes, more condensed
than natural, the cells being obliterated so  as to resemble the compact substance
of bone.  In some cases it may continue thus chronically thickened and  indu-
rated, but in other instances the tuberculous inflammation will give rise to rapid
and destructive  inflammation  of the surrounding  osseous tissue, which becomes
excessively vascular, and crumbles down into a carious state, with some necrosed
masses intermixed.  In  other instances, again, as is not unfrequently observed in
some of the  forms of caries of the spine,  or of white swelling,  slow  suppura-
tion takes place  in the interior of  the bone, and on the sides or in the centre of
the abscesses thus formed, hardened and white ivory-looking masses and knobs of
osseous tissue may be seen to be deposited, these apparently  consisting of the
tuberculous bone that has undergone some special modification  of structure.
  The treatment of tubercle of bone resolves itself into that of its effects.  As
its existence cannot be recognised except by  the changes that  it induces in the
bone, the treatment must be directed  exclusively to  these.  Thus, if it occasion
circumscribed abscess, that must  be opened; if caries,  the diseased cavity and
tissue must be scooped out, or removed in accordance with the  principles already
laid  down;  and, if disease of the neighboring articulations result, it must be
managed as will hereafter be explained.
  It  is of importance, however, to recognise the  dependence  of these various
affections on a tuberculous state of the bone; for, as this is always of  a scrofu-
lous  character, it should necessarily occasion the constitutional measures that
are employed to be specially directed to the removal  of this cause.  Thus, good
food,  sea-air, the administration of iron, of the  iodides, and  cod-liver oil, will
form most important  elements in the treatment, without which, indeed, it cannot 
TUMORS  OF  BONE.
575
 be brought to a successful termination.  The progress of these cases is generally
 excessively tedious.  Stanley gives, indeed, two years as the time required for a
 strumous bone to recover itself, and in very many instances this period may even
 be exceeded.  In this, as in all other of the chronic inflammatory affections of
 the bones, it is of  considerable moment to continue the means of cure until the
 disease  is  fully recovered from, for relapse  will  occur with special readiness
 in the tubercular affections, if the patient be allowed to use the diseased limb or
 part too soon.

                              TUMORS OF BONE.
    Exostosis.—By exostosis is meant the growth of a bony tumor from some of
 the osseous structures of the body.   The causes that immediately give rise to
 this disease are usually extremely obscure.  There can  be  no doubt that, in
 some instances, it is predisposed to by syphilis, scrofula, or cancerous affections;
' and that in other cases, again, it is hereditary; but, in general, it occurs without
 any distinct or appreciable exciting cause.
    Exostoses are of two kinds :  the one hard and compact, the other  softer, and
 more  spongy.   The hard, or ivory exostosis, is  a structure that differs both in
 appearance and composition from true bone.  It is extremely compact and white,
 having a granular section closely resembling that of  ivory, and  presenting some-
 what radiating fibres.   In chemical composition, it is found to differ from healthy
 bone in containing more of the phosphate and less of the carbonate of lime, and
 also in the proportion  of animal matters being smaller.  This  kind of exostosis
 principally grows from the flat bones, and as it is generally of small size, seldom
 produces much inconvenience, unless it be by projecting  into and compressing
 important parts.  Thus, Cloquet relates the case of a tumor of this kind growing
 from the pubes,  and perforating the bladder; and they are occasionally found to
 project into  the orbit, or from the  inner table  of  the skull, upon  the  brain.
 When these bony tumors are left to themselves,  they usually become stationary
 after a  time.   In some  instances  they  have  been  known  to  necrose, and to
 slough  away, as  it  were, from the  parts  on which they are  situated.  Of this
 termination Hilton and Boyer relate instances.
    The  spongy, cancellous, or  cellular exostoses grow rapidly, often attain a con-
 siderable size, and are very commonly  multiple.   When numerous, they will
 often be found to  be  somewhat symmetrical  in their  arrangement.  Not un-
 frequently they stretch  across from  one  bone  to another, bridging over joints,
 and thus giving rise to anchylosis; in shape, they vary greatly, sometimes being
 globular, at  others spinous.   In structure and chemical composition, they are
 identical with  cancellated bone.
    The  symptoms of  exostosis are simply those produced by a hard, thick, and
 slowly-growing tumor, connected with a  bone, and pushing forwards the soft
 parts covering it.  In many cases, it produces serious inconvenience by its pres-
 sure, either upon  neighboring organs  or mucous canals, or it  may occasion
 ulceration of the skin  lying above it.
    Treatment.—If  an  exostosis is  so situated as to occasion inconvenience or
 deformity, it will be necessary to remove it; and  as it is a local disease, there is
 no fear of its returning, provided this be fully done.   But if the whole of it be
 not taken away,  it  may grow again,  and Stanley accordingly recommends that if
 it be so situated, as upon the cranium, that its base cannot be extirpated,  potassa
 fusa or nitric acid should be applied to the part that is  left, so as  to produce
 exfoliation  of  it.  The removal of  these tumors is best effected by a Hey's or
 chain saw, or cutting pliers.   In some situations, as  when  close upon joints, or
 springing from  the cervical  vertebrae, they cannot  be  interfered  with;  and in
 other cases, as occasionally  happens  in  the neighborhood of  the orbit,  their
 density and hardness may be such, that the saw can scarcely work its way through 
576
STRUCTURAL  CHANGES  IN  BONE.
them.   There is a peculiar kind of exostosis occurring from the upper surface of
the last phalanx of the great toe, pushing up  the nail, and giving rise  to great
inconvenience.  This must be removed by exposing its  base and  cutting it off
with a pair of sharp pliers, without amputating the toe.    There is a species of
bony growth, called osteoma, consisting of a uniform elongated mass of new bone,
deposited on  some  of the  osseous surfaces,  somewhat  resembling  a node, and
differing from ordinary exostosis in not being  pedunculated, that does not admit
of removal, and is not  amenable to  any treatment.
   Enchondromatous, or osteocartilaginous tumors are often met  with.  These
have already been described when speaking of  enchondroma and its pathology,
and need not, consequently, be more than  adverted  to here.   They  usually
require the resection or amputation of the affected  bone, according to the attach-
ments  and size of the  growth; but Stanley states that in some cases, where the
cartilaginous tumor of  bone is of small size, it may be influenced and eventually
dispersed by the local  application of iodine and  mercury.
   Cystic tumors  of  bone of various kinds are commonly included  under the
terms osteosarcoma  and spina ventosa, which  terms having also been occasionally
applied to various other solid growths, whether  of  a fatty, fibrous,  gelatinous, or
cartilaginous character, as well as to various kinds  of malignant tumor springing
from bones,  have occasioned much confusion in  the pathology of these affections.
The cystic tumors of bone have been well described by Nekton.   They consist
                              of cysts, having various kinds  of fluid and solid
                              contents.  The cysts may be unilocular, and these
                              are  commonly  filled with solid matter, or multilo-
                              cukr, and they then  contain fluid.  The solid
                              masses are usually of a fibrous or fibro-cartilagin-
                              ous  character,  filling up completely the cavity in
                              which  they are situated, and often  attaining a
                              very considerable  size.   They occur  principally
                              about the jaws and  articular ends of  long bones,
                              especially  the  humerus, the femur,  and the tibia.
                              The cysts  with fluid or semi-fluid contents attain
                              a much larger size than the last, being often met
                              with as large as  a cocoa-nut or a fcetal head.   On
                              a section being made of them, they are found to
                              be composed of a multilocular  cyst, each cavity
                              having distinct  walls, and often communicating
                              with others.   The  fluid  contained within these
                              cysts is of various characters,  thin  and  serous,
                              sero-sanguinolent,  viscid, or dark  colored, often
                              associated with masses of fibrous tumor, appearing
                              as if it proceeded  from the  central softening of
                              these large  growths.   The same situations  are
                              affected by the compound as by the  single cysts,
but they are also met with in the shafts of long bones.   From whatever part they
proceed, their walls are composed of expanded bone, not uniformly thinned, but
thickened and  noduled  at  various   parts,  whilst it is perforated at others
(Fig. 179)..  ^
   These cystic tumors principally occur in  adults, being rarely met  with in
children.  They  constitute  smooth,  round, or  oval  growths, increasing slowly
but steadily,  with little or no pain,  the skin covering  them being of the normal
color, and the veins usually blue, enlarged, and tortuous.   AVhen a  certain size
has been attained, so that the shell of bone is expanded into a very thin lamella,
and before it is perforated, pressure on the tumor  occasions a peculiar crackling
or rustling noise, like  that produced by pressing together  a broken egg-shell, or
Cystic tumor of lower end of femur. 
            CYSTIC  AND  CANCEROUS  TUMORS OF BONE.        577

 the crackling of tin-foil.  Under this the elasticity or even  semi-fluctuation of
 the tumor may be  felt.   This fluctuation is  particularly marked after  a  time,
 when  the osseous  envelope  has become still  more expanded, or is partially or
 wholly absorbed.
   Treatment.—When the contents are solid, there is usually no means of rid-
 ding the  patient of the tumor, but  by the  removal of  the whole growth; by
 excision,  if it is favorably situated for such  procedure, as in  the jaws; by am-
 putation,  if in the limbs.   AA7hen the contents of the tumov  are fluid or  semi-
 fluid, it must, if large, be treated in the same way as the solid g 'owths are; but, if
 small, or  of moderate size, so as not to have materially affected the integrity of
 the bone, then it may suffice to remove one side of the wall  of the cyst by the
 trephine or by excision;  and then  stuffing the cavity with lint, allowing it  to
 granulate, and  its walls to  contract.   This plan has proved especially successful
 in some of the  cystic tumors of the lower jaw.
   Hydatids.—Cavities are occasionally, but very rarely, found in bones, in which
 large numbers of hydatids are lodged; according to Stanley, both the  acephalo-
 cyst and  the cysticercus  cellulosa have been found in this tissue, but most fre-
 quently the first.    In  these  cases a cyst forms in the bone, which becomes thin
 and expanded, resembling the  ordinary fluid cystic tumor;  but  which on ex-
 amination, is found to contain  these  entozoa.  The treatment, as Mr.  Stanley
 observes,  must depend on the situation and extent of the disease; if it is a long
 bone that is affected,  and that is  much expanded,  amputation must  be had
 recourse to; if a flat bone, the cavity must be scooped out, and dressed from the
 bottom with  stimulating applications, so as to get it to fill with healthy granula-
 tions.
   Osteo-cancer or  osteo-cephaloma are true malignant tumors  of bone, constitut-
 ing very serious but not very rare forms of cancer.   Two distinct forms of cancer
 of bone are included in this disease.   In one form the morbid growth is  central,
 springing from the  medullary canal; in the other it is peripheral, being attached
 to the compact osseous substance.
   In the  central cancer of bone, the tumor is found to grow in the substance of
 or to spring from, the interior of the medullary canal of the bone.  It is usually
 situated at or about the articular ends, expanding the bone, which becomes com-
 pletely enveloped and incorporated in the  structure of the growth, either in the
 form of osseous rays diverging from the centre of the tumor, or more rarely as a
 thin shell of bone surrounding the mass, as in the more simple growths springing
 from this  tissue.  Under either  circumstance  it is important to bear in mind
 that this form of the disease is never localized, but always invades the whole of
 the bone; the freedom of communication between the upper and lower ends of a
 long bone isso  great, that, as has  been  shown by Bichet, water injecte4 at one
 end exudes in a few seconds at the other.  Hence the  juices of a malignant
 structure might easily traverse the whole length of the bone, and we accordingly
 find on examining the  osseous tissue at a  distance from the  tumor, that there
 are red patches in it here and there indicative of its infiltration with the  morbid
 structure.
  In the peripheral form of cancer of bone, which is probably the most common '
 variety of the disease, the osseous tissue is not so completely invaded; for, although
it may be  situated upon, or be in intimate contact with, the outer layers of the
bone, which are incorporated  in it,  it does not extend into the  cancellous tissue,
or the medullary canal.   The tumor appears to spring from the periosteum, and
after removal and maceration, stakctitical projections and  radiating fibres may
be traced into it from the outer layers of the bone.
  These tumors, whether central or  peripheral, are chiefly of the encephaloid
species of  cancer, and  are met with in all  stages of development and of decay.
Occasionally, some colloid, and more rarely melanotic matter is intermixed; but
                                    37 
578
STRUCTURAL  CHANGES IN  BONE.
scirrhus, I believe, is never found in bone.  They most frequently occur  in the
head of the tibia, and the lower end of the femur; occasionally in the humerus
and in the jaws, more especially about the antrum.  It is a remarkable fact, long
ago pointed out by Petit, and more recently insisted on by Bichet, that although
the epiphysis may have been completely converted into encephaloid matter, the
cartilage of incrustation and of the neighboring joint (Fig. 181) never becomes
implicated;  and this, although the growth may eventually involve  and include
the whole of the rest of the articulation, by extension to the capsule and its soft
parts.
   The symptoms of these tumors are as follow : there is a rapidly-growing enlarge-
ment of the bone, usually with  much lancinating pain,  having a globular shape,
feeling  elastic, and sometimes  semi-fluctuating.   The skin  covering it, at first
pale, with numerous reticulated and blue  tortuous veins, afterwards becomes dis-
colored, being eventually implicated in the morbid mass.   In some  cases, frac-
ture of the  bone takes  place at the affected part (Fig. 180); the  neighboring
tissues are speedily contaminated, the lymphatic glands become enlarged, cancerous
cachexy sets  in, and the  patient eventually sinks.  In  other cases, again, the
progress, especially in the  early stages of the disease, is less  rapid, though it at
last  developes itself with  fearful violence.  In  some instances, pulsation of a
thrilling kind, with a blowing murmur, is  distinctly perceptible, especially in an
advanced  stage of the  affection, when the vascularity of the tumor is greatly
increased.
   The diagnosis of osteo-cancer has to be  made from  other tumors of bone, and
from aneurism.   The malignant growth of bone may readily be confounded with
those various forms of non-malignant disease  that are  commonly included under
Fig. 180.                              Fig. 181.
the term spina ventosa.   In making the diagnosis,  we  may reasonably come to
the conclusion that the growth is cancerous, if it occur in early life before puberty,
 Fig. 180.—Osteocephaloma of the head of the humerus with spontaneous fracture of the shaft, in which
I amputated successfully at the shoulder-joint.
 Fro. 181.—Section of tumor; upper end and head of humerus destroyed, but cartilage of incrustation
unaffected. Tumor divided by white vertical lines,—the periosteum, inside which only were the osseous
spiculoe found. 
OSTEO-CANCER.
579
or between this period and the early adult age ; if it increase with great rapidity,
and with  much  pain, especially of a lancinating character; if, to  the touch, it
present a  somewhat diffused pulpiness, with much  elasticity, great tension, and,
at points, a semi-fluctuating feel;  and more especially, if the veins  are greatly
enlarged and tortuous, the neighboring lymphatic glands involved, and cachexy
ultimately setting in.   These conditions differing from the slow growth,  the
more circumscribed character  and  more solid feel of the non-malignant tumors,
which have no tendency to the implication of neighboring structures, and which
occur at later periods of life, usually enable us to make the diagnosis.  There is
one tumor, however, viz., enchondroma,  which occasionally in the rapidity of its
growth, closely resembles the  malignant diseases.   Here the diagnosis is con-
fessedly extremely difficult, though the more  solid character, the less degree of
elasticity, and the absence of lymphatic ^enlargement,  or implication of con-
tiguous tissues, will often enable us to establish the true nature of a tumor before
its removal.
   The diagnosis from aneurism is necessarily unattended by any difficulty so long
as the sac is pervious to fluid blood, and presents the characters that are met with
in  this condition.  But if the sac have become consolidated by  the deposit of
stratified lamina, and thus have assumed the characters of a solid tumor, it may
readily enough be mistaken for a  tumor  springing from the osseous structures,
and amputation has occasionally been  performed on this supposition.   In  these
cases, however, the history of the progress of the disease will do more to elucidate
its true nature than anything else, attention  being more especially paid to  the
early symptoms of the  tumor,  when the aneurism was still filled with blood.
   Treatment.—No means are of any avail in cases of osteo-cancer, except  the
removal of the part diseased  by amputation or excision.  These operations are
however not very promising, as there are few forms of cancer in which the disease
returns more rapidly in a secondary manner, than that of the bones.  The rapidity
of recurrence will,  however, greatly depend upon the  time at which  amputation
is performed, and on the part  where it is practised.   It should always if possible
be had recourse to in the earliest stage of the disease,  before glandular or consti-
tutional infection has set in.  If the glands are enlarged, and cachexy has already
occurred,  little can be expected in  the way of ultimate cure, but yet I have known
cases in which, even under these unfavorable circumstances, the patient has made
a good recovery; his life having been prolonged for  months.   The  selection of
the line at which amputation should be performed is of great importance, and the
result will materially depend upon the judgment displayed in this.   If the limb
be removed in the continuity of the diseased bone there must necessarily be a
great probability of the very rapid return of the morbid action in the stump, and
this probability amounts to a certainty in those cases in which the disease is cen-
tral, and in which the  whole of the medullary canal and cancellous structure are
implicated, and infiltrated with cancer.  In cases of peripheral osteo-cancer, this
return may not take place; indeed, I have seen one case of the kind in which
the disease affected the lower  end of the tibia, and that  bone was amputated in
its upper third.   In this  case, after a lapse of some months, fatal recurrence of
the disease took place in the pelvic bones, but not in  the stump.  As, however,
the peripheral is more  rare than the central  form of the disease, and as there are
no means of ascertaining the precise kind  before removal, the rule, I think, should
be definite to amputate at or above the next joint;  at  the hip-joint, in cancer of
the femur; in the thigh, for that of the bones of the leg.
  The propriety of excision of bones, as of those of the face, in this disease, must
depend on whether the morbid deposit is limited to the  structures that can be
excised.   This  operation  can  rarely be  advantageously  practised in malignant
tumors, there being in  general  too great an  implication of the soft structures in
the neighborhood to make such a proceeding justifiable. 
580
STRUCTURAL CHANGES  IN  BONE.
   Sanguineous tumors are occasionally met with in bones;  according to Stanley
they are of two kinds.   1st. Those in which the tumor is composed of a vascular
substance, having the general  characters of erectile tissue, and bearing on section
a close resemblance to certain nevi (Fig. 1S2).  This tumor may be removed
without the liability to reproduction.   The second form of sanguineous  tumor
consists of a cyst formed  in the cancellous  structure of a  bone, and containing
either fluid or coagulated blood.   According to Stanley, this tumor expands the
osseous walls, and will gradually cause ulceration of the skin and profuse hemor-
rhage.  The treatment consists in the amputation of the limb, or the excision of
the affected bone, as was successfully  done  by Travers, who removed a clavicle
that was the seat of this disease.
    them from a neighboring artery; but  the  true  pulsating tumors of bone owe
    their pulsations to some inherent peculiarity of structure, which appears to consist
    either in the development of a vascular tissue of abnormal character, or else in
    the simple enlargement and dilatation of the vessels of the bone.   In the first,
    and most frequent class of cases, those in which a new tissue is developed in the
    osseous structure, we usually find them partake of an encephaloid character; a
    creamy, curdy, or brain-like, soft and very vascular mass is formed as an essential
    and principal constituent of the tumor.   This might consequently with propriety
    be termed  an encephalo-osteo-aneurisma.   This abnormal mass will be found to
    present  every shade of transition from true encephaloid cancer to a purely vascu-
    lar tissue  of  an erectile character.   In the second, and more rare form of the
    disease,  a structure is developed in the bone which originally, and, in many cases
    throughout, is  a vascular, erectile  growth, closely resembling  capillary nevus in
    its structure, composed of an infinity of bloodvessels, interlacing in every possible
    way, so  as to form a soft, reddish-yellow tumor.  In other cases, again, a hollow
    cavity is formed in the bone,  scooped  out of the cancellous  structure and filled
    with blood, which is partly liquid and partly coagulated, and into which arterial
    branches freely open.   The shell of bone  surrounding this  cavity is very thin
    and  expanded, being usually absorbed  at one  point, where it often becomes at
    last perforated.  This is the form of disease that constitutes  the  true aneurism
    of bone.
      These various kinds of pulsatory tumor of bone have  been met with in almost
.   all parts of the body; most commonly  the cancellous articular ends of the long
    bones, more  particularly of the tibia,  the radius, the humerus, and the femur,
    have been found affected.   The pelvic bones are also not unfrequently  the seat 
OSTEO-ANEURISMA.
581
of these growths, and they have been encountered in the cranium, the ribs, and
indeed in connexion with most of the osseous structures.
  In its early symptoms an osteo-aneurisma closely resembles the ordinary forms
of spina ventosa, being oval in shape, uniform, and elastic to the touch, growing
slowly, without enlargement of  the veins or discoloration of  the  skin, characters
that it possesses in common with most other tumors of  bone.  The special  signs
by which it is individualized, however, are its pulsation and  bruit: the pulsation
is very distinct,  superficial, and commonly of a thrilling  character; in  other
cases it is directly impulsive, and distinctly expansive; the bruit is most usually
soft and blowing, but not unfrequently harsh,  loud,  and whizzing.  In  some
cases the bruit is absent, though the  pulsation continues distinct;  this, according
to Nekton, is most frequently the case in true osteo-aneurisma.  In the pulsating
encephaloid form of the disease, I have  heard the bruit peculiarly loud, rough,
and superficial.  On compressing the main artery leading to the part of the limb
in which the tumor is situated, all  movement  and bruit commonly cease in it,
and it lessens in  size.   By pressing upon the  tumor when it is thus  diminished,
it will commonly be found  to  have  a bony margin, with  a central depression,
more especially in those cases in which there is  no encephaloid entering into its
composition,  the growth being apparently composed of erectile and expanded
osseous tissue, filled with fluid blood.  In some cases, however, the tumor is fed
by several  arterial branches, which  may be felt distinctly pulsating  under the
skin.   This is more particularly the  case when it occurs upon the bones of the
pelvis and the scapula, and then the bruit and pulsation cannot be made to cease
in it.   All these signs are commonly somewhat intermittent, appearing perhaps
in the earlier stages of the disease, and disappearing as it advances;  or the reverse
may occur, the pulsation and bruit becoming distinct as the disease  increases in
size and meets with more resistance  in its outward growth.
  Diagnosis.—It is of considerable importance in many cases to diagnose the
different forms of pulsating  tumor of bone from one another,  some being  of a
truly cancerous character, whilst others appear to consist of simple expansion of
the vascular  element of the bone, with atrophy of its osseous substance, and con-
sequently the prognosis also in the  two conditions is very different.  The true
osteo-aneurisma has  so many signs  in common with the  pulsating  encephaloid
tumor of bone, that in many cases it is almost impossible to effect the diagnosis;
yet it is well  to bear in mind that the malignant form of the disease is not un-
frequently multiple, occurring,  with pulsation and bruit, in  more situations than
one.  Thus  I  have  seen growths of this kind, with  their signs well  marked,
springing both from  the pelvis and  ribs.  The true osteo-aneurisma is only met
with in the articular ends of long bones, whereas the malignant disease, though
commonly occurring in these situations, is also frequently found seated in other
parts of the body.  Besides these, there are two conditions which, in  many cases,
will enable the surgeon to determine that the pulsating tumor  is an  osseous
aneurism;  viz., the absence of all  bruit, though  the  pulsation be distinct, and
the detection by firm  pressure, and after the tumor has been diminished by the
compression of the artery leading to  it, of an osseous margin around its depressed
centre.
  From ordinary aneurisms, the diagnosis of these affections is, in many cases,
attended by almost insuperable difficulties.  So great  are these, that there are
many cases on record  in which the  most experienced surgeons of the day have
ligatured arteries for  tumors that were  supposed to be aneurismal, but which
have turned  out to be pulsating growths connected with  bone.  The principal
points to be attended to in effecting the diagnosis, are the situation of the tumor,
which may occur away from the ordinary sites of aneurism,  in parts of the body
where  there  is no vessel large  enough  to give rise to such a disease,  as for
instance, about the head of the fibula or the side of the pelvis.  Then, again, its 
582
STRUCTURAL CHANGES  IN  BONE.
 incorporation with the subjacent bone, the want of a distinctly limited and circum-
 scribed outline, and the existence in many cases of plates of bone in the wall of
 the tumor, giving rise, perhaps, on pressure, to the peculiar rustling or crackling
 sound characteristic of bony growths, will enable the surgeon to come to a conclu-
 sion as to the true nature of the tumor.   In this he will be further assisted by its
 giving on compression a soft, doughy, or spongy feel, or appearing as a depression
 surrounded by an osseous margin.   In many cases also the less impulsive charac-
 ter of the beat of the tumor, the peculiar shrill and tremulous whizz in  the pul-
 sation and bruit, will throw much light on the nature  of the disease.   But yet
 it cannot be doubted, that when  tumors of this kind occur in some of the ordi-
 nary  situations of aneurism, as about the brim of the pelvis, and in the popliteal
 space, that the diagnosis is surrounded with difficulties that no amount of surgi-
 cal skill or  tact may be able to overcome.   From ordinary tumors of bone, the
 existence of pulsation and bruit will always suffice to distinguish the growths
 under consideration.
   Treatment.—Incisions into a  pulsating tumor of  bone,  or any  attempt to
 remove it without its osseous connexions, is clearly contrary to the rules of good
 surgery; and when  it has been practised, the hemorrhage has  been of the most
 alarming and dangerous character.  Besection has been had recourse to in some
 instances, as when the disease has been seated on the cranial bones, but without
 success.   Liston, in a tumor of this kind  growing from the scapula, which he
 called "an ossified  aneurismal  tumor of the  subscapular artery/' excised the
 greater portion  of the  bone from which it sprang; but  fungous growths reap-
 peared in the wound by which  the patient was at last exhausted.   AA'hen the
 disease has proceeded to such an extent as to produce extensive alteration in, and
 destruction of the tissue of the bone affected, amputation of the limb is the only
 resource left to the surgeon.  This  operation is also called for in those cases, in
 which the disease returns  after  other means, such as the  ligature of the artery,
 have  been practised.  In these cases  if the disease partake at  all  of the ence-
 phaloid character, the limb must be  removed at a point above the affected bone.
   The result of  the ligature of the main artery leading to the tumor depends
 greatly upon the nature of the growth.   AVhen it is partly  composed of ence-
 phaloid or other solid tissue, but little good can result from this proceeding, the
 tumor continuing to increase by an inherent growth, that will continue as long as
 the vitality of the limb is maintained; and we accordingly find  that in all such
 cases  in which this operation has  been practised,  the progress of the tumor has
 either not  been  retarded, or if  the  pulsations have been stopped, and its  size
 lessened for  a  time, the activity of the  symptoms has speedily returned, and
 amputation been  rendered necessary.  When,  however, the tumor has partaken
 more  of the characters of true osteo-aneurisma, then a more favorable result has
 followed the ligature of the main artery of the  limb.   In a case  of this kind
 seated in the radius in which Boux ligatured the brachial artery, a complete cure
 resulted.  The same  also occurred  to Lallemand; and in a patient of Dupuytren's
there  was no return of the disease for six years, when it recurred, and amputa-
tion became  necessary.   These  results are  sufficiently satisfactory to justify the
surgeon in having recourse to the  ligature, or perhaps the compression of the
main  artery of the limb, in those cases in which the tumor could be  ascertained
not to partake of the nature of encephaloid. 
SYNOVITIS.
583
                         CHAPTER  XLIII.

                         DISEASES OF JOINTS.

   The various joints of the body may become the seat of inflammatory affections
of an acute or chronic character, of strumous disease, or of various other morbid
conditions, such as more or less permanent rigidity, or anchylosis, the formation
of foreign  bodies within their cavities, or their malignant degeneration.   In
studying these various articular affections, it must be borne in  mind that a joint
is composed of a number of different tissues, of synovial  membrane, cartilage,
ligament, bone,  and capsule,  or investing  fibrous expansions.   In any  one of
these structures the disease may primarily begin, though eventually the morbid
action often spreads to  other tissues- besides that which was originally involved.
The merit of having been the first to point out the true mode of studying these
affections in reference to the different structures in which they have originated,
and to have set  aside that coarse pathology which, under  the general  terms of
"arthritis" and of "white swelling," confounded together these various  dis-
eases, is certainly due to the labors of Sir B. Brodie.

                                SYNOVITIS.
   Inflammation of the synovial membrane,  the  most  common perhaps of all
the articular  affections, may be acute, subacute,  of chronic in its characters.
AA7hatever form it assumes, synovitis usually results from  exposure  to cold, espe-
cially in rheumatic  or syphilitic constitutions.    In these cases it  commonly
happens  that more joints than one are implicated at the  same time; and  the
affected articulations are most frequently those that are most exposed  by  the
thinnest covering of soft parts, and by being especially subjected to transitions of
temperature, such as the  knees and ankles.  Injuries of joints, as blows, bruises,
wounds, or sprains, will  also  frequently occasion  this  inflammation; but when
arising from this cause, it is seldom of an unmixed kind, being usually associated
with  inflammation of the other textures that  enter into  the composition of the
articulation.
   As uncomplicated acute synovitis is never a fatal affection, it is seldom that we
have an opportunity of studying its pathology.   It would, however, appear from
the result of the examination of some cases, as well  as from the experiments of
Richet, Bonnet, and others, who have induced  traumatic synovitis in animals,
that there is in the first instance an inflammatory congestion and  vascularity of
the membrane,  attended  by loss of its peculiar satiny polish.   The synovia is
then increased in quantity, as well as altered in quality, becoming thin and serous
and after a time intermixed with plastic matters that are  poured out with it.   If,
the disease progress favorably, these products are more or less completely absorbed.
If, however, as is more rarely the case, the inflammation goes on to an unfavora- *
ble termination, the vascularity and swelling of the synovial membrane increase,
until at  last it becomes so turgid and distended with blood and effused fluids,
that a kind of chemosis of it results; a thin, purulent-looking fluid, composed of
granular corpuscles floating in a serous liquid, is poured out, and disintegration,
with thinning and erosion of the cartilage, and probably complete destruction of
the joint, ensues.  In  other  cases, granulations are thrown out on the looser
portions of the membrane, which, becoming  injected with bloodvessels, consti-
tute fringed and villous membranous  expansions, lying upon the subjacent,  dis-
integrated,  and eroded cartilage.
  The most frequent  termination  of synovitis is in  resolution;  the effused 
584
DISEASES  OF  JOINTS.
matters being absorbed, and  the joint, though weakened, gradually recovering
its functions.  Occasionally, as the result of long-continued inflammatory action,
plastic matter is thrown  out, that either gives rise to warty vegetations or con-
cretions, or else to  permanent  stiffness of the articulation.   More rarely still,
suppurative action is  set  up in the joint.   AVhen this happens, it  is almost
invariably the result, either of traumatic synovitis, or  of the inflammation of
the articulation  in cases of pyemia, in which affection  it is not  uncommon to
find several joints filled with  puriform  fluid, and  presenting traces of synovial
inflammation.
   The symptoms of synovitis consist of pain and heat of the joint with disten-
sion and fluctuation of it.  If it  be large  and exposed, the  pain is severe,
especially at night, being greatly  increased  by moving or  pressing upon  the
articulation; it is  usually  sharp,'but when the disease  occurs in rheumatic or
gouty  constitutions, of a gnawing  character.  In purulent synovitis  occurring
from pyemia, it is usually  very superficial, indeed almost cutaneous.  On laying
the hand on the joint  it will be felt to be hot.
   The swelling  of the  affected joint is considerable, and evidently depends  on
the accumulation  of fluid within the synovial sac, the extreme  outline of which
is rendered apparent by the tension to which  it is subjected.   Thus in the knee
it rises up high  in the thigh  under  the tendon  of the  quadriceps extensor.
There is but little if any effusion  into the surrounding tissues, and  hence -the
outline of the joint can be distinctly felt,  and undulation perceived in it.  The
limb is usually semiflexed, as  giving the patient  most ease.   The constitutional
febrile  disturbance is  tolerably severe, especially if the  affection occur in a
rheumatic  constitution.
   The disease, at  first acute,  may terminate in a subacute or chronic form; or
subacute at its  commencement, may  fall into  a chronic condition.   Chronic
synovitis is characterized by all  the symptoms of the acute variety of the disease,
but in a less severe degree.  The swelling and weakness of the joint are  the
most conspicuous  local conditions.   In some cases, the swelling from  accumu-
lated serous fluid  is so considerable as to  constitute a  true dropsy of the joint,
hydrarthrosis.  This accumulation of fluid, partaking in various  degrees of the
characters  of serum and synovia, is usually preceded or accompanied by evidence
of synovial inflammation; but,  though this generally happens, it  is not invaria-
bly the case.  Bichet, in particular, has recorded instances from  which it would
appear that inflammation is not a necessary, or invariable accompaniment of the
affection, the synovial membrane being indeed preternaturally white, and looking
as if it had been  washed or soddened;  and though these cases  are  rare, those
that commonly present themselves to the surgeon being of a decidedly inflam-
matory character, yet  their occasional occurrence  is sufficient to establish  the
existence of a passive  as well as an inflammatory form of the disease.
   The presence of an abnormal quantity  of fluid in the joint is  always readily
perceived by its fluctuation and undulation, by the deformity that it produces,
and by the peculiar shape that it communicates to the part.  Thus in the knee,
which is the most common seat of this  affection, the patella will  be felt to float,
as it were, on the subjacent  liquid; and the capsule of the joint projects dis-
tinctly in three situations, viz., on either side of  the  ligamentum patellae, and
above that bone.   In the  elbow there is a soft and fluctuating swelling on either
side of the olecranon, and under the tendon of the triceps, and in the shoulder
there  is general roundness and distension of the articulation.  It is said,  that
in some cases, the distension  of the  joint has been so great, that the synovial
membrane has been ruptured,  and the fluid poured forth into the  surrounding
cellular tissue.  In these  cases, it is probable, however, that some destructive
change in  the synovial membrane preceded its rupture.
   The chronic subacute synovitis and hydrarthrosis, usually terminate favorably; 
SYNOVITIS — HYDRARTHROSIS.
585
but, occasionally,  more particularly in  strumous constitutions, the disease runs
on to suppurative destruction of the joint.   This, however, is  rare,  but yet its
occurrence, in some instances, should make the surgeon careful not to confound
the fluctuation of the serous accumulation with that of the  purulent collection.
In the latter instance there will always have been  the precursory symptoms of
inflammation.
  The treatment of synovitis depends  partly on the severity of the  symptoms,
and partly on the cause of the disease.  If the inflammation be acute and arise
from injury, it requires to  be  actively treated by venesection, if the patient is
young  and strong; but in all instances  by the free  and repeated application of
leeches to the  inflamed articulation, followed by fomentations and accompanied
by perfect rest of the part on a  splint, or on pillows properly arranged.   In some
instances the cold irrigation will be found  to be of essential service.  At the
same time saline purgatives with antimony, must be given, and the patient kept
on a low diet.
  If the disease is of a rheumatic character, leeches must be applied,  followed
by hot fomentations  and rest of the part in  the elevated position; at the same
time colchicum, with salines, if there be much febrile  disturbance, and if there
be much pain at night, in combination with Dover's powder should  be  adminis-
tered.   In  some  instances, where  colchicum disagrees, great benefit will result
from the administration of Dover's powder  and calomel, in small but  frequent
doses.   AVhen the disease is of syphilitic origin, leeches are not often required;
but the application of blisters, followed by calomel  and opium, will  be  attended
with marked success.
  AVhen the synovitis is of a subacute or chronic character, the same principles
of treatment must be adopted, modified according to the intensity of the affec-
tion.   In these forms of the disease, rest is  perhaps the most important element
in its treatment, everything else proving nugatory  unless this  be attended to;
the limb is usually best fixed by leather splints, buckled on  so that they may be
removed in order to  make  the necessary  applications  to  it.   In  these  cases
repeated blisterings over the  whole of the joint  constitute perhaps the most
useful  local means that we  possess; in a more advanced  stage, counter-irritation
by  means of stimulating embrocations, together with douches, either  of warm
sea-water or of some of the sulphurous springs, such as those of Harrowgate,
Aix, or Bareges,  will prove most useful; and when all inflammatory action has
been subdued, and weakness of the joint merely is left, this should be  properly
strapped with soap-plaster, spread upon leather.  Amongst the internal  remedies
likely to be of most service, may be mentioned the iodide of potass, either alone,
or in some bitter  infusion.
  In hydrarthrosis, rest and repeated blistering will usually promote the removal
of the fluid.   In addition to this, the employment of pressure and friction, with
absorbent remedies,  as the  iodine or iodide of lead  ointment, conjoined  with the
internal administration of salines and the iodide of potass will often  procure the
absorption of the fluid.  If these means fail, we have a very powerful means of
cure at our command in the injection of the joint with tincture of iodine.  This
[dan, a sufficiently bold one, has been much employed in Paris  by Jobert and
Velpeau, and  in  Lyons, by.Bonnet.  These surgeons use the tincture diluted
with two or three parts of water.   A small trochar is introduced into the joint, a
moderate quantity  of the  serous fluid is let out, but not all, and then  a corre-
spoding quantity  of  the iodine solution is thrown in; and after being left for a
few minutes, allowed to escape.  Inflammation of the joint, which is a necessary
result  of this  procedure, comes on.   This is then  treated by ordinary antiphlo-
gistic means, and, according to  the statements of the French surgeons, has in no
case been followed  by any serious  consequences, but  in several  instances by a
complete cure without anchylosis;  a new and healthy action having been im- 
580
DISEASES  OF  JOINTS.
 printed on the synovial membrane.   This mode of  treatment does not appear as
 yet  to have  met with much support in this country, yet it certainly deserves a
 trial, though  it should not lightly be had recourse to, as it is  evident  that the
 induced inflammation might exceed  the expected limits.   After dropsy of the
 joint has been removed, the articulation is usually  left weak for some length of
 time, in consequence of  the stretching to which its  ligaments have been sub-
 jected;  here cold douches and  an elastic bandage will constitute the best modes
 of treatment.
                                 ARTHRITIS.

   By arthritis is meant inflammatory disease of an acute or chronic kind, of the
 whole or greater part of the structures that enter into the formation of a joint.
 This affection may commence in the synovial membranes, and then spread to
 the other articular tissues, or it may begin in the cartilages or bones, and in some
 rare instances it may perhaps take its origin in  the fibrous  capsule surrounding
 the articulation; whether it can ever commence in the  ligaments is a question
 that is not as yet satisfactorily determined.
   In arthritis, the  principal changes are undoubtedly  found to take place in the
 cartilages, at the same time it must not be supposed that all morbid appearances
 that are found in these structures are the result of  inflammation, as erosion and
 absorption of their tissue  may take place, independently of any diseased action.
 The long-continued disuse of a joint, as in the treatment of  fractures, may occa-
 sion this; and in old people it is very common to meet with a porcellanous or
 ivory-like deposit on  the  articular ends  of the bones, which, however, does  not
 prevent the joints being used, though it may occasion stiffness and pain in them.
 According to Queckett, this porcellanous deposit is  of two kinds,  one consisting
 of unorganized earthy matter, the other, of true bone,  having the Haversian
 canals filled with phosphate of  lime.
   In acute arthritis, the  cartilages  are usually found ulcerated and  eroded in
 patches of  varying size, exposing bone, which is rough and vascular.   The re-
 mains of the cartilage are  softened, inelastic, opaque, and thickened, and separate
 easily from the  subjacent  bone,  which can be felt rough  and grating.   The
 synovial membrane is usually much thickened and vascular; the vascularity being
 most  distinct about those  parts where the erosions  and grooves in the cartilage
 are deepest, and  often assuming a dentated  or fringed  appearance.  In other
 parts, especially about the circumference of the joint, masses of  plastic matter
 are deposited  underneath  and  upon  the synovial membrane; these are smooth
 and semi-transparent, having a somewhat fatty  look;  the ligaments are  relaxed
 and  softened,  and  the interior of the joint  filled  with thin, flaky, and light-
 colored  pus.   The capsule and the  cellular tissues around are thickened, and
 either infiltrated with pus, or clogged with the same kind of plastic matter  that
 is seen in the interior of  the joint.   The articular end of the bone is enlarged,
 soft, and vascular;  and in strumous  cases may be the seat  of tuberculous infil-
 tration.
  The changes that take place in the cartilage in this disease have excited much
 attention amongst surgeons, and a good deal of difference of opinion exists as to
 the mode in which they  are induced.   Many surgeons  hold the doctrine  that
 cartilage being extra-vascular, the changes that take place in it are accomplished
 through the medium  of the contiguous synovial membrane  or bone, and conse-
 quently are  secondary to  disease  of these tissues.   That the cartilage may be,
 and very frequently is, diseased by inflammation, primarily set up in the synovial
 membrane or bone, is doubtless the case, but that it is exclusively so, can I think
scarcely be conceded.  Aston Key advocated the doctrine that a peculiar disease
was set up in the synovial membrane, by which a fimbriated or  fringed vascular
network or tissue was formed, by means of which  the cartilage was absorbed; 
             PATHOLOGY AND  CAUSES  OF  ARTHRITIS.          587

and that as this membrane extended, so did the removal of the cartilage  go on.
That an appearance of this  kind in inflamed joints is of common occurrence, is
doubtless the case, but Goodsir has shown that Key erred in attributing the dis-
integration of the cartilage to  this membrane ; for he states that a fibrous tissue
forms in a diseased joint as the result of the  disintegration  of the cartilage, and
that this, which is connected either with the synovial or osseous surfaces, speedily
becomes vascular.   So far, therefore, from being the organ by which the carti-
lage is removed, it is the  result of  prior disease in this structure.  That  inflam-
mation of the subjacent bone occasions in many cases  loosening of the encrusting
cartilage, with separation  and  ultimate disintegration of it, cannot be  doubted.
In cases of diseased joint removed by amputation, I have often  observed that the
cartilages are separated from  the  subjacent bone by a bloody fluid, and being
thinned, are at last perforated by a small aperture; the portion that is separated
being detached  to a considerably greater extent,  and having the under edges
bevelled off towards the aperture.
  That cartilage is susceptible  of primary change of  the nature of inflammation
or ulceration, induced by the action of its own vessels, is the opinion of Brodie,
Mayo, and  Liston, all of whom have observed true vascularization of  cartilage.
This condition, however, is extremely rare, and is  certainly not one of the  more
common forms of joint  disease, seldom occurring  except  in the more chronic
stages of arthritis.
  These, however, are not the sole changes that take place in cartilage in ar-
thritis ;  the observations of G-oodsir, of Bainey,  and  of Bedfern, all point to the
fact that cartilage, like other extravascular tissues, is subject to other transforma-
tions, independent of the prolongation of vessels into it.  The changes that ensue
are of the  following kind:  The  cartilage-cells  enlarge, become rounded and
granular-looking, and instead  of containing  two or three nuclei, a considerable
number are inclosed in the cell-wall;  eventually these corpuscles break up, and
are disintegrated.   The matrix of  the cartilage now softens,  and, according to
Redfern, splits up into fibres  or bands, which become nucleated.  A species of
fatty  degeneration,  also, as pointed  out  by Bainey, takes place, and helps to
soften and  break down the structure of the cartilage.   In the more  advanced
stages of disease of  cartilage,  we find masses of porcellanous deposit attached to
the ends of the bones in plates and layers, taking the place of the eroded  carti-
lage.
  In  other cases, again, a soft, pulpy, and  vascular fibro-plastic deposit  of a
grayish, ashy, or reddish-brown color, with whitish streaks of a firmer material,
running through it in various  directions, takes the place of the cartilage that has
been removed, or that has undergone fibro-cellular degeneration.   On  examina-
tion under the microscope, this will be found to be composed of plastic material,
with  cartilage-corpuscles  intermixed, and  with the subjacent bone in  a state of
disintegration and softening.   This condition of joints I believe to be analogous
to the " pulpy degeneration of the  synovial membrane" of Brodie.   It would
appear, from the microscopical  examinations  that I have made  of this  material,
in various  cases  after  the removal of joints,  to which my attention  was  first
directed by Dr. Quain, as occurring in a patient of his whose elbowjoint I excised,
that it is either fibro-cellular degeneration of the cartilage, or an imperfect attempt
at repair set up in the articulation after the removal of the  cartilage by previous
disintegration and disease.   On making a vertical section of the surface  of the
diseased  articulation in the case  alluded to,  it was found that the pulpy and
villous substance covered the bone to the thickness of a line and more in some
parts.   The bone was  found  to have its cells filled with  oil-globules, but sur-
rounded by tolerably healthy osseous tissue, showing the usual lamina) and  bone
corpuscles.    Nearer the  diseased surface  the laminas and corpuscles became
less distinct, and, still nearer, the  cells of the bony tissue  appeared to be sur- 
588
DISEASES  OF  JOINTS.
rounded merely by a layer of fibrous texture, in which irregular particles of bone
were observed.  These particles, which  were elongated, irregular in  form, and
rounded off at the angles, were very aptly compared, by Dr. Quain, to crystals
in a state of  solution.   At  the diseased surface, the place of the cartilage and
synovial membrane was occupied by a fibrous texture  abounding  in cells, larger
than pus-cells, nucleated and spherical, containing  numerous granular particles.
Irregular masses of cartilage undergoing the  same  process  of softening as the
bony particles already mentioned, appeared in this fibrous texture.  The morbid
appearances found in this case were so characteristic that they may be  taken as
the type  of this  peculiar morbid condition, which I have  since repeatedly met
with in other articulations  besides the elbow, more particularly those of the
fingers and the knee, and which always, I believe, constitutes an incurable form
of disease.  I have only met with this condition in  instances  in  which the
articular affection has been of very old standing, and fallen  into a truly chronic
state.
   When repair takes place in a joint, the cartilages of which have been eroded
or destroyed, it is by the articular ends  of the  bones becoming  connected, and
the surface from which the cartilage has been removed filled up by fibro-cellular
tissue, forming a kind  of cicatricial material that leaves the joint permanently
stiffened.   In other cases,  again,  porcellanous  deposit takes the place of the
eroded cartilage, and, in some instances, the  exposed osseous surfaces may grow,
or become soldered together, forming a permanent anchylosed and immovable
state of the  articulation.  Under  no circumstances  does  cartilage, when once
destroyed, become regenerated.
   Causes.—It not unfrequently happens that  the  arthritic disease is the result
of a morbid condition of the articular ends of the long bones, or  of those short
bones that  enter  into  the  formation of the joint;  this  we especially see in
diseases of the foot, of the  elbow, of the knee, and  hip;  but it is a condition
that, I believe, may occur in any joint.   The bones usually  become, in  the first
instance, the seat  of tuberculous infiltration; this runs into unhealthy suppura-
tion, which gives  rise  to caries  and limited necrosis;   as  the diseased action
approaches the  articular surface,  the  incrusting  cartilage becomes loosened,
detaches,  and at  the  same  time gradually disintegrates, nutrition  in  it being
arrested or  modified by the  morbid state of the subjacent bone.   When once
the cartilage  becomes  affected, the whole  of the interior of the joint speedily
suppurates,  and is  destroyed.  In other cases, inflammatory congestion,  but
without the formation of tuberculous matter, takes place in  the articular bones,
which becomes somewhat expanded, and then, without any suppuration occurring
in  the  osseous  structure, the  cartilage gradually  separates  or  peels  off, and
becomes softened and necrosed.   This condition is often met with in disease of
the tarsal articulations.
   Diseased action  is very seldom primarily set up in the ligaments of the joint,
though  these structures commonly become  elongated, softened, and  destroyed,
as a consequence of other forms of articular disease.   But though primary in-
flammation of the ligaments is so rare an affection as to have been denied by
many, yet it  certainly  does  occasionally occur.  This is  especially  seen in the
hip-joint, where the inflammatory  affection may commence  in the ligamentum
teres;  illustrative  of which there is a very beautiful  model in the  University
College Museum.
   Inflammation may commence in the fibrous capsule of the joint: this wefindmore
particularly to be the case when the  affection is of a rheumatic  character; in
these cases inflammation, running into suppuration and  slough of this structure,
will commonly spread to the internal  parts.   In some  instances, this  form of
disease  gives  rise  to  the deposit  of masses and layers of bone in the cellular
structures outside  the articulation. 
SYMPTOMS  OF  ARTHRITIS.
589
  Arthritis commonly results from wounds of joints, or injuries, such as  sprains
and fractures, occurring in their vicinity, more particularly in young people, and
in those of a lymphatic constitution.   It also occurs as a not unfrequent  accom-
paniment of pyemia, and of some of the morbid conditions of the puerperal state.
Any joint may be affected, but those certainly are most predisposed to inflamma-
tion  that are subjected to the greatest amount of movement.   Arthritis not
unfrequently occurs as a consequence of scarlatina, and  I have especially seen
the knee-joint affected in a destructive manner after this disease.  In some forms
of albuminuria there is also a great tendency to inflammation of the joints, and
indeed I have so frequently seen that form of renal dropsy which follows scarlet
fever accompanied by serious  inflammation of some  of the joints, as almost to
look upon one condition as the sequence of the other.
  The symptoms of arthritis  that are most marked are the pain, heat, swelling,
and peculiar position of the joint.  The pain is often severe, tensive, and throb-
bing; so acute is it sometimes that the  patient screams  with  agony, he cannot
bear the bed to be touched, the room to be shaken, or the  slightest movement
communicated to the limb, any attempt at examination of the joint in such cases
being attended with insupportable agony.   There are usually nocturnal  exacer-
bations, and the pain is  commonly referred with especial severity to  one particular
spot in the joint.   Thus it is generally  felt at  the inner or under  side of the
knee-joint, and at the outer aspect of the hip.  The heat of the diseased joint is
considerable, and is often  accompanied with more or less superficial redness.
The swelling is uniform, involving the  whole of the articulation, and not pro-
jecting at certain parts of it,  as when the  synovial membrane  alone is affected.
It is generally not very considerable, and  has a soft and doughy,  rather than a
fluctuating,  feel.   As  the disease advances, however,  the swelling generally
increases suddenly, and to a  considerable extent, either  in  consequence of the
irritation of the synovial membrane, or of the accumulation of pus within the
joint.  The position of the affected  limb is peculiar, and that attitude in insen-
sibly adopted in which the patient will have the greatest amount of ease.   Thus
the knee is  semi-flexed and  turned  outwards, the thigh is adducted, and the
elbow is bent.   Spasms or startings of the limb, often of a very sharp and painful
character, come on at times, more particularly at night.
  The constitutional disturbance is very severe, and of an actively febrile type.
As  the disease  progresses, suppuration takes place within the  joint, which
becomes hot and red, with a good deal of throbbing pain, and at last, fluctuation
is perceived where  the coverings are thinned.   In some cases the  suppuration
occurs with very great rapidity, and luxation of the head of the bone takes place.
In other cases an abscess forms external  to the articulation,  and extensive puru-
lent  collections become  diffused through the limb.  As the joint  becomes loos-
ened by the destruction of its  ligaments, the bones become mobile, and  grate
against one another where the investing cartilage has been removed, thus giving
rise  to very severe  suffering.  But though abscess, either  within  the joint or
external to it, usually forms when the bones grate and the cartilage disintegrates,
yet it occasionally happens that these conditions may take place—those symptoms
that are indicative of the erosion of the cartilage, such as painful startings of the
limb, grating, and preternatural  mobility  of the joint,  ensuing—and  yet  no
abscess forms; all the symptoms subsiding under proper treatment, and the joint
recovering, though perhaps with a certain degree of anchylosis.  If suppuration
take place, the constitutional  disturbance usually partakes of the irritative  type,
the patient suffering severe pain,  and being worn out by want of  rest.   Hectic
may occur, and death from exhaustion  and  irritation, unless the  diseased part
be removed; in other cases it falls into a state of chronic thickening, with per-
haps fistulous openings  leading down to the diseased structures, and in some of
the more favorable instances the patient  may recover, with a permanently  rigid
joint. 
590
DISEASES  OF  JOINTS.
   In the treatment of acute arthritis, perfect rest of the articulation  is of the
first moment.  Unless  this be  secured no after treatment can be of any avail,
The limb should be comfortably supported on pillows, or laid  upon a well-made
and softly-padded leather splint; at the same time blood  should be freely taken
away by cupping or leeching the affected  part, and this local depiction must be
followed by assiduous fomentations.  In the acute stage of the disease the internal
remedy from which the most essential service may be derived is the calomel and
opium pill (gr. ij. and gr. .) every fourth or sixth hour, at the same time that a
strict antiphlogistic regimen is persevered in. After the violence of the symptoms
has been subdued the  joint may be repeatedly blistered; but in many instances
most benefit will be derived by  the application of the moxa, or of caustic issues
in the vicinity of, but not too immediately upon, the inflamed articulation.  Some
surgeons recommend scoring the joint with the  actual cautery  and speak highly
of its utility; but of this means I have no experience.   For counter-irritants to
be of any use, they must be employed before suppuration has set in; I believe
that it is only torturing the patient unnecessarily to have recourse to these agents
when once pus has formed in the articulation.   In order that full benefit should
be derived from this plan of  treatment it  must be persevered  in steadily for a
considerable length of time, and should be conjoined with a moderately antiphlo-
gistic and alterative treatment.   AVith  this view, the bichloride of mercury in
doses of from \ to ^V? of a grain  may be advantageously given with the compound
decoction of sarsaparilla, or, if there be much debility, with the compound tinc-
ture of bark, nourishment, and  even stimulants  being conjoined with it, in pro-
portion to the advance of the debility.   AVhen  suppuration has taken place in
the joint, more particularly if the skin covering  it be reddened at any one part,
the abscess should be freely opened.
   In some cases, even when abscess has formed, the joint being  perfectly loose
and grating, by perseverance  in the  above plan of treatment, both local and con-
stitutional, a good and  useful  limb has resulted.  And although there be mobility
and  grating, provided  there  be no  sign of abscess, the  surgeon should never
despair of obtaining a satisfactory result.
   The practice of  making free  incisions into a  suppurating joint, as advocated
by Mr. Gray,  is a great improvement on the former method of merely puncturing
it.   If a small aperture only is made, air  gets admixed with the pus, which
becomes  offensive and  irritating, and  being  unable to escape freely,  sinks to the
bottom of the articulation with debris  of the disintegrated cartilages, &c, giving
rise not  only to much  local mischief, but to proportionate constitutional distur-
bance.   By freely laying the  joint open all this is prevented;  exit is given to
the pus through one or two incisions that extend the whole length of the articu-
lation ; no constitutional disturbance can occur from pent-up and putrid matter,
and the joint has a better chance of healthily granulating.
   After  the  formation of abscess the prognosis is more unfavorable, when  large
joints such as the knee or hip are affected; or, when those are  implicated which
are important to life, such as  the articulations of  the vertebra;;  so likewise,  when
the articular ends of the long bones are affected it is seldom that  the joint can
recover itself, as we have caries  or necrosis complicating its disease and keeping
it up.  AA7hen the articulation is very sinuous as  in the carpus, or when a number
of small  joints communicate with one another, if not directly by synovial mem-
brane, at all events indirectly through the medium  of ligament and  of fibrous
tissue, as in the tarsus, a cure  can scarcely be anticipated.   In  all  these cases,
hectic and great constitutional irritation usually  come on; or the joint becoming
useless or cumbersome, its removal must be practised either by excision or am-
putation.
   When an inflamed joint appears to be disposed to undergo a cure, the repara-
tive action in it by the  formation of  anchylosis must be facilitated by keeping it 
NATURE  OF  WHITE  SWELLING.
591
  in a proper position, such as will  be most useful to the patient  in after-life;  the
  straight one for the knee and hip, and the semiflexed for the elbow.   At  the
  same time it may be useful to strap the joint firmly in the  proper position in the
  way recommended by the late Mr. Scott, when it is the knee that is affected, or,
  when the hip or elbow are implicated, fixing it well by means of starch bandages.
  Scott's plan of treatment consists  in spreading on pieces of lint, the strong mer-
  curial ointment, to every ounce of which 3j of camphor has been added; pieces
  of soap-plaster spread upon leather are then cut of a proper length  and breadth,
  and the joint firmly and accurately strapped up, the limb having previously been
  bandaged as high as the Joint that  is  strapped.   This dressing may be left on
  for a week or  two  until it loosens or  gives rise to irritation; over the whole a
  starch bandagemay be applied.  In many cases, I have found it advantageous to
  strap up the joint with a plaster composed of equal parts of the emplast. ammo-
  niaci cum hydrargyro and the emplast. saponis or belladonna). These applications
  not only fix the joint and promote the absorption of the plastic matter  that is
  deposited  around it, but by acting as gentle counter-irritants remove the remains
  of the inflammation that may be going on within it.

                      STRUMOUS DISEASE OF JOINTS.
   By "white swelling" is meant a very chronic form of arthritis  occurring in
  scrofulous subjects.  These diseases present peculiar characters;  the affected joint
  is enlarged and rounded, the  bony prominences being effaced by a uniform,
  doughy, semi-dastic, or  pulpy swelling, occupying the interstices of  the articu-
  lation.  The  integuments covering it  preserve their white color,  and there is
  usually but little pain felt except  in moving the limb, and the position is always
  that in which the  patient has most ease, the joint  being generally semiflexed.
  There is a degree of stiffness and rigidity in the joint, and in consequence of the
  wasting of the limb from disuse, the affected articulation  appears more swollen
  than it really is.
   This condition has not in many cases any definite  starting-point,  but appears
 slowly to supervene upon some slight injury, as a twist, or blow, or strain; at other
 times it  commences with a subacute synovitis, assuming its peculiar  characters
 by occurring in a strumous  constitution, and  is  especially liable to happen in
 children and females.  The general health does not appear at first to suffer much,
 but as the  disease advances symptoms of irritation and hectic declare themselves!
 This affection is always characterized by a special tendency to run on  to suppu-
 ration.  This tendency may be checked by proper treatment, but'in the "Teat
 majority  of cases it at last passes  into this  condition.   The joint has  exacerba-
 tions of intercurrent attacks of inflammation, the limb swells and becomes cede-
 matous, and abscess finally forms in and around the joint; often around, before it
 takes place within.   AVhen this is opened the  constitutional symptoms become
 more severe, hectic  speedily sets  in, and and  strumous deposit  takes place in
 other organs, such as the lungs, which at last carries off the patient.
   In this affection  the tissues immediately external to the joint, as the fibrous
 capsule and the investing cellular membrane, are always much thickened  and
 infiltrated with fatty and plastic matter; this gelatinous infiltration havino- a great
 tendency to run into unhealthy suppuration greatly adds to the mischief that
 ensues.  In the interior  of the joint we find much the same kind  of changes
 that have been just  described as  characterizing acute  arthritis; the cartilages
 have lost their polish, their elasticity, and their firm hard section, bein- softened
 eroded, and disintegrated;  the synovial membrane is removed in parts  and  is
 here and there vascularized; in others it is replaced, together with the cartilages
 either by large quantities of the semi-transparent gelatinous-looking fatty deposit'
 or by the  pulpy gray  or  brownish fibro-cellular material  that  is met with in
arthritis.   The ligaments are inflamed, softened, and destroyed, being converted 
592
DISEASES  OF  JOINTS.
into somewhat  similar materials;  and the interior  of the joint is filled with a
purulent-looking synovial fluid, thin  and yellow,  usually containing a large
quantity of fatty matter.   The bones undergo important changes in this disease
the articular ends becoming expanded and enlarged; and though this was denied
by Crowther, Russell, and others, it is affirmed by more modern surgeons, and I
have had repeated opportunities of determining the fact. In all cases the osseous
tissue has undergone important changes, the compact structure becomes thin and
expanded, and the cells of the cancellated filled with  a bloody and fatty serous
fluid.   It is softened, often  cutting readily with  the knife, and  owing to the
deposit of fat presents a  more homogeneous  healthy section than  healthy bone.
In many cases, tuberculous matter is deposited in it.   From this it would appear
that the principal changes that take place in  a joint affected with white swelling
consist  in a kind of fatty degeneration of the tissues that enter into the forma-
tion of  the articulation, associated  with an unhealthy strumous inflammation of
the parts, and the consequent deposition of considerable quantities  of semi-trans-
parent and lowly-organized plastic  matter, which, in its turn, has a tendency to
undergo the same structural change, or to run into unhealthy suppuration.
   In  the treatment of white  swelling, we must bear  in mind that we have to
manage a truly scrofulous inflammation and its effects.  Our first  object should
be to prevent, if possible, the occurrence of suppuration.  In the early stage,
when the affection has come on insidiously, without any very active symptoms,
we must trust to general antistrumous treatment, to the influence of diet, of sea-
air, and the administration of alteratives, cod-liver oil, and iodine.   In the local
treatment, rest, with perfect immobility of the articulation, is the most important
element, without which all the rest is futile.  The limb should be put into such
a position as is not only most  easy to the patient, but that would leave the most
useful member  in the event of a stiff joint resulting.   If the symptoms are of
rather an acutely inflammatory kind, leeches may  be  applied; these, however,
must be used as sparingly as possible, being confined either to the  earlier stages
of the disease, or to the subdual of any more active intercurrent inflammation.
Best is  best secured by leather or gutta percha splints in the earlier stages, and
at a later period, by the  application of the starch bandage to the limb.   This
kind of application will be found to give the most efficient support,  and will keep
the whole of the limb perfectly  motionless, so  that the patient can take  open
air exercise, and walk with the aid of crutches, without the risk of injuring the
diseased joint.   In  this  respect, the starch bandage presents great advantages
over the short leather splints generally used.   It may  readily be cut open oppo-
site the diseased joint, so as to admit of the application of proper dressings to it.
Most benefit is perhaps to be  expected from counter-irritation, more  especially
from the application of caustics and issues at a  little distance from the articula-
tion, so  that there may be no risk of the inflammatory action penetrating to it.
   After all inflammation  has, in this way, been removed, and nothing but thick-
ening and stiffness of the joint are left, measures must be adopted  for removing
these  conditions, and restoring  the flexibility of the articulation by frictions
with somewhat stimulating and counter-irritant embrocations, and  eventually its
strength  by douches  of  sea-water.   The swelling  and puffiness that are left,
together with the debility dependent on relaxation of the ligaments, is perhaps best
remedied  by the use of Scott's strapping, but pressure  should not be applied so
long as there  is evidence of  inflammatory action going on in the  articulation,
which it would certainly increase.
   If abscess forms, this must be freely opened by an incision of a proper length,
the joint poulticed, and the patient's general health attended to, so as to promote
the evolution of granulations,  and  the prevention of hectic.  In these cases, if
the limb can be  preserved, its^after-utility, and the patient's comfort, will mainly
depend  upon the position in which it is allowed to anchylose. 
ANCHYLOSIS.
593
                      ANCHYLOSIS, OR STIFF JOINT.

  Anchylosis is invariably the result of the destruction  of a joint by chronic in-
flammation, being the only mode in which nature can effect its repair, and con-
sists in the more or less complete consolidation of  the parts  around and within
the articulation.   It is of two kinds:  the incomplete, or fibro-cellular, and the
complete, or osseous.   In the incomplete, or fibro-cellular anchylosis, the cartilages
and synovial membrane are  in part-or  wholly removed,  and their place supplied
by a fibroid or fibro-cellular tissue,
by which the articular ends  are tied                   Fis-183-
together.   The  soft parts external
to, and in  the neighborhood of the
joint, are also rigid and contracted,
having been matted together by the
deposit of organized plastic  matter.
The complete  or osseous anchylosis
is of two kinds : in one, all  the soft
parts within the joint are destroyed,
and  the osseous surfaces  have coa-
lesced, or  are fused together.   This
is most  commonly seen in the hip,
knee, and elbow.   In  the other,
there has been fibro-cellular  deposit,
or degeneration within the joint, and
the bones united partly by this, are  also  tied together by arches or bridges  of
osseous  matter, thrown out  external to the articulation, and stretching across
from one side to  the other.   It has been supposed that these masses proceed from
the ossification of the ligaments, or even  the muscles; but I think from the
inequality of their  appearance, that  it is  more probable that they are new and
accidental formations.   In the  incomplete anchylosis there  is always some de-
gree of mobility, however slight,  and, indeed, perhaps only perceptible on deep
and close examination.  In  the  complete form of stiff joint, the articulation is
perfectly rigid and immovable.
  The treatment varies according as  the anchylosis is complete  or  not.   When
there is any degree of mobility, however  slight, motion of the articulation may,
as Mr. Tamplin has observed, be restored, provided all disease has ceased.  This
may be effected in several ways.   In the slighter cases, the continued and increas-
ing use of  passive motion, together with  methodical friction and douches, may
restore the mobility of the  joint.  If, as not unfrequently happens, after the
anchylosis has lasted some time, the  tendons in the neighborhood of the articula-
tion  have become very rigid, and seem to  offer  much obstacle to the restora-
tion of the proper position of the limb, they must  be divided.  In those  cases
in which the stiffness is the  result rather of consolidation and induration of sur-
rounding tissues, and of the contraction of the fibro-cellular  material  that  is
deposited within the joint,  forcible  extension or  flexion, according to circum-
stances, by means of a proper screw-apparatus may be advantageously employed.
In doing this,  however, care should be taken that too great  force be not  used.
Some years ago,  this plan  of treatment was a good deal employed in  Paris, and in
consequence of the violence that was employed, death resulted in several instances.
  In complete osseous anchylosis, the mobility of the joint may be  restored by
sawing out  a wedge-shaped piece of bone, and then bringing about union by the
deposit of  fibrous structure,  as in ordinary cases.   This plan was first proposed
by Dr. Bhea Barton, and has been successfully practised by him in several cases
of anchylosed knee;  and of  late it has been  done by others with much advan-
tage in the same condition of the elbow.
                                     38 
594
DISEASES  OF  JOINTS.
              ON OPERATING IN CASES OF DISEASED JOINT.

   The  question of operating on  diseased joints is  one,  the determination of
which often  requires a good deal of discrimination on the part of the surgeon,
who must not only be satisfied that the articular  disease is incurable, but that
anchylosis, so as to leave a useful limb, is impracticable, and that  any attempt to
attain it would  entail such  constitutional disturbance  as would cost the life of
the patient.   There are  two conditions  under which operation becomes  indis-
pensable.  One is, when the limb that is diseased is useless to the patient, so
long  as  the  affected joint is  allowed  to  remain; and  the other is when the
discharge is of so morbid a character, or so abundant, and the irritation induced
so great, as to  entail  risk of life.  The  surgeon has the  choice of two opera-
tions in  diseased joints; one is  the simple excision of the disorganized articula-
tion ; the other  the amputation of the diseased limb.
   The excision  of diseased joints and bones is practised  in order to  avoid ampu-
tation of the limb, and certainly  there  is  no greater triumph of conservative sur-
gery than the restoration  of  the utility of the limb by the  simple removal of
its diseased articulation, and the subsequent formation of a false joint.  Various
operations were  practised with this view during the latter part of the last cen-
tury ; but the subject never received the full attention  that it  deserved by the
profession  until  prominently brought  forward  by the labors of  Liston and of
Syme, and of late years there are few departments of surgical practice that have
been  more  assiduously cultivated  than this.   These operations  are especially
applicable to those cases in which a joint has become chronically diseased, and
the utility of the limb consequently sacrificed, sometimes without the patient's
general  health  having been  very seriously influenced  by it; at  others with a
very  dangerous amount  of  constitutional  disturbance.   The operation is also
more especially applicable to those cases in which the articulation itself rather
than the contiguous soft parts is involved.
   In all cases in which it is done, care should be  taken to remove as little of
the bone as possible, the excision being strictly limited to the diseased articular
surfaces.  Excisions should never be practised until the  disease of the joint has
fallen into a very chronic state;  indeed, as a general rule, the more chronic the
disease, provided the muscles of the limb be not  too  much atrophied, the  more
favorable will be the result.   If the joint be excised whilst any active or  acute
inflammatory process is going on in the bones that enter into its formation, there
will  be considerable risk,  not only of a return of the morbid action in the parts
left, and consequently of failure in the operation, but also  danger of the  exci-
tation of inflammation in  the bones, perhaps of a diffuse and suppurative  kind,
which may prove fatal to  the patient,  as I have  twice seen  happen in excision
of the elbow.
   These operations are always  of a serious character; in many cases fully as
much, or perhaps even  more  so, than the amputation  of  corresponding parts,
owing to the larger wound that is often inflicted, to the  more extensive division
of the bones, to the necessity of making the -incisions in the midst of disorganized
or injured structures, and to  the  more prolonged character of the necessary after-
treatment, as the wound must unite by granulation.   Almost every joint, either
in the upper or  in the lower  extremities,  has been excised; but the operation is
peculiarly applicable  to those of the  upper extremity;  for, as  here, the  great
object is to preserve the integrity and the motions of the hand, any alteration in
the length and shape of the limb is of comparatively little consequence if this
be secured.   In the lower limbs, however, length and strength are indispensable
to utility; and as these are in a  great  measure  sacrificed by these proceedings,
they are necessarily of less utility here.  In the  upper  extremity, the shoulder, 
EXCISION  OF  THE  SHOULDER.
595
Fig. 184.
elbow, and wrist have  all been excised.   In the lower, the hip, the knee, the
ankle, and some of the bones of the tarsus have been advantageously removed.
  Excision of the shoulder-joint  is  not  so commonly required as that of many
other articulations; disease of this joint not being a very frequent occurrence,
and  when it  happens,  often  terminating  in anchylosis, without  suppuration
taking place.   When  practised,   it has  usually been  required for strumous
disease, especially occurring in young people.
The  articulation may most readily be  exposed
by making a semilunar  flap  about three inches
in length, commencing at the  posterior part of
the acromion,  cutting across the  line of inser-
tion  of the deltoid, and carried up to the inner
side  of the coracoid process.   By a few touches
of the scalpel a  large flap composed of the
deltoid muscle may thus be  raised,  and the
diseased  articulation  fully exposed.   As the
capsule and the ligaments are destroyed by the
morbid action  that has taken place in them, the
head of the bone may readily  be  turned out  of
the glenoid cavity; and being freed by a few
touches of the knife, and isolated by passing a
spatula behind it, may be removed with  a saw.
In doing this,  the shaft of the humerus should
be encroached upon  as little as possible, not
only  that  the bone may not be shortened more
than is necessary, but in order that wound of the circumflex arteries may be pre-
vented, which  will  certainly happen if the  incision  be carried too low down.
After the removal of the head of the bone, the glenoid cavity must be examined;
if this be carious, it may be  removed most  conveniently by means  of gouge-
forceps and the gouge, care  being taken that all diseased  bone be thoroughly
scooped away.   After the operation, the  flap  must be laid down, and retained in
position by two points  of suture, and the arm well supported in a sling, the
elbow especially being  raised.   The wound unites  by granulation, and though
the deltoid muscle  does not recover its full utility, a very excellent  limb and
most useful forearm and hand are  left to the patient, as may be seen by the
accompanying  drawing (Fig. 184), taken from a lad whose shoulder-joint I had
removed a twelvemonth  before.   The excision  of  this  joint is not  devoid of
danger.   Velpeau  records thirteen cases of  death  following it, and states that
many more have occurred.
  Excision of the elbow-joint, first done by Park in 1781, has been more fre-
quently practised than that of  any other  of the articulations, and the result has
upon the whole been far more  satisfactory.  This operation may be required in
consequence of chronic disease of the joint, its anchylosis in a faulty position, or
for injury implicating it alone.   In those cases in which it requires to be excised,
it will generally be found that after disease  has existed for a considerable time
in the joint, the limb will be  useless, and the soft parts around it swollen, spongy,
and  perforated by fistulous  openings.   In other cases there  will,  however, be
very  little external  evidence of mischief, merely one or two fistulous apertures
leading down to the articular end  and to the  olecranon, the joint being perma-
nently fixed and swollen, and  the  arm  so useless  that it  cannot  support the
weight of the  hand.   On exposing the articulation, perhaps caries, with com-
plete destruction, and with or without  necrosis of the articular ends, and loose
pieces of dead bone lying in the cavity of the olecranon, or in  one of the con-
dyles, maybe found.   Most commonly the radius is the last bone that is affected,
the ulna and opposite side of the humerus  being  generally first  diseased.  If 
593
DISEASES  OF  JOINTS.
anchylosis have occurred, whether in the straight or bent position, excision of a
portion of the consolidated bone may also advantageously be practised, as in these
cases a useful and movable articulation may be substituted for one that is rigid
and fixed.
   The principal danger  after excision of the elbow-joint probably arises from
diffuse suppuration of the humerus.   I have seen this happen in two fatal cases;
and in a third, in which the patient lost his life, it is probable that death, which
was attributed to pneumonia, remotely occurred from the same cause.
   The elbow-joint may be excised either by a h or H shaped incision.  Of the
two, I prefer the first, as I think it leaves a better result afterwards; but many
surgeons of experience  practise the H shaped one.  The perpendicular incision
should be made parallel to, and a line or two to the outer side of the ulnar nerve;
being commenced at least two inches above the  olecranon, and must be carried
down to about the same distance below it.  The transverse incision should then
be made directly over its point, to the outer side of the joint, and extended as
far as the extremity of the  outer  condyle.   The two triangular flaps thus made
must be dissected up, the knife being  carried close to  the bones.  When this
has been done, the osseous  structures must be cleared to the inner side of the
joint;  in carrying the  incision in this direction, the edge  of the knife should
always be kept against the  bone,  and their sinuosities  closely followed, so that
the ulnar nerve may  escape injury, which will otherwise certainly happen.  If
the incisions are properly planned, and the knife carried in contact with the bone,
the nerve ought not to be exposed during the operation, more particularly as it
is usually imbedded in a quantity  of  plastic tissue.  When the posterior part of
the joint has been laid bare in this way, the knife should be carried round the
tip of the olecranon, and  this process  then removed with cutting pliers.  By
forcibly bending the joint, pushing the forearm backwards, and lightly touching
the ligaments with the point of the knife, the interior of the  articulation will be
fully exposed.  If the whole of it is diseased, the surgeon must excise it com-
pletely;  if it is only  partially affected, he must  limit the removal to those por-
tions that are  implicated.   By means of a small narrow saw, like a miniature
amputating one (Fig.176), the articular end  of the humerus is separated from
the rest of the bone;  the upper end of the ulna and  head of the radius may
either be removed in the same way, or by means of cutting pliers.   There is
never any necessity to place a spatula  before the bones, as the parts of importance
anterior to the joint  could  not be wounded  unless great  carelessness be used,
being completely  protected by the  brachialis anticus.   The ulnar nerve will
occasionally, however, be in some  danger, and it must be guarded or drawn on
one side by a bent copper spatula.  In this operation it is of  great consequence,
so far as the after-utility of  the arm is concerned, not to remove  more of the
bones than is absolutely necessary; the shaft of the humerus, for instance, should
never be encroached upon, but it will be  quite sufficient  to limit the excision to
the articular surface;  should any  carious portions of bone extend beyond this, I
think it better to scoop them out with the  gouge than  to  remove them in any
other way.  The excision of the ulna and radius should  never be carried so low
as to divide the insertions of the brachialis anticus and biceps.
  In  some^ instances, no vessels  require ligature; though  there may be free
general oozing; but most commonly one or two must be tied.  In some cases, it
is said, that the bleeding has proved  extremely troublesome.   After the opera-
tion,  the  limb should  be laid upon  pillows nearly in  the  extended position,
so that the  cut portions of bone are in  close approximation with one  another.
At the end of a week or ten days, when granulations have sprung up, it may be
put in a slightly bent leather splint,  and as the healing process goes on, this may
gradually be flexed, until at last  it  is brought to a  right angle.  The fibrous
union that takes place between the bones  will be closer, and a more compact and 
EXCISION  OF  THE  ANKLE.
597
 useful false joint will form, than if the osseous surfaces be too widely separated
 in the first instance, and be allowed to unite by a lengthened ligamentous tissue.
 Until the contraction of the cicatrix has fully taken place  and the neighboring
 tissues are quite firm, the joint should be well supported by lateral leather splints.
 Much of the success  in the result of excision of this  as of other joints, will
 depend  upon the care and attention  bestowed upon the after-treatment of the
 case.  The position of the parts  and the relation of the  bones to one another
 should be scrupulously attended to, bagging of matter prevented, and exuberant
 granulations repressed.   At the same time the patient's strength must be kept
 up by constant  attention to diet,  fresh air, &c.  In this way good ligamentous
 union will take place.   In a case which I had once the opportunity of examining,
 about sixteen months after the operation, it was found on dissection that the ends
 of the bones were rounded and firmly united by a dense ligamentous structure.
 In this way a most excellent and useful limb will result with but little deformity,
 as may  be seen by the  accompanying  drawing  (Fig. 185), which  was taken
 nearly two years after operation from a patient of mine.   A coachman, whose
 elbow-joint I  excised  was able  to
 drive, to lift a  pail of  water, and  to
 do all the duties of his employment
 nearly as well as if the arm had been
 left in its normal condition.
   Excision of  the wrist is  not an
 operation that has found  much  favor
 with surgeons. Most commonly when
 the carpus is diseased the  morbid
 action rapidly  extends with   great
 constitutional  irritation  to all the
 small bones that enter into its  formation, and although in some cases  a few of
 these may have been successfully taken away, yet methodical  excision  of the
 whole of the joint  has not been followed by  very satisfactory results, having
 either been attended by persistence of the disease  in  the  soft parts or  followed
 by a stiff and useless hand and arm.  A great objection to excision of the wrist
 consists  in the  superficial character of the articulation, and its  close connexion
 with the flexor and extensor tendons;  hence,  when the wound cicatrizes, conso-
 lidation of these and of their sheaths is  apt to result, and  loss of that utility of
 hand, the preservation of which should be the great object in the performance
 of the operation, would be  entailed.
   The excision  of  the joints of the lower extremity cannot be considered in so
 favorable a light as the removal of those of the upper; for as the lower limb
 acts as a basis of support to the  body, the preservation of its strength and length
 is indispensable  to the  proper performance of this duty. In some cases, however
 benefit has clearly  resulted from these procedures, and the  patient has been
 enabled to use the limb, though somewhat shortened, with more advantage than
 he could with an artificial support, however ingenious.
   Excision of the ankle has been  successfully practised for injury as well as for
 disease.  It was done  many  years ago,  by the Moreaus, and latterly by Mr
 Hancock.  An  incision should be made over the  fore and  outer part of  the
joint, the malleoli removed, and the lower end of the tibia sawn off if necessary •
any carious bone on  the surface of the astragalus being scooped out with a goui'
In doing all this, great care must be taken of the  principal tendons, and espe-
cially of  the posterior  tibial artery; for as the anterior one may have been
divided, though  this should, if possible, be avoided, the vitality of the foot after
the operation is dependent on that  vessel.  The after-dressings  and treatment
present nothing of any special moment, the foot and limb  being  carefully sup-
ported on lateral splints.                                                    r 
598
DISEASES  OF  JOINTS.
  When disease is limited to the head of the astragalus, that portion of bone
may occasionally be excised  with advantage, and  the patient left with a very
useful foot.   A case of this kind, occurred  at the University College  Hospital
about a year ago, in which Mr. Statham very successfully removed the astragalus.
The patient, a boy, made an excellent recovery, and has now  a very useful limb.
It is rarely, however, that disease is strictly confined to this bone, unless it be the
consequence of compound dislocation.  AVhen this has happened  and the astra-
galus has been thrown out of its bed, it may eventually become carious or necrosed,
and thus require excision.   These operations are of a somewhat irregular kind,
but may  usually  be  accomplished without  much difficulty, by making  a free
incision on  the outer side of the foot,  over the displaced  and  diseased bone,
taking care not to cut across the extensor tendons,  but dividing any ligamentous
attachments that may be left, and turning it out  by  means  of an elevator, or
removing it with a pair of bone forceps.  The removal of the astragalus is occa-
sionally much facilitated by cutting its neck across with pliers, and thus taking
it out in separate pieces.
  The os calcis not unfrequently requires to be partially or wholly excised.  In
most cases carious cavities, containing  small masses of necrosed bone, will be
found to perforate and  excavate it, having fistulous openings leading  down to
them.  The disease  may generally be removed by making a  "|" shaped incision
through th.e soft parts, so as to expose the bone; the gouge  may then be freely
applied to the edges and sides of the cavity, and  in this way all  morbid  tissue
may be removed, the  greater part, perhaps, of the  interior of the  bone requiring
to  be scooped out.   The  cavity left must  then  be  lightly  dressed  from the
bottom, and allowed to granulate; it fills by fibrous tissue, but leaves the calca-
neum in no way materially weakened or unfit for the  support of  the  body.  In
the great majority of instances of disease of this bone this simple operation will
suffice.   I have had several patients under  observation, in  whom I have per-
formed  it during the  last three or four years, in none of whom  has  any recur-
rence of disease taken place.  In other instances,  however, when the caries or
necrosis has been more extensive, little more than a  shell of bone having been
left, it  becomes necessary  to excise the whole of it.  The readiest  mode of
doing this is that adopted and described by Mr. Page; an incision  down to the
bone should be made directly across the sole  of the foot,  commencing about
half an inch below the inner ankle, and ending just  under  the outer one (Fig.
28).  The posterior flap must  be reflected from  the surface of the  bone, the
tendo-achillis divided, and the articulation between the astragalus and calcaneum
opened by  means  of a narrow-bladed bistoury.   The  lateral as well as  the
interosseous  ligaments  may readily be  divided,  the os  calcis  being forcibly
depressed so as to reach them.  In order  to effect  the  disarticulation  of the
calcaneum from the cuboid  bone, it is necessary to carry an  incision about two
inches  in length on either side of the sole of the foot, forwards from the  end of
the transverse incision.  The flap so formed must  be  dissected back, when the
articulation is  readily reached  and  opened.   The plantar arteries will require
ligature;  the edges of the wound being  then brought together and  dressed in
the usual way.  After union has taken  place, a sound and  tolerably useful foot
may result.  If, however, the integuments  about  the heel have  been diseased
before the operation, being infiltrated with plastic matter, it is seldom that they
recover themselves;  and  although  no  recurrence of morbid action  may take
place in the bones, the diseased condition of the  soft parts  will  leave a useless
limb, that will render amputation necessary.   The removal of the  os  calcis and
astragalus at the same time has been successfully performed  by Mr. T. AVakley,
who reports favorably of the results of the operation in his case.
   Excision of the cuboid bone  either in whole or part, is sometimes required,
and  has  been  successfully  accomplished;  in  fact by the  exercise  of a little 
EXCISION  OF  THE  KNEE-JOINT.
599
dexterity a surgeon may often thus succeed in saving the foot by the removal of
portions, or of the whole of the various tarsal bones.
  When disease attacks  any of the metatarsal bones, they must  be excised in
the way that  has already been described at  page 98.  Most commonly  the
metatarsal bone of the great or little toe is the one affected, and  then a regular
operation  may be  performed for its  removal,  the rest of  the foot being  left
intact.  AVhen more than one of the  metatarsal bones is  diseased, it commonly
happens that the soft parts are extensively implicated, and under these circum-
stances  it is better, I  think, to perform Chopart's operation than  to excise the
diseased bones.  In  one  case, in a patient at the hospital, I removed the three
outer metatarsal  bones for caries;  the man  died  of erysipelas,  but, had he
recovered, I doubt whether so useful a limb would have resulted  as if amputa-
tion had been performed through the  tarsus.
   AVhen the greater part of the tarsal bones are diseased,  amputation should be
performed  at  the ankle-joint by  Syme's  operation.  If a well-fitted artificial
limb  is applied  to the stump that is left, the  patient will be enabled to walk
with but little difficulty or apparent deformity.   In some cases strumous  disease
returns  in  the flap,  and  then renders  amputation of the leg necessary.   This
happened in a boy, in whom I  performed disarticulation of the ankle-joint for
strumous disease of  the  foot, and  although the »integuments of the heel were
healthy at the time that  the operation was done, they gradually became swollen,
blue, and infiltrated, so as to leave a useless stump which required to be removed
about six months afterwards.
   Excision of the knee-joint has not been  so  frequently performed  as  that of
many other articulations, and indeed for a long time an unfavorable impression
seems to  have existed in the profession  regarding it, its  performance  having
been discontinued; of late  years, however, this operation has been revived by
Messrs.  Fergusson, Jones, of Jersey,  and B. J. Mackenzie, and we are  now in
possession of a sufficient number of cases to come to some definite  conclusion as
to the utility of  the  procedure.
   The  object of  excision of the  knee-joint is necessarily,  as  of  all  similar
operations, to preserve the limb by the  removal of the diseased and disorganized
articulation, in those cases in which  the joint  is irreparably destroyed, and in
which, consequently, amputation would otherwise be the sole resource.
   The operation itself is easy enough of performance.  It  consists in exposing
the articulation  by  means of an  H shaped  incision; or, as  Mr.  Mackenzie
recommends, by  one of a semilunar shape, extending from the side of one
condyle of the femur, across the  tuberosity of the tibia, to the  other condyle.
By this incision  the ligamentum patella) is  divided, and the  patella  turned up
in the flap.  The  ends of the bones are then cleared somewhat, and the articu-
lar surfaces shaved off with a small amputating saw.   In  doing this as little of
the bones as possible should be removed, so that too much  shortening may not
result;  from half  to three-quarters of an inch of the tibia,  and about an  inch,
or an inch  and a half of the femur.   Any carious bone left on the cut surfaces
must be gouged  out.   If the patella  be much diseased this must be  removed;
or, if only  slightly roughened and carious on its articular  surface, as often  hap-
pens,  it had better be left, the  diseased portions being excised  with  a  gouge.
Mr. Mackenzie, with justice, attaches great importance to leaving this bone if
possible, as tending materially to strengthen the joint  in  after-life.  The bleed-
ing articular arteries are then tied, the limb put upon a splint, the wound lightly
dressed, and union allowed to take place by granulation.
   The result of this operation, so far  as the mortality attending it is concerned,
has been of a very favorable character.
   On looking  over the statistics of excision of the knee-joint,*  I find the fol-
» Vide Mackenzie, " Edinburgh Monthly Journal," 1853. 
600                       DISEASES OF JOINTS.

lowino- record of cases, which I have  arranged in the  order of their occurrence
as nearly as possible :—
OPERATOR.	NO. OF CASES.	RESULTS.
Me. Felkin.	1	Cured.
Mb. Park.	2	One cured ; one died.
M. MOREAU.	3	One cured; one died from operation; one died from Dysentery when limb was nearly well.
Mulder.	1	Cured of operation, but died of Tetanus after delivery.
Crampton.	2	Both cured ; though in one case six inches of femur removed.
Syme.	2	One cured ; one died.
Fergusson.	3	One cured; two died.
Jones.	6	Four cured ; one died; one convalescent.
Dr. Mackenzie.	2	Two cured.
Page.	1	Cured.
Dr. Stewart.	1	Encouraging.
Making in  all twenty-four cases, of which fifteen were cured, six died of the
operation, two were convalescents, and  in one, death occurred after a lapse of
three and a half months, from causes independent of the operation; and of the
last  eleven  cases, according to  Mr. Mackenzie, seven have recovered, only two
having died, and two being convalescent at the last report.
  The result of excision of the knee-joint, so far as after-utility of the limh is
concerned, is of considerable importance; as  the propriety of performing the
operation  turns in  a great measure upon whether the limb that is left is more
useful than  an artificial one.  On this point, also, the result of recorded cases is
in favor of the operation.  In one of Mr. Park's cases, operated on in 1783, that
surgeon states that  the patient, a  sailor, seven years after  the operation, "was
able to go aloft with considerable agility, and to perform all the duties of a sea-
man."  In  some of the later cases the result has been equally good.  One of
Mr.  Jones's patients, a boy,  " could run and walk quickly without any aid of a
stick, could stand on  the limb  alone, and pirouetted and hopped two or three
yards without putting the sound limb to the ground;" and in the other cases the
limb was found useful for all ordinary purposes.
  After  the operation,  osseous anchylosis takes place with  a firm cicatrix, the
limb is shortened  by from two to four  inches, but by  means of a high-heeled
shoe  this inconvenience  is  greatly remedied.  It  has  been urged against the
excision of  the knee-joint that convalescence is tedious  and prolonged, but  this
argument can with justice have but little weight;  if a useful limb can be  pre-
served to the patient, it can  matter but little if a few  additional  weeks are
devoted to the procedure by which it is maintained;—and, indeed, it is a ques-
tion, whether in many cases the patient may not be able to walk just as soon
after the excision of the knee-joint as after amputation of the thigh; for, as Mr.
Syme has very properly remarked, though the amputation wound may  be healed
in three or four weeks, it may be as many months before an artificial limb can
be worn.
  Excision of the  head of the femur has of late years  been a good deal  talked
about and  practised in some  cases of hip-joint  disease.   This  operation  may
however, most conveniently be  considered in  connexion with that affection (p.
618).
  In those  cases in which excision of the diseased joint is not advisable, in con-
sequence of the acute  character of the articular  disease, and the  existence not
only of considerable suppuration, as well as of great local and constitutional irri-
tation, or from the peculiar  nature of the joint affected, amputation may be the 
LOOSE CARTILAGES IN  JOINTS.
601
sole resource  left  to  the surgeon.  It is especially  in  articular disease of the
fingers and toes,  of  the  tarsus, carpus, ankle, and knee, that this  operation is
required; and though much less frequently practised now than formerly, yet the
cases of destructive disease of joints requiring amputation are amongst the most
frequent in operative surgery, and will doubtless continue to be so.  The surgeon,
however, must be  careful whilst he avoids continuing to make ineffectual attempts
to save the limb at the great hazard of the patient's life, not to amputate until
it is clear that all  other means have failed, the patient continuing to lose ground,
so that a further perseverance  in  local  and constitutional treatment  would
probably end  in his death, excision not being  practicable.   So far from amputa-
tion being an opprobrium to surgery in such cases as these, I  look upon it  as one
of the greatest triumphs of our art, that by a simple and easy operation  which
removes the spoiled and useless limb, the life of the patient  may be saved,  and
his health speedily restored.  It commonly happens that a patient who has been
racked with pain, and been wasting in body for weeks before the local source of
irritation was removed, sleeps soundly the night after the operation, and rapidly
gains flesh and strength.
  As phthisis  not unfrequently  co-exists with the advanced forms of strumous
joints, the question  of  amputation under  these  circumstances  becomes  one of
very considerable  importance.  If the phthisis be rapidly progressing, and there
be a strong hereditary tendency to the disease, or if it have advanced to  soften-
ing of the lung, and the formation of vomica, it would be useless to operate.   If,
however, the  phthisis be of a very slight and incipient  character, and be appa-
rently greatly due to the local irritation of and discharge from the disease, to the
confinement to bed that it  necessitates, and to the general depravation of  health
that ensues, amputation may not only be  safely but  advantageously  practised;
and I have done it in many such  cases, to the manifest advantage of the patient.

                      LOOSE CARTILAGES IN JOINTS.

  It sometimes happens that in the interior of the joint the synovial  membrane
assumes a warty condition, as the result of chronic irritation  of  the articulation.
For this condition, which gives rise  to occasional  uneasiness and puffiness about
the joint, with a  crackling or creaking sensation when it is moved, but little
can be done beyond  the application of discutient  plasters and the use of  elastic
bandages.
  Loose  cartilages, as they are termed, are not  unfrequently met with  in  the
different articulations.   These  in many cases are not truly cartilaginous  but
appear to  be composed of masses  of  condensed and indurated fibroid  tissue, not
very dissimilar in structure to the warty synovial membrane just referred to.   In
other cases, however, it  is probable that they may be  of a  truly cartilaginous
formation.  These bodies vary in size from  a barley-corn to a chestnut; when
small, being rounded in shape; when large, being somewhat flattened or depressed
on the surface.  They are smooth, shining, and usually of a yellowish or grayish
white color.   They are  most frequently met with  in  the knee, but not uncom-
monly occur in the elbow or the joint of the lower jaw, and  occasionally in  the
shoulder.  Most commonly only one is found, but their number  may range from
this up to fifty or  sixty.
  They commonly give rise to very severe  pain in particular movements of the
limb.   This  comes on  suddenly, prevents the patient  either straightening or
flexing the joint completely, and is often so intense as to cause faintness or sick-
ness.  It is usually followed by a degree of synovial inflammation and by relaxa-
tion  of the ligaments.   These attacks of pain and of sudden irritability of the
part  come on  at varying  intervals,  as  the result of  movements of it; they
commonly happen in the knee whilst the patient is walking.   It is difficult to 
602
DISEASES  OF  JOINTS.
say to what this severe pain  is  due.   Bichet thinks  it may be  owing to the
synovial  membrane being pinched between the foreign body and one of the
articular surfaces.  In some cases the loose cartilage can be felt  by carrying the
finger over the joint, when it  may be detected under the capsule, slipping back
perhaps when pressure is exercised upon it.
  The treatment consists in supporting the joint with an elastic bandage or knee-
cap, so as to limit its movements, and thus prevent the liability to the recurrence
of the attacks of pain.  Any inflammatory action that has been  excited requires
to be subdued by proper antiphlogistic treatment.
  If it occasion great and frequent suffering, so as to interfere seriously with the
vitality of the limb, and if the cartilage  appear to be  of large  size, and single,
means may be taken for its extraction.  No operation, however, should be under-
taken with this view so long as the joint is in an  irritated state, as the result of
a recent attack of pain; this must be first subdued, and  then the operation may
be proceeded with.   The extraction may be effected by directing the patient in
the first instance to make those movements  by which  he usually gets the carti-
lage fixed in the joint.  So soon as the surgeon feels it (as this operation is  com-
monly required in the knee) he should push it to one side of the patella, where
he  must fix it firmly with  his forefinger  and  thumb;  he then  draws the  skin
covering it to  one side,  so as to make it tense, and  cuts  directly down upon the
cartilage by a sufficiently free  incision to allow of its escape.   The wound which,
when the skin is relaxed, will be somewhat valvular, is then  closed by a strip of
plaster, and the limb kept at rest for a few days until it has united.  Severe
inflammation of the joint less frequently follows this operation  than might  have
been expected, the synovial membrane  having probably undergone some modifi-
cation of action that renders  it little liable to this process.   Should, however,
such occur, it must be treated on general  principles.
  It has been  proposed by M. Goyrand, in  order  to obviate the dangers of an
external wound into  the joint, to remove  the loose  cartilage by subcutaneous
section;  this  he proposes to accomplish in a way that  I have seen practised by
Mr. Liston; viz., by passing a tenotome obliquely under the skin after fixing the
foreign body in the way that  has already  been described, dividing the synovial
membrane freely, and then squeezing the  cartilage into the cellular tissue outside
the joint, where it may be allowed to remain until removed  by  a fresh incision
after that in the synovial membrane has healed, or left and be eventually taken
up by the absorbents of the part.

                          NEURALGIA OF  JOINTS.

  Severe pain may occur in joints without organic disease, either from the  pres-
sure on a nerve leading to the  articulation or distributed in its vicinity, or  from
some neuralgic condition of the joint itself.  Thus there may be severe pain in
the knee in consequence of pressure being exercised upon the obturator nerve,
or the joint generally may be  excessively  painful—especially in girls  or young
women—owing to some hysterical  condition or uterine irritation, the nature of
which  in many cases is not very clear.  It is this class of  cases, occurring in
hysterical females, that  should  especially be considered  as neuralgia of the joints,
to which the attention  of  the profession  has  principally been directed by the
labors of Sir B. Brodie.
  In these cases it is generally found  that  the  hip, knee, ankle, or shoulder is
the  joint affected—the hip and the knee being especially liable to it—severe
pain is complained of in it; and it is rendered comparatively useless,  often with
a good deal of distortion. . On examination it will be found that the pain, which
is commonly very severe, is superficial  and  cutaneous, not existing in the inte-
rior of the articulation or increased by pressure of the  articular  surfaces against 
CARIES  OF  THE  SPINE.
603
one another, and is not strictly confined to the joint, but radiates  for some dis-
tance around it.  This pain is often intermittent in its character, and is frequently
associated with neuralgia elsewhere,  as in the spine; and  not unfrequently with
uterine  irritation or disease.   At the same time it will be observed that all the
signs that ought to accompany a severe attack  of inflammation in a joint, such
as would be attended by a corresponding amount of pain, are absent; there being
no painful startlings of the limb at night, or constitutional fever and irritation;
and  the suffering  being  increased  by causes, such as mental  and emotional
disturbance, that do not influence organic disease.  Attention to these various
circumstances will usually enable the surgeon to diagnose the nature of the attack
without much difficulty;  the only cases  in which he will  really experience any
being those in which the tissues around the joint have been thickened, indurated
and altered in their characters by the application of issues, moxse, &c.
   The treatment must be of a general character, directed especially to re-establish
a healthy condition of the uterine organs.  If there be amenorrhcea, and anemia,
aloetics, and  the preparations of iron must be given; if uterine irritation  or
ulceration exist, that must be removed by proper local means, and the general
health attended to.   The  most efficient treatment that can be  directed to the
affected joint, is, I think, the  application of cold douches and the employment
of electro-magnetism, which I have found to cure cases in which all other means
had failed; the application of atropine  and aconite may be of service to allay
the pain when especially severe.
                          CHAPTER XLIV.

                      DISEASES OF THE SPINE.

   Caries of the Vertebras.—This disease, which consists, in its full development,
in destruction of the  bodies of the vertebras, with  disintegration  of the inter-
vertebral fibro-cartikge, most commonly occurs in young children, sometimes but
a few months  old;  but is  not unfrequently met with  at all ages  up to that of
thirty.  It is  always, I believe,  a strumous affection,  consisting  essentially in
tubercular  infiltration  of the  bodies of the vertebrae, followed,  as  commonly
happens, in this morbid condition, by congestion, caries, or necrosis of the
osseous tissue that is in contact with, or the seat of the deposit.  In consequence
of these changes going on  in the bodies of the vertebrae, they become thinned,
eroded, and gradually hollowed out anteriorly.   The disease is usually limited to
this part of the spinal column, leaving the spines, the arches, and  the tubercles
unaffected; but in some  instances even these  structures, which are of a more
compact  character,  become eventually implicated.   In this way the bodies of
from three to  six or eight of the vertebrae may be destroyed, the corresponding
intervertebral  fibro-cartikges,  which  derive their supply  from the contiguous
bones becoming disorganized, as  these undergo destruction.   These  changes
commonly  occur  about the middle dorsal vertebrae;   if  extensive,  they may
implicate  the  upper  or lower dorsal, or upper  lumbar,  and  always give  rise
to angular projection backwards of the diseased part of the spine, corresponding
in extent to the amount ef destruction of the vertebrae (Fig. 186).   The mecha-
nism of this excurvation, which  is the  most  marked  feature in this disease is
easily understood by reference  to the pathology of the affection.  The bodies of
the vertebrae being  thinned and  weakened, at last give way under the pressure
of the weight of the upper part of the body, and the remains of the disintegrated 
604
DISEASES  OF  THE  SPINE.
Fig. 186.
 bodies being fused together, cause the upper part to bend over, and the spines
 to project  posteriorly.  The degree of bending forwards and of posterior excur-
                                     vation correspond  to the  amount of the
                                     destruction of the bodies  of the vertebrae.
                                     It  is seldom that  the spinal  marrow be-
                                     comes compressed  or injured during the
                                     progress of this disease.   In  some cases,
                                     however,  more particularly in adults, it
                                     becomes softened opposite the seat of cur-
                                     vature, and thus paralysis may be occa-
                                     sioned.
                                      The symptoms of the disease, when it is
                                     fully developed,  are  well-marked; but in
                                     children  it often comes  on  very insidi-
                                     ously, commencing with a degree of weak-
                                     ness in the back, with an inability to stand
                                    upright, and with a tendency to lean the
                                    body forwards, or to  support it by resting
                                    the hands on the knees, or seizing hold of
                                    anything  that  will serve  as a  temporary
                                    support.   On examination, a  few of the
                                     spines about the  middle  of the back will
                                     be  found to be  a  little  more  prominent
                                     than the rest, and on pressing or tapping
                                    upon them, pain will  be complained of.
                                    The child usually becomes stunted in its
                                    growth, and if the  disease is not  arrested
                                    by  proper  treatment, continues more or
                                    less  hump  or round-backed for life.   In
other cases, it will  run on to the formation of abscess, as will immediately be
described, strumous manifestations occurring  elsewhere, and death eventually
resulting.
   In ^ adults, the symptoms  will vary somewhat according to  the seat of the
affection. It is most dangerous and rapidly fatal when the  cervical vertebrae are
implicated,  for as the bodies of these are  shallow, caries readily penetrates to the
spinal canal, and the cord may thus  be irritated.   When  the dorsal or lumbar
vertebrae become diseased, the affection is not of  so  immediately serious a  cha-
racter to life, though it may  be to the figure of the patient.  In adults  it often
commences  with pain in the loins or back, apparently of a rheumatic character,
shooting round the body or down the thighs.  On examining the spine, which
feels weak to the patient, tenderness on pressure or on tapping will be experienced
at one point, and he will wince when a sponge wrung out of hot  water is applied
to this part, although there  may be  no appearance of excurvation.   The lower
limbs now become weak, and the  patient walks with a peculiar shuffling, tottering
gait, the legs being outspread, and  the feet  turned out.   The weakness of the
limbs is especially marked in going up stairs, and may be tested by directing the
patient to stand unsupported on one leg, and raise the other so as to place the
foot upon the seat of a chair, which he will probably be unable to do.  The  de-
formity of the spine now slowly increases, the patient becomes unable to stand,
and  spasms of the  muscles  of the lower extremity come  on,  together with a
tendency to relaxation of the sphincter  ani, and retention of urine.   Abscess
now commonly makes its  appearance, and in some  cases it occurs before any of
the other signs except pain and weakness  of the  spine, but certainly before any
deformity has taken place.    When  the abscess forms, as  Mr.  Stanley has  ob-
served, the pain  and irritation of the  spinal cord are usually lessened for a time.
 
PSOAS AND  ILIAC  ABSCESS.
605
   It must not, however, be supposed  that abscess necessarily forms in all cases.
 Caries of the spine may take place to a very considerable extent, and yet no sup-
 puration occur, the bodies of the vertebrae undergoing erosion and absorption,
 and coalescing so as to become fused  together into one soft and friable mass of
 bone, across which bridges of osseous tissue are sometimes  thrown out, so as to
 strengthen the otherwise weakened spine.  In these cases, masses of porcellanous
 deposit will not unfrequently be found, intermixed with and adherent to the carious
 bone.   Indeed, this anchylosis and fusion of the bodies of the diseased vertebrae
 may be looked upon as the natural  mode of cure of angular  curvature  of the
 spine; the  only way, indeed, in which  it can take place when once  it has ad-
 vanced to any considerable extent.
  .When abscess forms in connexion with diseased spine, it may become the most
 prominent and marked  feature of the affection, giving rise almost to a distinct
 and independent disease.  The situation and course  of these abscesses depend
 entirely upon the part of the spine affected.   Thus, for instance,  when the cer-
 vical vertebrae are diseased, the abscess may come forwards  behind the pharynx,
 and may occasionally extend under the sterno-mastoid muscle to the side  of the
 neck, where it opens.   Sometimes, though very rarely, it may pass  into  the  chest,
 and in other cases down  into the axilla.   When the disease is seated in the dor-
 sal vertebrae, it usually passes forwards under the pillars of  the diaphragm down
 the side of the aorta, and the iliac vessels into the iliac fossa, and  then presents
 through the anterior wall above Poupart's ligament.  In other cases again, when
 the lower dorsal or upper lumbar vertebrae are diseased, the  pus gets into  the
 sheath of the psoas muscle, thus constituting the common affection termed "psoas
 abscess;" and passing along this, under Poupart's ligament, presents in the  thigh;
 or ft may continue  its course downwards, burrowing under the muscles of this
 region until it reaches  the popliteal space, and even pass from this some distance
 downwards on to the  calf or ankle.   I have seen an abscess opened by the side
 of the tendo achillis, which took its origin in  disease of the dorsal vertebrae (Fig.
 120).  In other cases again, these abscesses take a different course, and descending
 into the subperitoneal  cellular tissue into the pelvis, may present  by the side of
 the  rectum in  the perineum, or pass  out of the sciatic notch, and down  by the
 side of the  trochanter.  The quantity of pus  contained in these  collections is
 sometimes enormous, and abscesses of this description attain a greater magnitude
 than those of any other part of the body.
  The diagnosis of caries of the spine  is made at the first sight of  a patient
 affected by the disease, when once  the angular deformity has taken place.   It
 is,  however, difficult before excurvation occurs,  being  only indicated at this
 period by the  existence of pain in the back, and by some symptoms of spinal
 irritation.   At this stage it may be mistaken for spinal or intercostal neuralgia,
 for  rheumatism,  or for chronic nephritis.  The persistence, however,  of a con-
 tinuous fixed pain in the back should always lead to a suspicion as to  the true
 nature of  the disease, lest the  grievous error be committed of treating as mere
 neuralgia or rheumatism, what may turn out to be incurable disease of the spine
 itself.  Here the tenderness  on pressure, the increased sensibility to the  appli-
 cation of heat, with a tendency, though it be very slight, to projection of some
 of the spines, the feeling of weakness in the back, and especially the occurrence
 of these symptoms in early childhood or youth,  at  a period when the   other
 diseases rarely occur, would lead one to suspect the true nature of the  affection.
  The diagnosis of the connexion between abscesses in the situations mentioned
and  in diseased spine, is  not always  easy, as  purulent  collections of various
kinds may form in the  different planes  of cellular tissue in  the neighborhood of
the  vertebral column, without any disease existing in  it, and these often  attain
a very considerable bulk before they  present  externally.   Thus we may have
large abscess in the cellular  tissue of the back, or collections of matter around
the  kidney,  the coecum, or in the  iliac  fossa, closely  resembling  the   ordinary 
606
DISEASES  OF  THE  SPINE.
characters of abscess arising from diseased spine.  This has also been simulated
by purulent collections passing from the pleura between the abdominal muscles,
or taking their origin  in  the vicinity of the  hip-joint.   The  diagnosis of these
various collections may, however, with a little caution, be readily made from the
ordinary forms of spinal abscess, that descends along the psoas muscle.   In the
first place, in all these cases  there is an absence of that dorsal pain and tender-
ness, with more  or  less excurvation, which,  though not  invariably present, is
commonly met with in psoas abscess.   Then again,  if the collection be perine-
phritic, there  would have been previous,  or  there are  co-existing, symptoms of
renal disease.   If it occur in the cellular  tissue around the coecum, the pus will
be  peculiarly  offensive,  will present  itself in  a less distinct  manner, and will
probably be associated with  symptoms of intestinal irritation.   In  those rare
cases in which an empyema has found its way between the layers of the abdo-
minal muscles, and presented in the groin, the stethoscopic signs will point out
the nature of  the affection.  In abscess connected with disease of the hip-joint,
there will be special evidences of the source of the pus.  The only real diffi-
culty consists  in  diagnosing large psoas  abscess presenting in the thigh or in
other parts of the lower  extremity, and  dependent  on disease of the vertebra]
column, from  iliac  abscess  taking its origin  in the  loose cellular tissue of the
iliac fossa, whether it be connected or not with disease of the corresponding bone.
   In iliac abscess, the disease usually commences at or after the  middle period
of life, always in  adults;  and, as Mr. Stanley has observed, usually presents
itself externally  immediately above  Poupart's  ligament,  being  conducted for-
wards to this situation by the fascia iliaca.   Psoas abscess, on the contrary, most
commonly occurs in the earlier periods of life; extends  down into the thigh
along the course  of the psoas muscle, so that it always presents below Poupart's
ligament.  It is  also commonly associated with some  indication of irritation of
the muscle in the sheath of which it is situated.  Thus, there is an inability to
stand upright, to extend the leg, and pain is complained of in walking.  Psoas
abscess, also, in many cases,  occurs  suddenly, the  patient finding on washing
himself in the morning, that he has  got a large soft  tumor in  the upper part of
the groin, whereas iliac abscess comes on more gradually, and presents in a more
diffused and less  circumscribed manner.
   The prognosis in  caries of the spine  is  always  bad;  the  deformity always
continuing more or less  marked; and the patient, though he may eventually
recover, by anchylosis taking place, continuing humpbacked in after-life.  -Very
commonly the disease terminates in abscess and death.  It was long ago remarked
by Boyer, that the  most fatal  cases  were generally those in  which the spine
preserved its  straight position;  whereas, when it was  much curved, death
seldom resulted.   The truth of this  remark  I have had frequent occasion to
verify; and the circumstance would  appear to be owing  to the fact, that when
the spine continues  straight at the same time that  the bodies of the vertebras
are tuberculous and carious, anchylosis cannot occur, the spinal canal is opened,
and the  cord  irritated;  whereas, when they have fallen together and very con-
siderable  gibbosity has resulted,  anchylosis more readily  takes place, and thus
an  imperfect cure is effected.
   Treatment.—In infants the utmost that can be  done  is to direct that they
should be laid prone upon a pillow or small couch constructed  for the purpose;
that their general health should  be  attended  to by tonics suited to their age;
that they should have  the advantage of country or* sea air; and that some
counter-irritant, as the tincture of iodine, should be applied by the  side of the
spine.   In children that are somewhat older, and in  adults, great advantage may
be  derived by strictly forbidding them  to  walk, stand, or sit erect; confining
them rigidly to the prone couch, and  adopting a general plan of tonic treatment
At the same  time  counter-irritation may be applied with great advantage by
means of caustic issues or moxae to either side of the spine.   In fact the princi- 
PSOAS AND  ILIAC  ABSCESS.                  607
pies of treatment in these cases are extremely simple:  the improvement of the
general health by good diet, tonics, and sea air, in order to remove the strumous
condition with which this  disease is always associated,  and the employment of
counter-irritants suited to the age of the patient to lessen the local action in the
vertebrae, is all that can be done.   Best in the  horizontal  position is the  most
important element in the treatment;  if the patient  be  allowed to stand upright
or to sit, the weight of the head and shoulders will tend  to  curve forward the
weakened spine, and by their pressure  increase the already existing irritation in
it.   The horizontal position relieves the diseased parts of this additional source
of distress.   In these cases the prone position is preferable to the supine, and
the patient, if old enough, should always be  laid upon a properly-constructed
prone couch, such as was introduced into practice by the late  Mr. Verral.   This
position is certainly the best, for not only is the angle formed by the excurvated
spine not injuriously compressed, as it would be in the supine or lateral position,
but the patient is more comfortable;  and it is far easier to make  the necessary
application in the way of issues and moxae than could  otherwise be done.   At
the same time the back  not being the lowest  part of the body there is a less
tendency to congestion of  the spinal veins, and to  consequent  increase of the
inflammatory softening of the bones.   When  the disease has in this way  been
arrested, for which many months—at least twelve or eighteen—will be required,
the patient may be allowed to get up and move about, by wearing  proper stays,
so as to support the trunk.  It  is of considerable importance in the treatment
of this disease that the patient should not be allowed to get  or sit up too soon
before consolidation of the diseased vertebrae  has taken place, otherwise he will
to a certainty suffer a speedy relapse, or the excurvation will greatly increase.
 ^  If debility of the lower limbs or paraplegia should come on, the administra-
tion of the bichloride of mercury in doses from the twentieth  to the sixteenth of
a grain has been strongly recommended by Latham and Stanley.  Issues will
also  be of use in relieving the  nervous symptoms,  though they may have had
little effect on the disease of the bones.
   When  abscess  has formed the surgeon should be in  no hurry to open it, but
in accordance with the principles laid down when treating of those affections, he
should  delay doing  so, lest injurious fatal constitutional irritation be  set up.
When it becomes necessary, from  the approach of the  matter to the surface, to
give exit to it, this should be done by valvular incision, closed, as soon as the pus
has been discharged,  by means  of hare-lip pins, or  in  the way described (page
335).   The hectic or constitutional irritation that supervenes about this period,
must of course be treated on general principles.
  Disease of the atlas and axis, and of the atlas and occiput, constitutes one of
the most serious forms of vertebral caries.  In these  cases there is pain, swelling,
with great difficulty or absolute inability in moving  the  head; after a time in-
duration of the cellular tissue, with swelling and fluctuation behind the pharynx
come on, pushing forwards its posterior wall against the nasal  apertures,  causing -
the tongue to be extruded, occasioning much difficulty and distress in breathing
and giving rise to a peculiar  nasal tone in the voice.   The  abscess may point
here, or extend outwardly under the  muscles of the neck.   Patients affected
by this disease truly present a remarkable as well as distressing appearance.
The  neck being  perfectly rigid, they are unable to turn the head, but when
they want to look round have to  twist  the whole body; at the  same time, the
weakness in the neck usually compels them to support the head with both hands
putting one  under the chin, the other under the occiput, and  so holding it
Ihe disease often terminates fatally by luxation of the  vertebra) forwards  com-
pression of the cord and sudden asphyxia, or more slowly by hectic and gradual
interference with the respiratory functions.   The treatment must be conducted
on precisely the same principles as that of angular curvature, by absolute  rest,
counter-irritation and tonics.   As great and immediate danger may result from 
608
DISEASES OF  THE  SPINE.
the sudden displacement of the vertebrae, and the consequent compression of the
cervical cord, the head  usually requires to be steadied by machines calculated to
support it and limit its movements.
  Disease of the sacro-iliac articulation occasionally occurs.   I have had several
cases under my care at the University College Hospital, in which the symptoms
and post-mortem appearances were well marked.  It commences with pain, ten-
derness, weakness, difficulty in progression, abduction of the  limb on the affected
side, and some elongation of  it from swelling of the  affected  articulation, and
thus a tendency to displacement forwards and  downwards of the whole  side of
the pelvis.   After a time abscess forms,  which acquires a very considerable size,
extending under the gluteal  muscles, and at last, after many months, or even a
year or two have elapsed, pointing by the side of the coccyx.  Most frequently
this disease terminates in death by hectic, consequent on opening the abscess.
Sometimes, but very rarely, anchylosis may take place, and then the limb on the
affected side  may continue permanently lengthened, for the reason already ad-
verted to.  In the treatment the same principles of rest and counter-irritation must
be carried out that constitute the basis of the management of all similar affections.
                   LATERAL CURVATURE OF THE SPINE.
   This affection, on account of the frequency of its occurrence, and the tedious-
ness of its cure, has received a good deal of attention from various surgeons, and
much has been written upon  it by those who have  specially devoted themselves
to its  treatment, but yet, the whole of its pathology and management  lie in a
very narrow compass.
   Lateral curvature of the  spine  most commonly commences at an early period
of life, usually between the  ages of twelve and eighteen ; seldom before  the one,
and not very commonly after the other;  it rarely, if ever, occurs but to  females,
                         at  least I have never heard of, or seen, a case of the
                         kind in lads.   It  appears  to consist simply in a re-
                         laxation of the ligaments and muscles of the spine,
                         in  consequence of which the vertebral column, being
                         no longer able to  support the weight  of the head,
                         neck, and shoulders,  becomes curved  to one side, a
                         corresponding deviation taking place in the opposite
                         direction at a lower portion of the spine, in order to
                         preserve the equilibrium between the two sides of the
                         body (Fig. 187).  The first curve usually takes place
                         in  the  upper or middle dorsal  region, the  convexity
                         tending towards the right side; the second,  or com-
                         pensating curve, occurs  in  the  lumbar region, the
                         convexity looking  towards  the left.  At  the same
                         time  that these lateral  curves take place, there is
                         usually a slight tendency to rotation of the bones of
                         the spine upon one another,  in such a way that the
                         bodies  of the vertebrae that form the dorsal curve,
                         are twisted slightly to the left, whilst those that enter
                         into the formation  of the lumbar curve  are  slightly
                         turned  to the  right.  On examining the bones and
                         intervertebral  fibro-cartikges after  death,  even in
                         cases of very considerable distortion, no disease will
                         appear  in them, except, perhaps, that the bodies of
                         some may have been slightly compressed where they
                         form the principal concavity  of the  arch.  The liga-
                         ments appear to be stretched, relaxed, and somewhat
weakened in these cases; and the muscles are usually pale, flabby, and apparently
wanting in power.
 
CURVATURE OF THE SPINE.                  609
   From  a consideration of the pathology of this affection, and from the particu-
lar age at which it manifests itself, before  the bones have become completely
ossified, or the ligaments have acquired their due degree of rigidity, its mecha-
nism becomes sufficiently apparent.   The spinal column being composed of a
number of separate bones, possesses no firmness  in itself, or power of self-support,
but is maintained in the  erect position  by the close manner in which its separate
elements  are  knit together by ligamentous and muscular structures, and by the
way in which, when thus bound together as a whole, it is supported on  either
side by the  strong mass  of the  erector spinas muscles.  The  proper  tension of
these ligamentous supports, and muscular masses, is especially necessary for it
to maintain  the weight of the head and shoulders, which is thrown on the cervi-
cal and upper portion of the dorsal spine.  If, from any cause, the ligaments
become relaxed, and the  muscles lose their tension, or, if the weight of the  upper
part of the  body increase disproportionately to  the augmentation in the strength
of the ligaments and muscles that support  the spine, the vertebral column will
necessarily give way under the pressure to which it  is subjected in a direct line
from above downwards, and will consequently become curved.   Most commonly,
indeed almost invariably, this takes place in a  lateral direction, the spine yield-
ing more  readily in this  than in any other.  In some rare cases, however, the
lower portion of the cervical, or upper dorsal region, will project backwards in an
angular manner, and  in  other cases, of still less frequent occurrence, there may
be incurvation of the spine in the lumbar or dorso-lumbar region.
   These various kinds of deformity, as has  already been stated, chiefly occur in
girls  about  the age of  puberty; at a time of life when the tonicity of the
muscular system not unfrequently becomes lessened by the  occurrence of anemia
and  those states of impaired health that so  frequently attend the establishment
of the uterine function ; and before the osseous and ligamentous structures of
the body have fully developed.  At this period  of life, also  it frequently happens
that the spine becomes rather suddenly elongated by a rapid increase in growth
taking place, or  that  it becomes overweighted by the system developing itself,
and  the shoulders and bust becoming stout and expanded.   Indeed, so frequent
is the occurrence of a certain degree of lateral curvature of the spine from these
various causes, about the age of puberty in  girls, that few  escape a tendency to
deviation, of so slight a kind, however, as not to admit of recognition as a disease.
But if this  tendency be  allowed to go  on unchecked, or if it be increased by
injurious habits, amongstiwhich all one-sided postures in which the body is twisted,
as in playing some musical instruments, or in leaning over a table in drawing and
writing, the  slight deviation may rapidly increase until it assumes the  true cha-
racters of lateral curvature of the spine.   I do not think that there is any evidence
to show that this is either a strumous or a ricketty affection; indeed so far as my
observation goes, I should certainly say that strumous girls  are less liable to the
disease, than those of a nervous or  bilious temperament.   A ricketty  tendency
would, of course, increase the disposition to the affection, but  I think it is very
rarely associated with it.   Amongst the more common predisposing causes must
undoubtedly be reckoned the indolent and  sedentary occupations and the  luxu-
rious enervating habits that are commonly encouraged in girls in the higher ranks
of life, and which, by preventing due muscular development, at the  same time
that  they induce a general loss of tone in the system, may directly occasion the
disease.
  The signs  of this affection when it is  well marked, are distinctly obvious.   The
serpentine character of the curve, its double nature, the convexity on one side
looking to the right shoulder, and on the other to the left loin, will render its
nature evident.  Most commonly it  commences in a gradual  manner  the first
condition that  frequently attracts attention  being the  prominence of the  right
scapula, which  is  supposed  to be  "growing  out;" or the  sterno-clavicular
                                    39 
610
DISEASES  OF  THE  SPINE.
Fisr. 1SS.
articulation on the same side, or some of the cartilages of  the  ribs have been
observed to project.   Whenever the  surgeon is consulted  for such symptoms as
these, he should at once examine the spine, which he will generally find to have
an inclination to the right  side.  In the early stages of the disease, when the
deviation is not very distinctly marked, the  readiest mode  of determining it is to
let the patient stand upright, taking  care that the feet are well placed together,
and that the attitude is not  forced but natural; the surgeon  should then run his
finger down the back from  one spinous process to another,  touching each as he
                              passes it with a pen  dipped  in ink;  in this way
                              when he has reached the lower part he will have
                              mapped out  the course of the vertebral column,
                              and  thus may see at a glance the nature and
                              extent of its  displacement.  At the same time
                              he will  probably observe that the two hips  do not
                              exactly correspond,  the  left  being  somewhat
                              thrown  out.  Very  commonly there  is a good
                              deal of  neuralgic tenderness  about the spine, and
                              at this  early stage there may  be  anemia and
                              symptoms of impaired nutrition.  As the disease
                              advances, the curvature becomes more distinct,
                              and at the same time, owing to the torsion  of the
                              column, assumes  a slightly angular   character
                              where most  convex.   The ribs on the right side
                              are thrown  out and bulging, and carry up the
                              scapula  with  them whilst  those  on the left are
                              sunk  and depressed.  In  fact, the whole of the
                              right side of the chest and body partakes in the
                              projection of the  spine  on  that side,  and thus
                              adds  much to the general deformity; whilst the
                              left side of the chest is correspondingly hollowed
                              and sunk in (Fig. 188).  When the disease is
                              advanced in  this  way, it always occasions great
general debility,  emaciation,  and pallor, the  nutrition of  the  body  being im-
paired partly by the compression to which the thoracic and  abdomial  organs are
subjected,  and partly doubtless by irritation  set up in the spinal cord, induced
by the curvature.
   During the early part of the disease the  spine preserves its  flexibility, and
whilst the  curve is still recent, and the patient young, if the weight of the head
and  shoulders be taken off,  it will at once resume its straight direction.  Thus,
if the patient be lifted off  the ground by raising her up  with the hands  under
the axillae, or if she be laid down on her face on  a flat couch, the back will fall
into a straight position, or may readily be made to do so by slight traction.  After
the  disease, however, has existed for some years, or if the patient has passed that
age at which consolidation  of the bones and ligaments takes place, the distortion
will continue permanently in whatever position she is placed.  This is not only
owing to the deformity of the spine, but to the ribs, and ligamentous and muscular
structures  generally of the trunk, having become fixed in their abnormal position.
   The treatment of lateral curvature of the spine  should be conducted on rational
 principles, and when divested of the mystery with which  some interested and
 unprincipled specialists have surrounded it, it becomes as simple as that  of any
 other chronic surgical  affection of the  bones, joints, or muscles.   The first point
 to be attended to in the management  of these cases is the  improvement of the
 general health; unless this is  effected, nothing  can be done.   The administra-
 tion of some of the  milder  preparations of iron, with a course  of aloetics  for the
regulation of the uterine function, is of great moment; at the same time  a nour-
 
LATERAL  CURVATURE  OF  THE  SPINE.            611
ishing diet of animal food should be allowed, and the patient encouraged to take
exercise in the  open air.  By these means the nutrition of the system will  be
improved, and the tone of the  muscles greatly restored.  The muscular power
may be more directly strengthened  by having the back well sponged with cold
salt  or vinegar and water every morning, and methodically rubbed from  top  to
bottom.  The friction should be principally directed to the erector spinse muscles
on either side of the vertebral column, and may be done either with the naked
hand, or with some slightly stimulating embrocation.   At the same time,  if the
patient's strength will permit of it, but not otherwise, the use of the hand-swing
may be allowed, or calisthenic exercises practised; these, however should not  be
continued if they induce a feeling of fatigue or exhaustion.   Whilst this plan is
being persevered in, the patient should be made to lie recumbent for a few  hours
daily, sitting or standing as little as possible.   By these means, assiduously con-
tinued for some length of time, the muscles of the back may be strengthened,
and the increase of the deformity prevented ; and in this way the  slighter cases
of lateral curvature, those in which  there is rather  a tendency to, than a full
development of the disease, may be cured.
   When the affection is further advanced, though the spine still continues flexible,
there being decided projection of the ribs on one side, with prominence of the
shoulder and hip, with apparent difference in the length  of the limbs, and  much
impairment of the general health, more decided measures of treatment must  be
had recourse to.   In these cases, as  in those  just described, the  constitutional
powers must be carefully attended to on  ordinary medical principles; iron, and
good living, with  fresh air, being the basis of the treatment.  At the same time
that we endeavor to  improve the strength of the system in this way, and that
of the muscles of the back, specially by cold bathing and frictions, it is essential
that we adopt means to take off  the weight of
the head  and shoulders, and to prevent its
continuing to keep  up, and to  increase the
deformity.   This may be done  in two  ways :
by keeping the patient in the recumbent po-
sition, or by allowing her to  go about, wearing
proper supports.
  The recumbent position  in the  treatment
of lateral  curvature of  the  spine,  though a
valuable means as  an  adjunct to other mea-
sures, has, I think, been greatly abused, by
being employed as  an  exclusive plan.   This,
I think, should not be, except when the pa-
tient is unable to stand or walk with comfort,
as happens  in  some of these cases, when it
may be necessary to confine her for a time to
this position, until the proper muscular power
is restored  by other means.   These instances,
however, are very rare;  too much so to con-
stitute  the rule  in the  treatment.  Whenever
the recumbent position is employed, the prone
seems to me to be far preferable to the supine,
for reasons mentioned when speaking of angu-
lar curvature of the spine; and the best couch
for the purpose is  certainly Yerral's.   The
patient should  be  kept on  this during the
intervals of exercise, not being allowed to sit or stand, even at meals ; she will
very soon become accustomed to a  position that,  at  first appears constrained,
and will, probably, speedily be enabled to sleep on it.
 
612
DISEASES  OF  THE  SPINE.
  The best mechanical contrivance for supporting the weight of the head and
shoulders, is Tavernier's belt, either in its original form, or as  modified by
Lonsdale, and represented  in  the accompanying wood-cut  (Fig.  189).   By it,
the projection of the right shoulder may be gradually brought down, the left
one raised,  and the weight of the whole of the upper part of the body sup-
ported.   By this contrivance  alone, properly and carefully adjusted to the con-
dition of the deformity, many patients may be treated without the necessity of
any confinement whatever;  the spine being gradually restored to its  proper
direction by very gradually increasing the pressure and support of the  instru-
ment, at the same time that the  general  health  is carefully attended to, and
the patient  has the benefit of sea air.   In  the majority  of cases, however, I
think it is well  to conjoin the use of this instrument  with that of the prone
couch;  the  patient  sleeping  on the  couch, or reclining  on it at meals and
when in the house, whilst she wears the belt out of doors,  and  for  the purpose
of exercise; taking  care to apply it and take it off in  the  recumbent position.
In this way many severe cases of spinal curvature may be successfully treated
without interfering with the patient's  education, or her usual habits.  In long-
standing cases  of deformity  of  the  spine, when its flexibility is lost, and the
projection of the ribs  has become  permanent, the patient will derive great
comfort and support  from the use of this excellent instrument, and  the increase
of the disease may thus be prevented, even if direct amelioration be  not effected.

                              SPINA BIFIDA.

  It occasionally happens  from congenital malformation that the spinous  pro-
cesses of some  of the vertebrae  are deficient, and their laminae either  absent
or separated; in  consequence of  this the  meninges  of the spinal cord in this
situation are unprotected, and project through the  aperture in the bones,  giving
rise to a tumor at the part where the arrest of development in the osseous struc-
tures  occurs.    This tumor is usually of  an oval shape,  its  long axis corre-
sponding to that of the  spine.  It is generally met with about the size of a
walnut  or an orange, but  occasionally attains an immense bulk, equal  to  that
of a child's head.   In some  cases this tumor is  lobukted, having an  imper-
fect  septum stretching across it;  in other instances  two  or more of  these
tumors have been met with in the  spine.  The skin covering it is usually of its
normal  color, but when the tumor  is of considerable size it may have a bluish
or congested appearance, and admit of a  certain degree of transparency.  On
examining  the  tumor,  which  is hard though  elastic  when  the child is held
upright, it will be found that it becomes soft when the  child is laid  horizontally.
It usually becomes tense during  expiration, and softer  during  inspiration.  In
some  cases fluctuation is perceptible, and by pressure the bulk may  be lessened.
Spina bifida may be  met with  in any part of the vertebral column  ; it is, how-
ever, almost invariably found  in  the lumbar region, the  cases in which it occurs
higher  up being of very rare occurrence, but instances of the kind are men-
tioned by Cruveilhier.    When  it occurs high up in  the  cervical or upper
dorsal spine, it has  been found that the  spinal  cord  and nerves are usually
adherent to the walls of  the  tumor; when  in  the  lumbar region this is not
the case.
   The prognosis of this affection  is necessarily unfavorable, the child  usually
dying at an early age, of convulsions.   In other cases the tumor  increases  in
size, gives way, and death results from spinal meningitis.
   In the treatment of spina bifida  but little can  be done in the  way of operation
when the tumor is of very large  size, and the skin covering it inflamed or ulce-
rated ;  or when a large portion of  the bones appears to be deficient.  In those
cases, however, in which the child is otherwise healthy and strong, the  tumor 
DISEASES OF THE HIP-JOINT.
613
being of small size at its base, or pedicukted, and in which little  pain or other
inconvenience arises from  pressing upon it, some  means may be adopted  for
relieving or curing the deformity.
  The simplest mode of relief is to employ pressure  on  the tumor, by means of
a compress and bandage; or, what is  better, an air-pad, similar to those  used
for umbilical  hernia, and kept in place by an elastic India-rubber band. In addi-
tion  to pressure exercised  in this way, the recommendation  of Sir  A.  Cooper
may  be followed, and the tumor punctured with a grooved needle  from  time to
time, care being taken, however, to prevent the ulceration of  the  punctures  by
covering them with collodion.   In this way, by the combination of puncture and
compression,  cases have been cured.  All other plans of treatment, by which the
tumor is opened and air allowed to enter it, are fraught with danger, and will, I
believe, be inevitably followed by the  death of the child from inflammation of
the meninges  of the cord and convulsions.
                          CHAPTER  XLV.

                    DISEASES OF  THE  HIP-JOINT.

   Hip disease presents so many points of peculiar and serious importance that
 it is usually, and not improperly, considered  as  a distinct affection, apart from
 other joint-diseases.   Like all these it  may be of an acute, subacute, or chronic
 inflammatory character, most commonly occurring in strumous subjects.  Indeed
 I think its connexion with  scrofula is  generally more  distinctly  marked than
 that of most other affections of the joints.  It almost invariably occurs before
 the age of puberty.   Out of 48 cases  of this disease, of which  I have taken
 notes, I find  that in 16 only did  it occur at or  after fifteen  years of age, and
 of these, in 6 cases only did  it occur above the age of twenty; thus it may be
 considered essentially a disease of childhood or early youth.  It commonly comes
 on  from very slight  causes;  over-exertion in a long walk, a sprain in jumping,
 a fall, or sitting  in the wet, are  usually the circumstances to which  its occur-
 rence is attributed.
   The disease may commence as  an inflammatory affection in any of  the struc-
 tures of the joint.   Mr.  Aston Key was of opinion that it frequently commenced
 in the ligamentum teres; other surgeons have referred its origin to each of the
 different structures that enter into the composition of the articulation.   Without
 denying the possibility of the affection sometimes commencing in the ligamentum
 teres, illustrative of  which, indeed, there is a beautiful model in the University
 College Museum, I believe that it most frequently begins either in the cartilage
 or bone: for though  it is extremely difficult to prove this, dissection of hip-joint
 disease in the early stage being extremely rare, yet the symptoms  that attend it
 so_ closely resemble those accompanying the diseases of these structures in other
joints, that it is  impossible not to be struck by the similarity.
  In the  early  stage of the  affection the whole of the structures  of the joint,
 as well as  the head and neck of the femur, will  be found to  be  inflamed;  by
 proper treatment this morbid  action may be gradually subdued, without destruc-
 tion of the articulation taking place, though it must necessarily be left in a some-
 what rigid or even anchylosed state.  Most  frequently, however,  abscess forms
outside the joint, under the gluteal muscles or the pectineus, sometimes within
 the pelvis.   These abscesses may either communicate with the interior of the
 inflamed articulation, or may occur altogether externally to it.  In this stage of 
614
DISEASES  OF  THE  III P.
the affection, the head and neck of the femur will commonly be found  to be in
a carious state, disintegrated, softened,  red and gritty, closely resembling bone
that has undergone tuberculous infiltration, and consecutive inflammation.  The
acetabulum is commonly affected at the same time, being either carious around
its edge or base, perhaps even perforated;  the head of  the  bone having been
known to pass through it into the pelvis; or else partially filled by fibro-plastic
masses resembling vegetations, which occupy the space left by the diminution in
size of the head of the femur.  In these advanced forms of disease, dislocation
of the head  of the  femur commonly occurs and may arise from three causes:
the destruction of the joint, the capsular  ligament having given way in conse-
quence of inflammatory softening and ulceration, and the head of the bone being
thrown  out of its cavity by the action of  the surrounding muscles.  Or, caries
and partial absorption of the head of the  femur may  have taken  place, so that it
no longer fills up the cotyloid  cavity, and the ligaments being at the same time
destroyed,  it slips out on to the dorsum  ilii. Or, a fungous fibro-plastic mass may
sprout up from the bottom of  the cavity, and thus tend to push  the  bone out of
it, and  after  it  has been so  extruded,  this  growth  will  completely  fill the
acetabulum.
  The occurrence of dislocation is, in the great majority of cases, preceded  by
the formation of abscess in and around  the joint.  But in some instances it hap-
pens in  consequence apparently of the  softening of the  ligaments,  the  head of
the bone being thrown out of the acetabulum, without the occurrence of abscess
or any sign of suppuration.  In these cases a false joint may be formed upon the
dorsum ilii, where the head of the bone lodges.  When  it is lying in a suppu-
rating cavity it will always be  found to be in a carious state, and then no attempt,
or at  most a  very imperfect one, is made at the construction of an articulation
around it.   If the head of the  bone remains in the acetabulum after the destruc-
tion of a joint, anchylosis, either complete or incomplete, will take place, as in
similar affections  of  other articulations.
   The symptoms of  hip-joint disease, consisting of pain in the limb, and altera-
tion in  its  position, length, or shape,  come on  in very different ways, according
to the form  that the affection  assumes.   AVhen of a subacute character—as
frequently happens in young children—the  first symptom that  usually attracts
attention is  that the child limps  and walks  in  a peculiar shuffling, hopping
manner; he  does  not stand firmly upon both feet, but rests on  the  toes of the
affected one, the  knee of which  is bent.   On examining the condition of the
limb it will be seen to be everted, somewhat abducted, slightly flexed upon the
thigh, with the knee partly bent, and apparently shorter  than the  other.  This
shortening, however, is  apparent and not real; for  on laying the  child on  its
back  it will be found that the pelvis  is  placed obliquely; the anterior superior
spine on the affected side being raised to a higher level than that on the sound
one,  and  at the same time turned  somewhat forwards; measurement  of the
limb from this  point to  the  ankle, will show that  there is  no alteration in  its
length.   This obliquity of the  pelvis, which is  of very early occurrence in
diseased hip, is owing to the  child lifting the foot off the ground  in  order to
avoid pressing on it  in walking or  running, and in  doing this he is obliged to
raise not only the limb, but the corresponding side of the pelvis.  This apparent
shortening will commonly give place, after  keeping the  child in bed for a few
days, to a simulated elongation of the limb; the pelvis on the affected side
descending below its natural level.  At the same time that these symptoms  are
noticed, the  child usually complains  of pain in  the  hip, especially on pressing
over the pectineus muscle, or behind  the trochanter; this is increased by stand-
ing, walking, or any attempt to bear  upon the joint; abduction also, and rota-
tion of  the limb outwards is particularly painful, and  any concussion of it, as by
striking the heel or  knee, will  greatly increase the suffering.  At  this  stage of 
SYMPTOMS  OF  HIP-DISEASE.
615
the disease, the patient will often refer to  the knee rather than the  hip as the
seat of pain, and a careless surgeon might be misled and treat the wrong joint;
the more so as there is  not unfrequently a good deal of cutaneous  sensibility
about the inner side of the knee-joint.  This pain appears to be seated in the
obturator nerve,  the articular branch of which sent to the hip becoming impli-
cated in the disease,  communicates a radiating pain that is felt at the'extremity
of the long descending branch which is distributed to  the knee.   On turning
the child upon its face it will be observed that the nates are somewhat flattened,
the fold being in a great  measure obliterated, and, if it be a female, the vulva
on the affected side will be seen to be placed at a lower  level than on the sound
one.
  As the disease advances, abscesses may form at any part in the vicinity of the
joint.  They most commonly occur under  the glutei muscles, but sometimes at
the anterior  part, under the pectineus.   When in this  situation, they occasion-
ally give rise  to  very severe suffering  down the inner side of the thigh, by
exercising pressure  upon the obturator nerve,  which  may sometimes become
tightly stretched over the subjacent cyst of the abscess.
If the acetabulum be involved in the  diseased action,          F'=-,90'
matter may form within  the  pelvis.   It is  about this
period that true  shortening of the  limb takes  place;
which at the same time becomes adducted and inverted,
thus assuming a very different position to what it pre-
sented in the early stage  of the disease.  The different
positions into which the limb falls in the two stages of
the complaint, are evidently due  to  alterations  in  the
muscular action brought  to bear upon it.   In the early
stage, the strong  external rotators, which  are in close
relation  with the joint, become irritated by the exten-
sion of inflammatory  action to them, or by the pressure
to which they are exposed by the distended  capsule;
and hence,  being called into  increased  action,  the
limb is everted,  at the same time  that it  is slightly
flexed and adducted by the irritation to  which  the
psoas and iliacus are subjected.   As  the  disease  ad-
vances,  these  muscles become wasted, undergo fatty
degeneration,  absorption, or  disintegration,  by  the
formation of abscesses underneath and around  them;
hence, the  action of the adductor muscles being no
longer counterbalanced,  the limb is  drawn  upwards
and forwards and turned  inwards (Fig. 190).
  The  shortening of the  limb may  arise, in very
chronic  cases,  from  general  atrophy of the member,
consequent  upon disuse; and this,  no doubt,  in all
instances, after a time, influences its condition.   Most
commonly, however,  it occurs from  absorption of the head of the bone, and in
other cases from its dislocation upon  the dorsum of the ilium.   In these cases
the  remains of the dislocated head can  be felt through the thin and weakened
muscles  in its  new situation, and in other  instances may be felt  lyino- at the
bottom of a cavity in a carious state.
  After the formation of abscesses the health, which may up to this  time have
kept pretty good, speedily gives way, exhaustion and hectic coining on, and the
patient perhaps, at last, sinking from the wasting influence of the diseased bone,
and the  discharges it occasions.
  In the more acute form of the disease, the affection sets in in a very  different
 
616
DISEASES  OF  THE  III P.
manner : here  the patient is seized with signs of acute inflammation of the
joint, coming on pretty rapidly, and with great constitutional disturbance and
pyrexia.  The  pain in  the joint  in these cases is of the most excruciating
character,  accompanied  by spasms and twitching of the limb, and marked by
nocturnal exacerbations.  The suffering  is so intense, that  the  patient cannot
bear the slightest movement of the  limb; a fit of coughing, the weight of the
bed-clothes, or  the shaking of the  bed by a person leaning against it, will give
rise to the  most intense agony; and in the intervals of his suffering the patient
is in constant fear of a return of the pain, to which he looks forward with much
anxiety.  In these cases the  limb is everted, abducted, perfectly helpless, and
motionless; the nates  will be found flattened, and there  is usually some fulness
about the anterior part of the joint, under the pectineus muscle, or to  its outer
side, above the trochanter.   There is  also sometimes true  elongation of it, in
consequence of  the capsule becoming distended with fluid, and  pushing the head
of the bone downwards.  In measuring the limb, in order to ascertain its true
length, it is necessary  to examine the two together,  and  to place the  sound in
exactly the same position as  the  diseased one;  unless  this  be done,  error will
very probably creep in, for in measuring the lower extremity, from the anterior
superior spine to the lower border of the patella or the inner malleolus, it will be
found to be of greater length when adducted or extended than when  abducted
or bent.
  In  some cases the distension of the capsule with synovial fluid, as the result
of the  inflammation in the joint, may be so great as to lead to its rupture, and to
the sudden dislocation  of the  head  of the bone on to the dorsum ilii, with great
pain and much shortening.   This, however, is of very rare occurrence; the dis-
location seldom  taking place until after abscess has formed within the joint, and
the articulation been thus destroyed.   In this, the  acute form of hip disease,
various terminations may occur;  the  result depending greatly upon the constitu-
tion of the  patient, and the manner in which the affection  is treated.  Under
the most favorable circumstances, as the inflammatory action is  subdued, the dis-
ease falls into the subacute condition, and recovery gradually but very slowly takes
place,  with a limb that continues somewhat stiff and partially anchylosed, as well
as wasted and somewhat shortened  from disuse.  In other cases, again, complete
anchylosis  occurs without the  previous formation of abscess.   In other and the
majority of instances, abscess forms,  and then the patient may either be worn
out by the continued irritation of  diseased bone, or by  the  profuseness of the
discharge; or great shortening taking place either by the absorption of the head
of the bone, or its dislocation out of  the  acetabulum, the cavity of the abscess
may ultimately contract, the carious portions of bone exfoliate, and the sinuses
close after  years of suffering.  Under  the  most favorable circumstances, when
once the joint has been acutely inflamed, a year or  two  will elapse before the
patient can use his limb with any degree of security.  The safety of the patient
depends in a great measure on preventing the occurrence of suppuration.  If the
constitution  be  of a very strumous  character, this can rarely be done, but  if
tolerably healthy, the disease may be prevented passing on to this stage, and then
the patient may recover with a useful though somewhat  stiff and crippled limb.
If suppuration occur, it is very seldom that an adult patient recovers, hectic and
exhaustion  speedily carrying  him  off.  The life  of children may, however, be
saved even under these circumstances; but they will be left permanently lamed.
  In making the diagnosis  of  this  affection, care must be taken not to confound
it in its early stages with an ordinary attack of rheumatism; a mistake that not
unfrequently happens;  the  alteration  in the shape and position of the  limb, the
obliteration of  the fold of  the nates, and the limitation  of the pain to the one
joint, will usually prevent the surgeon falling into this error.  With disease  of 
TREATMENT  OF  HIP-DISEASE.
617
the knee, care must be taken not to confound hip disease in consequence of the
pain in the early stages being commonly referred to that joint; here the absence of
any positive sign of disease about the knee, and the existence  of all the signs of
disease in the hip that have already been  noticed, will enable the surgeon  to
diagnose the true seat of the affection.  Lateral curvature of the spine, accom-
panied by neuralgic  tenderness  in the hip, occasionally gives rise to apparent
shortening of the  limb with  pain and rigidity; but in  these cases the existence
of the spinal affection, the superficial nature of the pain, and  the absence of in-
crease of suffering when the joint is firmly compressed,  or of painful startings at
night, will indicate the true nature of the affection.  Abscess may occasionally,
though rarely, form in the vicinity of the hip without that joint being diseased.
Should this take place towards the anterior aspect of the articulation under the
pectineus muscle, it may, by its pressure upon the obturator nerve, occasion pain
in the thigh and knee, as in those cases in which  the  articulation is affected;
here,  however, the sound state of the joint at its posterior and  outer part, the
absence of all obliquity of the pelvis, and  of the other signs of the true hip-
disease, will enable the diagnosis to be effected.
   The treatment of disease of the hip must be  conducted with reference to the
acuteness of the  attack,  and the  severity of  the local  and constitutional symp-
toms.  In all cases  this  affection must be managed in accordance with those
general principles that guide us  in the treatment of inflamed joints.
   When the disease is of the more  acute  kind, the patient  must of course be
kept  in bed, and  treated with  calomel and  opium,  pretty freely administered,
having a full dose of  opiate at night, in order to prevent the painful startings of
the limb.   The inflamed joint should  be leeched, or, if the patient can bear it,
cupping glasses may be applied  behind the trochanter; it must also be comfort-
ably arranged upon pillows, so as to be kept in as easy a position as possible, and
great relief will be  afforded  to the patient  by the application  of* hot poppy
fomentations.  When the inflammatory action has  been somewhat subdued,  the
joint may be conveniently fixed by means of a leather splint or the starch bandage.
Of the  two,  I prefer the starch bandage, as  being more easily  applied,  and
forming a better fitting and more secure casing to the limb.  In applying it,  the
limb should be bandaged from the toes upwards, well padded about the knee with
cotton wadding, and the  bandage carried  in  repeated turns round the  hip and
body  in  the form of a  spica;  at the posterior part  of the hip  it should be
strengthened with  a piece of pasteboard lined  with calico, sufficiently long to ex-
tend down the whole  of the back  of the thigh to below the knee, so as  to sup-
port that joint also.   It is of much importance  to do this, as otherwise  the hip
cannot be kept  immovable.   In applying  this, or  any other apparatus,  in the
more  acute form of the disease, the patient will commonly require to have chlo-
roform administered,  as the pain occasioned by the necessary movements would
otherwise  be too severe to be borne.   After  the starch bandage has well set, a
trap may be cut  in it opposite any part of the joint to which  it may be thought
necessary  to make applications,  and the perineal aspect of the  apparatus must
be well lined and covered with oiled silk, so as to prevent its being injuriously
soiled.  In  this way the  limb may be immovably fixed in a  proper position by
a light and  firm  apparatus  that will  seldom require to be  changed during the
treatment of the case.
  When the disease  has fallen  into a somewhat chronic condition, or from the
very first of the subacute variety, a different  and less active  line of treatment
requires to be pursued.  In these cases, rest and perfect immobility by means of
the starch bandage are indispensable;  in conjunction with this, the employment
of counter-irritants, more  particularly  the  caustic issue, will  be attended with
great advantage; the  issues may readily be applied through traps, cut in the ap- 
618
DISEASES  OF  THE  HIP.
paratus behind the trochanter, and at the fore part of the joint opposite the pec-
tineus muscle.   At  the same time a course  of  moderate alteratives and  tonics
conjoined, will be found most advantageous.   To children, a powder composed
of a grain of mercury and chalk, two grains of carbonate of soda, and three of
rhubarb, with or without half a  grain of quinine, may be administered twice a
day.   To adults, the bichloride  of mercury in small doses with sarsaparilla or
bark will be  found most useful.   This alterative plan must be persevered in  for
a sufficient  length of time,  and  as the  symptoms  of inflammatory action sub-
side, and those of strumous disease manifest  themselves more unequivocally,
cod-liver oil, with the iodides of potass or of iron, may be advantageously sub-
stituted.
  During the whole of the treatment, the general health requires careful super-
vision, the  diet must be attended to, and should be as nutritious as possible, the
state of the bowels regulated, the skin kept in  good  action with a flesh-brush,
and the patient reside in well-ventilated apartments.   It will very  generally be
found  that  the liver is  peculiarly apt  to get out of order in this disease, the
patient becoming jaundiced and  feverish ; these complications must  be treated
on general principles.  As the health improves, a change to the sea-side will  be
attended with great  advantage, and  the patient  may be allowed to move about on
crutches, having the foot suspended  in a  sling, as in the case of a  fractured
thigh.
  As abscesses form they should  be opened early;  no good resulting by delaying
to give exit to the pus, which only  spreads more widely, disorganizing the soft
structures, and means should be taken, by tonic remedies and  nourishing food,
to keep off  hectic.  If dislocation has taken place and the limb consequently
becomes a good deal shortened or deformed, being perhaps adducted and inverted
so far as to be twisted over the other, or drawn up upon the abdomen, much may
be done to lessen the deformity by putting the patient under chloroform, bringing
down the limb, and fixing it down in a  starch  bandage.   Anchylosis may thus
be sometimes got in a good position, and the patient's condition  be greatly im-
proved.  It is a question whether an  attempt at reduction should be made in
these cases of consecutive dislocation, as it is very rarely that it  would prove per-
manently successful, the  acetabulum being either filled up with fibrous matter, or
the head of the bone so diseased and lessened in size, that it would not remain
in its cavity when put back.  Occasionally, however, the reduction  may he suc-
cessfully effected.   In a woman, under  my care, at  the Hospital, with sponta-
neous dislocation of the hip  of about a month's duration, reduction was effected
by  means of the  pulleys,  and the  head of the bone replaced in  the cotyloid
cavity, where it remained for some  weeks; becoming, however, displaced  again
in consequence of its being necessary to remove a bandage that  was applied, as
she became  affected with inflammation  of the chest,  and could not bear  its
pressure.
  The excision of the head of the femur, in some forms of hip-disease, has of
late years been much discussed.  This subject has more especially had attention
directed to it by the writings of Fergusson, H.  Walton, and II. Smith.
  Mr. Walton states, that this operation has been done twelve times, and of these
six  cases have survived.   " But even yet," says Mr.  Fergusson, who is one of its
greatest advocates, " experience as to the results of this operation is so limited,
that I can scarcely say more  on the  subject than  express a belief, that in some
instances of disease, and of  gun-shot injury of the neck or head of the  bone,
such a proceeding might be of service."   The  cases requiring it are necessarily
not very numerous.   It  may, however, be  stated, that when the disease  about
the hip is limited to the  head and upper end of the femur, the acetabulum and
pelvic  bones  not being involved, but  the head of the bone displaced from its 
CHRONIC RHEUMATIC  ARTHRITIS.
619
cavity, and lying in a carious or necrosed condition on the dorsum of the ilium,
with sinuses leading down to it, the patient's general health reduced  by hectic,
consequent upon  the profuseness of  the  discharge  and the  irritation of the
disease, the surgeon would certainly be justified in  cutting  down  upon and  re-
moving the source of all  this mischief, with a view of  preserving the patient's
life, in accordance with those general  principles that guide us in the manage-
ment of diseased bone in other situations.   The cases, however, in which this
peculiar combination of circumstances  occurs, and in which such an operation
would consequently be required, are rarely met with.  The great objection to the
operation, in the majority of instances, being the extension of disease to the coty-
loid cavity and the bones of the pelvis, involving them to a considerable extent,
and in such a  way as to  prevent  the complete removal  of the  diseased osseous
structures.
   In hip-disease the acetabulum will be found to possess  far greater reparative
powers than the head of  the femur, so that even when  diseased it may recover
itself;  its disease, when  moderate, is therefore no bar to the performance of exci-
sion of the head of the femur.
   In many cases examination with a probe will enable the surgeon to detect the
existence of disease in the bones of the pelvis, as  well  as  in  the head of the
femur;  but in other instances it may not be possible for him to do so.   Under
these circumstances, the  question as to the propriety of performing the operation
may, to a  certain extent,  be determined by the position of the head of the femur.
If this has been dislocated early in the disease, and be  lying in a  carious condi-
tion upon  the dorsum ilii, the probability is that the morbid action is confined to
it, the acetabulum being  filled up with fungous plastic matter.  If, however, the
displacement has been of recent occurrence, it is not unlikely that the osseous
surface  of the cotyloid cavity is involved.   If the head of the bone still con-
tinue in its socket, the operation should not, I think, be undertaken ; for in these
cases, if the disease  is far advanced, the morbid action will almost  invariably
have extended to  the bottom or sides of the acetabulum.
   The operation itself is not difficult  of performance,  the  carious head of the
femur, lying at the bottom of an abscess or of sinuses, may readily be exposed
by a T shaped incision over it.  When it is exposed it  may be turned out  by
drawing the limb over the opposite thigh, and rotating it outwards, when it may
be cut off  through  the neck or trochanter  by means of an ordinary saw.  In
planning the incision, care must of course be taken not to cut too far forwards, lest
the anterior crural nerve be wounded;  or too freely backwards, lest a gluteal artery
be injured.  After the operation the wound must be dressed in a simple manner,
and a long splint applied.   Mr.  Fergusson recommends that the extension,  by
means of the perineal band, should be  made from the opposite  thigh, round the
upper part of which a laced socket is fixed, to which the band  is  attached.   In
such cases as these, much advantage, I should imagine, would be derived by the
use of the bracket thigh-splint, as figured at page 224.  Shortening of the limb
will necessarily result, but as this is the inevitable consequence of all disease of
the hip, that gives rise to the dislocation of the bone, it need scarcely be taken
into  account;  the operation being  rather done with the  view  of savins the
patient's life in the only way that is practicable, than to improve  the length of
the limb.

                     CHRONIC RHEUMATIC ARTHRITIS.

  A peculiar disease has  of late years been described by Mr. Adams and B. W.
Smith, to which the name of "chronic rheumatic arthritis'  has been given.  It
commonly  affects the hip, but has been met with in the temporo-maxilkry arti-
culation, and also, I think,  occurs in  the shoulder;  at  least I  have  met  with 
620
DISEASES  OF  THE  HIP.
cases of disease of this joint presenting all the characters of this affection during
                                                 life, though as there has been
                                                 no opportunity of examining
                                                 the state  of the  parts after
                                                 death, it is impossible to speak
                                                 positively as to the true nature
                                                 of the disease.  Chronic rheu-
                                                 matic  arthritis  is  an active
                                                 disease of the bones and fibrous
                                                 expansions  about  the joint
                                                 being especially characterized
                                                 by considerable increase in the
                                                 size and by alteration in the
                                                 shape  of  the osseous struc-
                                                 tures, which  become  porous
                                                 in some parts, porcellanous in
                                                 others, with thickening of the
fibrous capsule of the joint, deposit of masses or plates of bone in it, and ulti-
mate destruction  of the  cartilages  and  synovial membranes.  The suffering
attending the disease is considerable, it greatly cripples  the utility of the joint,
at last produces incomplete anchylosis of it, and is incurable.
              CHRONIC RHEUMATIC ARTHRITIS OF  THE HIP.

  This form of the disease commences with a degree of pain and stiffness about
the joint, increased at night, and especially in damp or cold weather, presenting
in this respect, the ordinary characters of a rheumatic  affection;  as the disease
advances the pain is much increased by standing or walking, and the movements
of the joint become gradually more and more inpaired.  The patient experiences
the greatest  difficulty in bending the body forwards from  the  hips;  he conse-
quently is unable to stoop, or to sit in  the ordinary position, being obliged to
keep the limb straightened in nearly a  direct line with  the trunk.  The diffi-
culty in  walking, in  standing erect, in  stooping, and in  sitting increase.  The
limb becomes shortened to the extent of about an inch or more, owing to changes
that take place in the head  of the bone.   The pelvis also assumes an oblique
direction, and hence the apparent shortening becomes considerably greater.  The
knee and foot are everted, and the heel  raised.  The shape  of the hip also alters
considerably; it becomes flattened  posteriorly, the folds of the nates disappear,
but the trochanter seems to project, and  on examination seems larger and thicker
than natural.  On rotating  the limb it will be felt that the movements of the
bone are extremely limited, and crackling or osseous crepitation will often be felt
around the joint.  As Mr.  Smith remarks, the lumbar vertebrae acquire great
mobility, the thigh on the affected side is wasted,  but the calf retains its natural
size and firmness.
  On examination after death it will be found that the joint, the  bones, and the
surrounding parts have undergone remarkable changes.  The capsular  ligament
is thickened, and the synovial membrane is of a  bright-red color, vascular, and
fringed in some  parts, whilst it has disappeared in others.  The ligamentum
teres is destroyed, and the head  of  the bone denuded of membrane, the vascular
fringes being attached around the neck.  The head of the bone becomes remark-
ably altered in shape, being flattened, greatly  increased in  size, or placed more
or less at a right angle with the shaft, sometimes elongated, and  always very
irregular and tuberous.  The neck is more or less absorbed, and in some cases
appears as if it had undergone fracture.  The acetabulum  generally becomes
enlarged, sometimes of a more or less circular and flattened shape; at others, pro- 
          CHRONIC  RHEUMATIC ARTHRITIS  OF  THE  HIP.       621

jecting at its rim, narrowed, and embracing tightly the head of  the femur (Fig.
191).  Both it and the upper part of the thigh-bone  become porous, and perfo-
rated with numerous small foramina.  Stakctitical masses of bone and  porcella-
nous deposits are commonly thrown out about the base  of the trochanter, but more
particularly  along the intertrochanteric line within the capsule of the joint, and
not unfrequently in the soft tissues around it.   These masses of bone constitute
one of the most  important characters of the disease, and it is their presence that
communicates the peculiar crackling that is felt  in  the  hip during life.   The
muscles and soft  structures in the vicinity of the  joint are  necessarily wasted,
partly from  disuse and partly from the pressure of the morbid masses of bone.
  This disease most frequently occurs amongst  the poorer classes, and is almost
invariably met with in males.   It usually occurs about the age of fifty, though
sometimes earlier.  I have seen two instances of it in  individuals little more than
thirty years  of age, one of whom was a female.  It is  an incurable affection, and,
as it is commonly attended  by much suffering, constitutes a source of  great dis-
comfort to the patient.
  It occasionally happens that individuals laboring under this affection meeting
with a fall or contusion on the hip, present many of the signs of fracture of the
neck of the thigh-bone, such as  shortening, eversion,  with some crepitation, and
inability to move the limb.   The diagnosis may in general readily be effected by
attention to  the history of the case, and by eliciting the fact that these symptoms
have existed before the  accident, although the pain  and immobility may have
been increased by it.
  In the treatment of this affection little can be done.   Best and  the habitual
application of  warm or stimulating plasters will afford relief, and, in  many in-
stances, the  administration of the iodide of potassium  with sarsaparilla will lessen
the nocturnal pain.  Mr.  Smith recommends an  electuary composed of guaiacum,
sulphur, the bitartrate and carbonate of potassa, and ginger, with a small quantity
of rhubarb, and I have certainly seen benefit result  from the administration  of
this remedy in some cases.   When the disease is once fairly established, and has
assumed a very chronic  character, nothing can be done except to mitigate the
pain by some such means as those recommended, conjoined with rest and careful
attention to  the general health.
  Chronic rheumatic  arthritis has also been described by Mr. Smith as occasion-
ally affecting the temporo-maxilkry articulation in individuals of rather advanced
life. This disease is mostly symmetrical, and gives  rise to an enlargement of the
condyle of the jaw, which can  be felt under  the zygoma, attended with much
pain in opening the mouth, a sensation of cracking or grating in the joint, and
some enlargement of the  lymphatic glands by the side of the  neck.  The pain is
generally increased  at night, and influenced by the state of the weather.   The
face becomes distorted, the affected side of the jaw projecting and being pushed
towards the opposite side, but when both joints are affected  the chin  projects,
the entire jaw being  drawn forwards.  This distortion is chiefly owing to the
destruction  of the articular eminence;  for when this takes  place, the external
pterygoid muscle draws the jaw forwards and to the opposite side; but when both
articulations are equally affected, these muscles  displace it directly forwards; the
glenoid  cavity becomes enlarged, the fibro-cartilage disappears, and the  condyle
is sometimes greatly thickened and flattened, and always rough, being  devoid of
cartilage.  In such  cases as these there  is little to be  done by medicine^,  but the
treatment must be conducted on the same  principles as  in  the same  affection
when attacking the hip.
  When affecting the shoulder, chronic rheumatic arthritis gives rise to consider-
able enlargement of the head of the humerus, wasting and rigidity of the del-
toid, and inability to move the  elbows  upwards, except  by the rotation of the
scapula on the trunk.   In fact, the scapulo-humeral articulation being fixed, all 
622
DISEASES OF  THE BURS'vE.
movements of the shoulder are effected through the medium of the scapula,
which becomes more mobile than natural.  The articulation is the seat of much
pain, lancinating at  times, but generally gnawing and intermittent, being de-
pendent on the state of the weather, and greatly increased in  cold and wet sea-
sons.   The whole of the arm becomes wasted and weakened in power. In two
instances I have seen this disease in young and otherwise robust and healthy men,
between twenty and thirty years of age, coming on without any apparent cause.
In both cases the joint continued  permanently rigid, though  the pain was re-
lieved by the use of the iodides and local counter-irritation.
                          CHAPTER  XLYI.

        DISEASES OF  THE  APPENDAGES OF THE JOINTS.

                        DISEASES OF THE BURS.E.

  The bursje which naturally exist, either  under the skin, beneath the muscles
and ligaments, or around tendons, are subject to various diseases.   Not only do
the normal bursae become  affected, but these sacs are  sometimes developed from
continued friction in situations where they are not naturally met with, and here
also they may undergo  disease; thus, for instance, bursae have been found to be
formed at the projecting point of a hump-back, on the  prominent parts of club
feet, or at the extremity of stumps.
  In the following situations bursae naturally occur, and may consequently be ex-
pected to be met with in a diseased state.   Behind the angle of the lower jaw,
on the symphysis of the chin, on the angle  of the thyroid cartilage, on  the acro-
mion, external and internal condyles of the humerus, olecranon, styloid processes
of the ulna and radius; on the dorsal surface of the metacarpo-phalangeal  articu-
lations, as well as on their palmar surfaces, and on the dorsal aspect of the pha-
langeal articulations; on the anterior  superior spine of the ilium, the great  tro-
chanter, the ischium, the  lower and the superior and outer parts of the patella,
on each condyle of the femur, the tuberosity of the  tibia, the two malleoli,  the
calcaneum, the dorsal aspect of the toes, and on the plantar aspect of the heads
of the first and fifth metatarsal bones.   Besides these situations they occur under
the deltoid, the gluteus maximus, and between the lower end of the scapula,  and
the latissimus dorsi.
  The continued irritation of bursae by the pressure that is exercised upon them,
may cause them to enlarge, to become  thickened, and to undergo various changes
in structure.   This enlargement of the bursae in particular  situations is often
connected with special  employments, by which continuous and severe pressure is
exercised upon certain  parts of the body.   Thus frequent kneeling will occasion
enlargement of the bursa patellae, hence called " housemaid's knee."   Miners are
occasionally subject to an  enlargement of the bursa  lying over the olecranon,
hence called " miner's  elbow,"  and in any  situation a new bursa may be formed
by continuous pressure and friction conjoined.
  The contents of enlarged bursae vary greatly; they may be composed simply of
a serous fluid of a clear straw color; at other times this becomes dark and  brown-
ish, with  much cholesterine  intermixed, and  may contain a number of whitish
bodies, of a fibrinous or cartilaginous appearance, about the size of grains of rice
and not unlike them.   On examination under the microscope, I have found these
granular bodies composed of a fibro-plastic material, in some cases resembling im- 
ENLARGED  BURSA
623
 perfectly developed granulation-cells;  they would therefore appear to consist, as
 Sir B. Brodie long ago pointed out, of masses of lymph that have either been de-
 posited in  the shape in which they are formed, or that  have been  divided and
 broken down, after being originally formed  in larger masses.   The wall of  the
 enlarged bursa is sometimes thin, at others greatly thickened  by the  deposit of
 concentric layers of plastic  material within  it.   In some cases the  deposit of
 plastic matter may go on into the interior of the bursoe, until their walls assume a
 very great thickness, and almost a cartilaginous hardness, and indeed may Continue
 to increase until the cavity is obliterated, and a dense fibrous tumor formed in its
 place.
   Enlarged bursas are readily recognised; forming, whilst their contents are thin
 and serous, indolent oval tumors with distinct fluctuation;  commonly occurring
 in the situation of some  of the normal bursae.   As they become more solid they
 become  elastic and  hard, and often crackle  on being  pressed  when  they con-
 tain the rice-shaped bodies; but at last acquire all the characters of an ordinary
 solid  growth, as the deposition within  them  increases.   Not unfrequently these
 enlarged bursae inflame;  or, indeed, an attack of inflammation in  them maybe the
 first cause of their enlargement.   In either case they become hot and tense, the
 skin covering them is red, often doughy and  cedematous;  and  although there is
 no connexion  between the bursa and the  neighboring joint, yet it may happen
 that the inflammatory action spreads to  the latter, from simple continuity of tissue.
 Suppuration very frequently occurs in an inflamed bursa;  the tension increases,
 the oedema and redness become more considerable, and the pain assumes a throb-
 bing character.  When the bursa is opened thick pus often mixed with shreds of
 sloughy tissue is evacuated.
   The treatment of these bursal tumors must  depend entirely upon their nature
 and actual condition.  When inflamed, rest,  the application of leeches, followed
 by tepid lead-lotions or poultices, and  general antiphlogistic treatment will com-
 monly subdue the increased action in them.  If suppuration take place, they
 must be freely opened and the pus evacuated.  When in an indolent condition,
 the surgeon has the choice of various plans of treatment, conducted on different
 principles.   If the sac  be thin,  the fluid of a serous character, and the disease
 recent, it may often be removed  by blistering, more particularly when it  occurs
 in the ham or under the  deltoid muscle.   In  some cases it may conveniently be
 obliterated by puncturing the cyst and then employing pressure upon it.  The
 surest mode, however, of closing the sac consists in exciting inflammation in it,
 either by the injection of the  tincture of iodine as recommended by Velpeau, or
 by passing a small seton  through  it.  The injection is readily effected by tapping
 the cyst with a moderate-sized trochar and  then  throwing in  about 5j of the
 compound tincture.  Inflammation will be excited, some discharge will usually
 take place, and on its cessation the walls of  the cyst will have become aggluti-
 nated together.  In these cases I generally prefer, however, as the most certain
 method, the introduction of a seton composed  of  a double  silk thread.   This
 may conveniently be passed through the canula after tapping the sac, in the way
 figured in page 336; a  poultice  should afterwards be applied, and the threads
 left in for about six days.  Discharge will  take  place through  the aperture  by
 which they have been introduced, and which may, if necessary, be enlarged; the
 cyst gradually contracts around them, and after their removal it will be found to
 be closed.   When  the cyst contains a number of the rice-like bodies, the seton
 may still be used, but it should be thicker than that just recommended, and the
aperture by which it  is  introduced should be very free, in order to admit of the
escape of the pus and granules.
  If the walls of the cyst are  very thick, or if the tumor have become  solid, it
must be dissected out.  This operation is most commonly, I think, required for
solid bursal tumors situated over the patella or the tuberosities of the ischium; 
624
DISEASES  OF  THE  BURSjE.
from both of these situations they may be removed with facility.   In  dissecting
out these solid bursae, an operation by the way which is occasionally required on
both knees, care should be taken not to make the incisions too wide of the disease,
and  more  especially to  avoid  separating the attachments of the fascia of the
limb from the edge of the patella, otherwise the layer of  cellular tissue leading
into the popliteal space will be opened up, and deep infiltration and  abscess of
the limb, sometimes even of a  dangerous character, may result.
  When the bursa that lies towards the plantar surface of the head of the me-
tatarsal bone  of the  great  toe becomes enlarged, or when a  new serous sac is
formed upon the inner and posterior  aspect of this bone,  the disease termed a
bunion occurs.  In this  affection the enlargement of the bursas is usually secon-
dary to an  alteration in the shape and position of the great toe, which, in conse-
      F\g. 192.         quence of the  pressure of narrow, pointed boots, has  been
     I        f/       thrown outwards in an oblique direction, so as to lie over,
     /        I       or under some of the contiguous digits (Fig. 192); in this
     /        \       way a sharp angle is formed at  the junction between the
    A/     x f      nrs* ph-akQX an°l the metatarsal bone  of the  great toe.
    / / \     |f      This angle being constantly pressed upon by the boot, be-
   \          I       comes irritated,  and, for its  protection,  the bursa that is
                     there  naturally situated becomes  enlarged, or an adventi-
                     tious one  forms.   From time  to time the bursa and the
                     projecting angle becomes irritated and  inflamed, and the
                     morbid action  thus set up may run on to suppuration of a
                     very troublesome kind, a thin, unhealthy pus being formed,
                     which is discharged through an opening that speedily be-
                     comes fistulous, and may degenerate into a most troublesome
                     indolent sore.
  In the treatment of this affection, the first thing to be done is to change the
direction of the  toe,  by wearing  properly-shaped boots.   The  faulty position,
which appears to be  the primary cause of the  affection, may perhaps be more
effectually  remedied in some cases, by the  division of the external lateral  liga-
ment of the metacarpophalangeal articulation, or of the tendon of the adductor
pollicis, or-the inner  head of the flexor brevis pollicis; the toe, when restored to
its position, being for a  time kept  fixed upon an under-splint.   Pressure upon
the bunion may at the same  time be prevented, by wearing over it  a piece of
amadou spread with soap plaster, and perforated in the centre with an aperture
corresponding to the  size of the tumor.   If accidental  inflammation  be excited
in the  part, it must be allayed by the application of leeches, warm foot-baths, and
poulticing; the cutaneous irritation  that is left may be best removed by painting
the surface with a strong solution of nitrate of silver.

                                 GANGLION.

  Two distinct kinds of ganglion are met with: the simple,  situated upon the
sheaths of  tendons, and  the compound, consisting in a  dilatation of the sheath
itself.   The simple ganglia consists of cysts, varying in size from a cherry-stone
to a large marble, and containing a clear  transparent fluid of a yellowish color,
which  is sometimes thin and  serous, at others,  gelatinous and semi-coagulated.
They occur as a smooth,  globular, elastic, and- tense  tumor, usually situated on
the back of the wrist, where it forms a distinct round projection; they may also
occur on the dorsum  of  the foot.   In both situations, they are distinctly con-
nected with the sheaths  of the extensor tendons, and, indeed, Paget looks  upon
them as being cystic transformations of the fringe-like  processes of synovial
membrane  lining  the sheaths  of the tendons.   As they increase  in  size, they
often give  rise to painful sensations in  the parts below them, by pressing upon
 
TENDONS.                            625
 neighboring nerves.   Thus, a ganglion at  the  back of the wrist often  produces
 pain  and weakness in the hand, by compressing some of the  branches of the
 musculo-spiral nerve that are stretched over it.
   The compound ganglia are chiefly met with  in the palm of the hand, and the
 dorsum, sole or inner side  of the foot. They consist of a dilatation of the sheaths
 of the tendons in these situations, and may often attain a very considerable bulk,
 and then usually become  irregular in shape,  owing  to  several tendons  being
 implicated by them.  Most frequently, in this form of ganglion, the  sheath is
 simply thickened as well as dilated, and the contained fluid is  clear and yellowish,
 though usually thinner than in the simple ganglion.  The sheath itself is vascular,
 and lined by a red, fringed, and velvety membrane; the fluid may be dark and
 bloody, and contain a large  number of granular bodies, like those  met with in
 certain  forms of enlarged  bursae.   These  I have  found in one  case, in which I
 had an  opportunity of examining them, to  be composed of imperfectly-developed
 granulations, in which the remains of bloodvessels were visible, probably thrown
 off from the inner wall of the vascular sheath.
   This  form of the disease, at times, puts  on almost a malignant appearance, is
 extremely chronic in its characters, and may  occupy a very extensive  surface ;
 in a case of the kind that was  under my  care, some  time ago,  the  dorsum and
 greater part of the inner side of the foot were involved.  The treatment of these
 diseases  must depend upon their character and size.   When small  and simple,
 as on the back of the wrist, they may commonly be got rid of by being  ruptured
 by forcible pressure with the thumb, or by a blow with the  back of a book, or
 by being tightly compressed, by .means of  a sixpence wrapped in a piece of lint,
 and firmly strapped upon  the swelling. If they do not disappear in this way,
 the better plan is to puncture them by means of a valvular opening, to squeeze
 out their contents, and then to employ pressure.   If they give rise to much pain
 and weakness, and do not disappear by the means indicated, they may be  dissected
 out, if it be thought advisable to have recourse to this somewhat severe procedure,
 which is not altogether unattended with the risk of inflammation extending up
 the sheath of the tendon.   I have, however, on two occasions done it, without
 any troublesome  consequences ensuing.
   A ganglion situated in the palm of the hand, and extending under the annular
 ligament  some little  distance  up  the  flexor tendons of the forearm,  is a very
 troublesome disease.  Mr. Syme recommends that the cyst should be kid open,
 and the annular ligament divided.   This seems to me a somewhat severe pro-
 cedure, and I have in several instances cured the affection by milder means; in
 one, by injecting a small quantity of tincture of iodine into the  cyst through a
 puncture in the palm, and in two or three  other cases by the use of the seton;
 and this  is the plan that I  should recommend for adoption.
   In  some cases  ganglia  appear  to take on a  truly malignant action, becoming
 vascular, lined with a bright-red villous membrane, and  containing a  quantity
 of dark-red grumous fluid, usually having  small seed-like bodies floating in it.
 Under these circumstances, amputation may be  required.
   Tendons.—Inflammation of the sheath of the tendons is occasionally met with
 as the result of strains and twists  of the hand,  about the wrist, of the  extensor
 tendons,  or the long head of the biceps.  In this affection there is swelling of a
 puffy character, with tenderness upon pressing  upon  or moving  the  part; and
 usually a peculiar  crackling sensation  is  communicated  to the surgeon's hand
 when  he examines  the affected part.   This crackling is peculiarly marked in
 those cases in which the inflammation and  effusion have become  chronic, where
 the disease appears to participate in the nature  of a ganglion.
   The treatment, when the disease is acute, consists in leeching and blistering,
with rest of the part;  when it is chronic, the application of blisters and discutient
plasters will be found useful.
                                    40 
626
DISEASES  OF  THE  MUSCLES.
                         CHAPTER  XLVII.

             AFFECTIONS  OF MUSCLES AND FASCT2E.

   Strains  of muscles, especially of those of the back  and  loins, attended by
pain, weakness, and some rigidity, are not unfrequently met with  as the result
of sprains or injuries of various kinds, more especially in rheumatic constitutions.
They may be  best remedied by the use  of  Corrigan's iron,  dry cupping,
stimulating embrocations, and  the  internal administration   of  colchicum or
guaiacum.
                   CONTRACTIONS AND RETRACTIONS.
   Under the  head of muscular contractions are included various deformities,
such as squint, wry-neck, club-foot, club-hand, some of  which  are  congenital,
others acquired.  In all of these conditions, the deformity is  primarily owing to
an affection of the muscular system, and not to disease of the bones or ligaments,
which are only secondarily implicated.  The causes of these deformities are very
various, but they may be referred to three  heads.   1st.  The continuous faulty
or abnormal position of a limb, as in an unreduced dislocation, or an  anchylosed
joint, will  be  followed by the disuse of a  certain  set of muscles, which con-
sequently become shortened and atrophied, and acquire a rigid state.   This con-
dition is consecutive to the displacement, but renders it  permanent;  it is apt to
occur after fractures, if the parts are kept for too long a  time in  one position,
and more  particularly  if bound and  matted together by the  pressure of tight
bandages.  A somewhat similar cause sometimes operates on the foetus in utero;
an abnormal position in the uterine cavity being very frequently the immediate
occasion of some of the varieties of congenital club-foot.
   2dly.  Irritation being set  up in the central portions  of the nervous  system,
may produce deformity by deranging the proper  antagonistic  action  of certain
groups of muscles.  This condition gives rise to many of the  congenital, as well
as the  non-congenital deformities.  It may act by producing more or less com-
plete paralysis of one set of muscles, the contractility of  their antagonists con-
tinuing normal, and thus the  relative balance of action being destroyed, the
stronger will draw the part over to their side.   The  influence  of this want of
proper  balance of  parts  in paralysis, producing deformity, may be well  seen in
palsy of the portio dura, where the face is distorted by being drawn to the sound
side; or in squint,  where the external rectus, being paralysed, the eye is drawn
inwards.   According to Mr. Tamplin, deformity from paralysis is never congeni-
tal, though it is not unfrequently met with in the non-congenital cases.  Central
irritation  may occasion deformity in another way, by producing tonic or perma-
nent  spasm of one set of muscles, the  other  remaining perfect in  their con-
tractility, but over-balanced by the  continued  contraction of  their antagonists.
This would appear  to be the case  in some forms of squint.
   3dly.  Peripheral nervous  irritation may occasion contraction of the  muscles
and deformity.  This  we commonly see happen in cases of contraction occurring
from the irritation  of worms in the intestinal  canal  in  the  so-called hysterical
contractions from uterine irritation, &c.   From all these  various causes  contrac-
tion and  deformity may arise.   In some cases  deformity will  cease after the
removal of the cause ; but in other instances in which it has  been of  long dura-
tion, the deformity will continue, owing to the muscles having fallen into a kind
of rigid atrophy, being shortened and wasted,  and consequently unfitted for the
proper exercise of the actions of the part.
   The general treatment of deformities consists in removing  the cause of the
contraction in  those  cases in which it is dependent on central, peripheral,  or 
TENOTOMY — SQUINT.
627
nervous irritation that admits of remedy.  Thus if squinting arise from pressure
upon  the brain the eye will resume  its straight direction when the congested
vessels are relieved, or the effused  fluids absorbed;  or  if a  contraction  of the
ham-string muscles arise from the irritation of worms, in the  intestinal canal, a
dose of purgative may cure  the affection.  When, however, the deformity is of
a congenital or more permanent character, the employment of orthopaedic means
and the division of the tendons is the only mode of restoring the natural condi-
tion  of the  part.  This  orthopcedic department of surgery owes, in a  great
measure, its  existence to the labors of Delpech and Stromeyer, and its perfection
to those of Little and Tamplin.
  By tenotomy, as at present practised, is meant the subcutaneous division of a
tendon by means of a very narrow-bladed knife  (Fig. 193) introduced obliquely
                                  Fig. 193.
through a puncture by its side.   The tendon may most conveniently be divided
in the majority of  cases, by introducing the blade beneath it sideways and then
turning the edge against it, scratching through it by a kind of sawing movement,
whilst the parts are made tense by an assistant.  A drop or two of blood only are
lost in  this simple  operation, and, as the divided tendon retracts with a kind of
snap, a gap will he left between the two ends, of from half an inch to an inch in
width, according to the previous amount of tension in the part.  If the muscles
have been contracted for  some  years it will commonly be found  that the fasciae
in the  neighborhood of the tendon have become rigid and unyielding, forming
cords or bands stretching across  from the side  of the gap.   If these  are  very
tense they may be  divided in the same way; but in many instances it will  be
found after a lapse of a short  time that they will  yield, and consequently will
not require division.  After the  section has been made, the small puncture should
be closed  with a strip of plaster or some  lint soaked  in collodion.  The  part
should  then be left without any apparatus  being applied for three or four days.
At the expiration of this time lymph will have been thrown out and then proper
mechanical contrivances may be adjusted for gradually restoring the normal  posi-
tion of the limb or part;  if this be done too soon, the cicatrix will  be  extended
at too early a period after the deposit of the plastic matter, and the  division will
become weakened and too much elongated.   The divided tendon unites like one
that  has been ruptured, by  plastic matter  that gradually assimilates to and at
last closely resembles its substance.  Tamplin states that on examining the tendo
Achillis of a boy who died twelve months after it had been cut  across, no trace
of injury could be  noticed, except a slight globular appearance opposite the seat
of incision.
  In cases of  congenital malformation, the question  frequently  arises as  to
whether tenotomy  should  be performed  in  early infancy, or delayed to a more
advanced age.   I think with Tamplin, that  the sooner these operations are done
the better; they are not more difficult at an early period of life than at any other,
no danger attends them, and by being performed during infancy there is a far
less chance of the deformity being permanent than if the operation is delayed for
some years.

                         SPECIAL DEFORMITIES.
  By squint or strabismus is meant a want  of parellelism in the position and
motion  of the eyes.  Most commonly a squint is convergent, the edge of the cor-
nea being buried under the inner angle of  the lids, more rarely the divergent
form is met with.  In convergent strabismus, one eye only is generally affected,
but in some cases both are implicated, though one eye is almost invariably worse
than the other; and  this gives  an appearance as if there were an alternation  of 
628
SPECIAL DEFORMITIES.
squinting in the two eyes.  In order to ascertain which eye squints, the simplest
plan is to direct the patient to look at a distant object, when the sound eye only
will be directed towards it, the affected one being turned inwards.
   Squint may arise from a variety of causes; it  not unfrequently comes on in
children  after infantile'complaints, such as  measles or scarlatina, and as Sir C.
Bell has  observed, commonly depends upon  weakness  of the external rectus,
owing to some paralytic  affection of the sixth nerve, seldom upon spasm of the
internal rectus.   In many cases it is indicative of disease of the brain or nervous
centres, occasioning paralysis or  irritation of the motor nerves of the eye; in
other instances it may occur from the irritation of worms in the intestinal canal,
and  not  unfrequently is dependent upon some disease of the eyelids or eyeball.
Thus the various  inflammatory affections of  the conjunctiva and eyelids  may
occasion  it; or,  it may, as not unfrequently happens, when it occurs in adults,
be dependent on the difference in  the focal length of vision, owing to amaurosis
or the failure of sight in one eye;  and lastly, in children it may be induced by
habit or imitation.
   The treatment of squint must to a certain extent be influenced by its cause.
Thus the removal of congestion  of the brain or the expulsion of worms from the
intestines may cure the affection;  or, if it have followed simple debility in chil-
dren, it will disappear as their strength improves, and they will  thus outgrow it.
If, however, the deformity be of a permanent character, it may readily be reme-
died by the simple operation that was introduced by Dieffenbach.  The operation
for squint should not I think be performed until the child has attained its eighth
or tenth year, as it is not very easy to do it satisfactorily before this period, owing
to the restlessness of the infant; and, in very many  instances, the squint gradu-
ally disappears as a child grows  older without any operative procedure being had
recourse  to.   On the other hand,  it should not  be delayed  too long, lest some
contraction of the features or deformity in the other eye be left, and thus a very
satisfactory result be not obtained.   The operation is sufficiently simple;  it  may
most conveniently be done by bandaging the  sound eye, and then directing the
patient to look outwards with the affected  one; a fold of the conjunctiva near
the inner canthus is then seized with the forceps, and snipped  transversely with
a pair of rather sharp-pointed scissors.  By dilating  the wound slightly with the
scissor blades, the tendon of the internal rectus will be exposed,  which  may be
seized with the forceps, and readily cut across; or, a very convenient plan consists
in passing a curved director underneath it, raising it upon this, and then dividing
it either  with the scissors or a small curved bistoury.  During the operation the
eyelids must  be held  apart by an assistant,  who may if  necessary use the eye
speculum for this purpose.  After the operation, a piece of wet lint should be laid
upon the eye, and if any fungous granulations spring from the wound, they must
be snipped off or touched with the nitrate of silver; some  double  vision  may be
left, but  this gradually wears off.
   Wry-neck, torticollis, or  Caput obstipum may arise either from  spasm  or from
paralysis of one of the sterno-mastoid muscles, the head in the first  instance being
drawn  to the affected side, in the second to the opposite one.  Although wry-
neck is  usually owing to contraction of the sterno-mastoid muscle, yet in some
cases the trapezius  is also at fault, more especially its anterior border and clavi-
cular margin.   It usually  comes  on  in  childhood,  and  not unfrequently  com-
mences with  an ordinary stiff neck from cold; after existing  for some time it
becomes  conjoined with  a certain  amount of twist  of the cervical spine, and a
tendency to lateral curvature.   Besides these, which may be considered the true
forms of wry-neck, deformity in this situation may  occur from diseased  cervical
vertebrae, or from  the traction  of  the cicatrix of a  burn.   These, however, are
peculiar  conditions depending upon causes that are irrespective of the state of
the muscles, and may readily be distinguished from the true form  of the  disease.
   The  treatment of torticollis  arising from permanent  spasm  of  one of the 
                 WRY-NECK — FORMS  OF  CLUB-FOOT.              629

sterno-mastoids, which is  the  common form  of the  affection, may best be  con-
ducted by dividing the inferior attachment of the muscle, and thus allowing the
head to regain its proper position.   The  division of the muscle is  a somewhat
delicate operation, on account of the important structures that lie immediately
behind it.   By making the incision, however, through it, close to  the sternum
and along the clavicle, there can, if ordinary care is employed, be little  risk of
doing any damage, as these bones carry the  lower attachment  of the  muscle
forwards, and separate it from subjacent parts.   The  tension  also into which
it  is thrown by its spasm draws it away from the carotid sheath.   In  several
instances  in  which I have had occasion  to perform  this operation, no difficulty
whatever has been experienced in dividing the sternal attachment of the muscle,
which is also very tense and prominent,  by passing  an ordinary tenotome with
its flat side towards the tendon just in front of the upper margin of the sternum,
and then  cutting  forwards, whilst the muscle was  put well upon  the stretch.
In dividing the clavicular insertion, the safest plan  I think consists in making
a puncture with a scalpel upon and down to  the  clavicle in  the  cellular space,
that lies between  the two attachments of the muscle, and then pushing a  long,
blunt,  narrow-bladed tenotome between that  bone and  the insertion  of the
muscle, dividing  this in a  direction  forwards.  After the operation  the  head
should be drawn to the opposite  side by means of proper  straps passed round
it, and buckled to a belt that passes under  the axilla; and the patient should
wear for some time  a high and stiff stock.   In this way the  curvature of the
cervical vertebrae may gradually be corrected;  should  it however have  existed
for a considerable time  it  may have assumed a permanent character; and a
twist in the neck will continue for life.   After the division of the tendon the
deep fascia of the neck will sometimes be found stretching across in firm and
tense bands, these however had better not be interfered with, as they will gene-
rally yield, and much risk  of  injuring the subclavian  and  carotid vessels would
attend any attempt at their division.
   In those cases  in which the wry-neck  appears rather to be dependent  upon
paralysis of one  sterno-mastoid,  than  spasm of the other, electricity, and the
application of strychnine to the blistered surface  over the muscle, will be found
most useful.
   Club-foot.—Deformities  of  the feet are commonly single; but not unfre-
quently they affect both  extremities.   They appear to  be more frequent  in boys
than in girls.  Four varieties  of club-foot are recognised;—the talipes  equineus,
in which the heel is elevated; the talipes calcaneus, in which  the anterior part
of the foot is drawn up; the talipes varus,  in which  the foot is twisted inwards;
and the talipes valgus, in which it is twisted outwards.  These conditions may
occur in the simple forms just mentioned, but most commonly the varus  is com-
plicated with the talipes  equineus, and not unfrequently the valgus with  the cal-
caneus.   Bonnet, of Lyons, has made a classification of talipes, according as it
is occasioned by an affection of the internal popliteal nerve.   When the muscles
supplied by the internal  popliteal are affected, we  have  the  talipes equineus,
equineo-varus, and varus.   When the external popliteal is affected  we have the
calcaneus and valgus.
  On dissecting a foot affected by talipes, it will be seen that but little alteration
has taken place in the condition of the  bones.  In some  preparations  of this
kind that are in the  University College Museum, these are nearly in a  normal
condition.   Indeed, in the talipes equineus  and calcaneus, they are scarcely, if
at  all, altered, but in the varus  and valgus, if of old  standing, the astragalus
will generally be found atrophied, more particularly about its head, which  may be
somewhat  twisted, and the scaphoid and cuboid will  be seen to have undergone
similar changes.   The ligaments are  necessarily somewhat altered in  shape,
being lengthened on the convexity, and shortened on the concavity of the foot; and
the muscles not only of the foot, but of the  leg  and thigh, are generally atro- 
630
SPECIAL  DEFORMITIES.
Fig. 194.
Fig. 195.
phied from disuse, so that the limb in old cases is withered  and shortened;  in.
deed  so  great  an incumbrance may it occasionally become under these circum-
stances that amputation of the leg may be  insisted on by the patient, and may
with propriety be performed by the surgeon.
   Talipes equineus is characterized by elevation of the  heel, and great tension
of the tendo achillis, so that the foot is extended  in  nearly a straight line with
the leg, and the  patient walks on his  toes, which are placed at  a right angle to
the foot (Fig. 194).   In this deformity there is no lateral displacement.  Accord-
in"- to Mr.  Tamplin it is  never congenital.  It most  commonly arises from dis-
turbance of the nervous system, during  teething  or from irritation of worms  in
                    children.   In  adults it may
                    come  on from  some disease,
                    such as abscess  in  the  calf of
                    the leg, by which the gastroc-
                    nemius muscle is crippled.  It
                    is  the  most important  of all
                    the forms of club-foot,  as  it
                    commonly complicates the other
                    species.   The  treatment con-
                    sists  in   dividing  the  tendo
                    Achillis, and bringing the heel
                    well down.
                      The tendo Achillis  is best
                    divided  about  an  inch  above
                    its insertion into the  os calcis.
                    The  patient  should  be  laid          .
                    prone, and the surgeon grasp-
                    ing the foot extends  it forci-
bly, so as to throw out  the tendon  in good  relief and  make it tense; he then
slides a tenotome beneath it, and cuts slowly through it  from beneath upwards,
bearing well upon the foot;  as the  division proceeds, he will  hear the tendon
cracking as its fibres are successively cut through.  The  division should never
be made from above inwards, as the posterior tibial artery or its malleolar branches
might readily be wounded.
   [Many,  indeed most American surgeons,  prefer  the division  of the tendo
Achillis from  without inwards by a subcutaneous incision.   If  the operation  be
carefully performed there is no risk of wounding the  posterior tibial artery.   In
the division from within outwards mentioned in the text, great liability exists of
entangling the point  of the knife between the fibres of the tendon, and therefore
effecting but a partial division.   Another objection also to this mode of operating
arises from the fact, that in consequence of the previous long-continued contrac-
tion of the tendon, the  superjacent integument has been rendered tense, and is
liable to be wounded as the knife approaches the surface.—Ed.]
   Talipes  varus.—In this deformity the foot is twisted inwards  and  the sole is
contracted, the patient walking on  the outer  side of the foot, where the skin
covering the tarsal end of the fifth metatarsal bone often becomes excessively dense
and firm, and a bursa occasionally forms (Fig. 195).  In  most cases there is some
elevation of the heel, the affection partaking somewhat of the equineus character.
It is the most common form of congenital deformity, both feet being  found simi-
larly affected;  but it may be non-congenital, and then it is limited to one. The
treatment consists in the division of the tendo achillis, together with the tendons
of the tibialis anticus and posticus,  which are the muscles principally at fault.
In most cases the plantar fascia is  contracted, and requires  division wherever it
feels tense and projecting.   In the section of  the  tibialis posticus tendon in  the
sole of the foot there is  much danger of wounding  the posterior tibial  artery,
which lies close  to it.   The  best way to  avoid this  vessel  is to puncture  the 
CLUB-FOOT.
631
sheath of the tendon with  a sharp tenotome introduced directly  downwards,
and then to divide it in  a direction forwards, away from  the vessel.   There will
also be less risk of this  accident occurring if the tendo Achillis be divided first,
so that the others maybe rendered more tense, before their section is undertaken.
But in cutting through  the tendo Achillis there is  also  some risk of wounding
the artery, as in bad cases  of varus, these two  structures lie nearly parallel  to
one another, the tendo Achillis being drawn out of the median line  towards the
inner ankle.   Indeed, in one instance, I have  seen  the posterior  tibial artery
punctured  during the division of  this tendon, or rather  in an attempt to divide
some  tense bands that lay beneath it;  the bleeding, which was very free and  in
a full jet, was, however, readily stopped  by pressure, no bad consequences  re-
sulting.  The proper plan of treatment, when such an accident occurs, is, when
the artery is  merely punctured,  to cut it  completely across,  and then  to apply
firm pressure, by means of  a pad and bandage, over the  bleeding orifice.  If a
circumscribed false aneurism has formed, it must be  laid open, the clots  turned
out, and the vessel tied.  No extension of the foot should be practised for some
time in such cases, lest  the coagulum be disturbed.
   In  ordinary  cases of varus, after a lapse of four or five days,  Scarpa's  or
Little's shoe may be applied;  or the foot be well abducted by means of a wooden
splint, fixed to the outer side of the leg, and provided with pegs, so placed  that
the toes  can be  drawn  up, and the foot well turned out by rollers and tapes
attached to them.
   [In the  treatment during the first year of life of the  simplest form of varus,
viz., that in which a mere inversion of the tarsal and phalangeal  bones exists,
accompanied  by little or no elevation of the heel, the  surgeon  is rarely called
upon  to divide the tendons ; the application of  a properly contrived mechanical
apparatus generally answering every indication.  In Fig. 196 such an appara-

                  Fig. 196.                                 Fig. 197.
tus is represented, concerning which Dr. Mutter
says,* " The apparatus I prefer is a simple contri-
vance of one of my pupils, Mr. H. K. W. Boardman,
of Connecticut, which answers the purpose of evert-
ing a foot, better than anything I have seen.  The drawings exhibit the instru-
                       » Liston and Mutter on Surgery, p. 476.
 
632                     SPECIAL  DEFORMITIES.

ment, as well as the mode of application.  The foot and leg should be enveloped
in a narrow roller, and then the instrument adjusted,—when to attach it to the
leg a second roller must be employed.   The splint itself is attached by means of
a sloat and movable pin connected with the upper plate.   The  operation of this
instrument is obvious : the upper pad forms one point of resistance, the lower is
the fulcrum  upon which  the  ankle is  made to turn, and  the projecting end
serves for  the attachments of the bandage, by tightening the  turns of which,
from day to day, the foot is  brought into a line with the  leg.
   " This simple contrivance  has answered perfectly in my hands, not only for the
cure of congenital varus, but also for those cases of this defect met with at more
advanced ages, where it has  been necessary to divide the tendons.   I also employ
it in valgus.   After, by the  use of this measure, the foot has been brought to its
proper  position, it may be prevented from returning to its original shape, by a
common high-quartered shoe, made stiff on the inside.   This is to be worn until
all tendency  to relapse has been done away with."
   If the surgeon  be called to a simple case of varus, occurring in a child between
the first and  sixth year of age, the same  general treatment must  be observed; an
everting shoe however being substituted for the everting iron.   In varus of the
second degree, in  which the heel is elevated, and the contraction of the tibial ten-
dons increased, two indications  in the treatment are presented :  first the eversion
of the foot, and secondly the extension of the tendo Achillis..  If the patient be
seen  within  the  first year  after birth, the  eversion may  be  effected  by the
machine of Boardman before  described;  and for the  fulfilment of the second
indication, mechanical extension will at this age generally prove sufficient.
  If, however, the child  has attained  the age of two or three  years, it will be
better for  the surgeon to divide the tendo  Achillis at once, and then to avail
himself of such an apparatus as that  represented in Fig.  197, which is thus
described by Dr.  Mutter:  •' This instrument is an invention of my own, and is
intended for  bringing the heel down to its proper position.   It consists of a pair
of leg-irons,  extending above the  knee, or, in cases  of double  club-foot, to the
pelvis, to which the  instrument is attached by a circular band,—of a movable
foot-plate of iron,  in which there are several openings  or slits ; the posterior third
of the plate should be elevated an inch and a half, and formed into a sort of socket
for the reception of the heel, and in order to ascertain when the foot is in its proper
position an'^oval opening, through which the finger may be passed, is made in the
elevated margin just described.   There should also be attached  near the anterior
extremity of the plate a hook or button, to which the cord intended for altering the
angle of junction between  the  plate and leg-irons, is fastened; and again, to
secure the foot, leathers similar to those of a common shoe are attached to the
anterior portion of the plate.   There is also an instep strap and pad, intended for
keeping the  heel  in its proper position; but the same end is often better accom-
plished by means  of a gaiter, the straps of which pass through slits in the heel
of the plate.   Lastly, to change the angle of junction between the leg-irons and
the plate, a rachet and cord  are attached to the outer splint near the knee.
  The instrument is applied in the following manner: A narrow roller is first put on
from  the toes up to the knee, the leathers are then opened and the angle between
the plate  and leg-irons made to correspond with  that formed between the foot
and the leg.   The straps of  the leg-irons are  then brought around the limb, and
the sole of the foot placed in contact with the plate of the instrument; the heel
being set as far back  as possible, and the pad of the instep-strap placed upon the
instep so  as to diminish the pressure upon the integuments; next the leathers
are laced so as to  embrace the foot, and the  cord of  the rachet attached to the
catch on the  side  of the foot-plate.   All being secured the rachet is turned, and
it is obvious  that as the toe  ascends under its influence,  the heel must descend.
The reduction is of course gradual, a few turns of the rachet from day to day,
being sufficient, until the heel  and toe are  placed on  the  same plane.  This 
           1
                        FLAT OR  SPLAY  FOOT.                     633

accomplished, the foot is placed in  a stiff walking-boot, and  leg-iron, and the
patient allowed to ran about."—Ed.]
   Talipes valgus—fiat or splay foot—is the antithesis to varus.  In it there is
a tendency in  the first instance to the obliteration of the arch of the instep, so
that the sole becomes perfectly flattened; and  as the disease  advances, a ten-
dency to eversion of the foot usually takes place (Fig. 198).  When it  has ad-
vanced to this extent the toes and anterior part are often somewhat  raised,  so as
to constitute the variety termed calcaneo-valgus.   In this kind of deformity the
ligaments of the sole of the foot,  which bind  the bones together so as  to  form
the arch, are weakened and elongated,  and the peroneal and  extensor  tendons
commonly tense.   It is not so frequently a form of  club-foot as the other varie-
ties, and commonly affects  only one extremity.  When both feet  are  everted
there is  usually knock-knee  as well.   The treatment consists in the division of
the tendons of the  peroneus longus, and brevis, behind the outer ankle; and
of that of the extensor communis on the dorsum.   Scarpa's shoe may  then  be
applied, and the arch of the foot restored by wearing a pad under the sole for

            Fig. 198.                                  Fig. 199.
some considerable time.   The talipes calcaneo-valgus is not a congenital affection;
and as it commonly arises from a partially paralysed state of the gastrocnemius,
the treatment is not very satisfactory.
  The talipes calcaneus is an extremely rare variety of club-foot.   In it the heel
is depressed, the toes and  anterior part of the foot being elevated (Fig. 199);
it is always, I believe,  congenital, and arises from  contraction  of the extensor
tendons.   In  order to bring down the foot,  the tibialis anticus, the extensor
communis, the extensor pollicis, and  the peroneus tertius, may all require to be
divided as they pass over the dorsum; a straight splint should then be applied,
and the foot drawn down to it.   A minor degree  of this  affection consists  in  a
peculiar projection upwards of one or two of the toes  associated with some tension
of the extensor tendon ; by dividing this, and keeping the foot on a flat splint,
this deformity may commonly be corrected.   In some cases, however, the  toe is
so prominent, and  the contiguous ones are  squeezed under it in such a manner,
that the foot  is  completely crippled, and amputation of the displaced digit is
required in order to restore the utility of the member.
  In talipes calcaneo-valgus the projection of the heel backwards is obliterated,
and the outer side of the foot  curved round towards  this,  so that the little toe
approaches the point of the heel.
   Weak ankles not uncommonly occur in ricketty children;  the ligaments being
relaxed, the joints appearing to be swollen, and the child unable to walk or stand
without great difficulty.   Under these circumstances attention to  the state of
the  general health, douching with salt-water, the application of an elastic India-
 
634
SPECIAL  DEFORMITIES.
rubber bandage round the ankle, or the use of light iron supports, will be found
most useful.
  The deformity termed genu-valgum, knock or Xknee  usually affects both ex-
tremities, though it is generally more fully developed in one than the other.  In
it the knee forms the apex of a triangle, the base of which would be represented
by a line drawn from the trochanter to the outer ankle.   It is usually conjoined
with some curvature  of the  bones of the  leg.  It is not a congenital affection,
but commonly occurs in consequence of children being put upon their feet too
early, the limbs thus giving way under the weight of the body.   Brock  states
that out of  221 cases that he examined,  17 originated about the period of the
first dentition ; and  about 200 between that  age  and  the 15th or 18th year.
Some occupations are said to predispose to  it, smiths being especially liable to
the disease.   In it there is relaxation of the internal lateral ligament; the biceps,
the external lateral ligament, and often the vastus  externus are very tense; and
the patella thrown outwards.   The external condyle of the femur will generally
be found to be small and the hollow of the ham  to be obliterated. The treat-
ment consists,  in the slighter cases, in applying a well-padded  splint along the
outside  of the leg and thigh ;  this must extend from the trochanter to the outer
ankle, being fixed to a pelvic band at the upper  part, and into a boot below.
Where  it corresponds to the  knee it should be provided with a hinge, and should
have  a broad well-padded strap passing from its under side, over the inner side
of the knee, and attached by buckles to the upper part of the splint, in such a
way that by tightening these the knee may be drawn outwards.   This apparatus
should be constantly worn for many months, and if properly adapted may effect
a cure.
  When the deformity is of old standing,  and the  parts about the outer side of
the joint very tense, the biceps tendon may require division.   In doing this care
must be taken  not to injure the peroneal  nerve.   In some  cases the  vastus ex-
ternus  and contiguous  portion of  the  fascia lata may also be advantageously
divided, and the  padded splint then applied as directed.
   Contraction  of the knee-joint is not an uncommon kind of deformity; the leg
being flexed upon the thigh, often to such an  extent that the heel nearly touches
the nates.   It arises from very various causes,  in some instances it appears to be
of a  purely hysterical,  or  spasmodic character, coming on gradually in young
women  of a nervous temperament, and being associated with a good deal of pain
and neuralgic tenderness about the spine,  hip, and knee.   In other cases again
it maybe  connected with talipes  varus; and, again,  in  other instances, be
dependent on a state of partial anchylosis of the knee-joint.
  The treatment of this affection must of course have reference to its cause. If
it is hysterical  or purely spasmodic, and the extension of the limb be accompanied
by much pain, I have  found  it a very useful plan to  put the patient  under
chloroform, when the muscles will become relaxed, and the limb may be extended.
It should  then be  fixed  upon a  long splint, or in a strong starch bandage, so
that retraction may not again  occur.  The patient must then  be subjected to
proper  anti-hysterical treatment, the cold douches employed, the uterine func-
tions  and general health regulated.   If it arise from intestinal irritation, a free
purge will sometimes remove it.  In this  way I have seen a knee that had been
contracted for several weeks cured after the action of  a dose of castor-oil and
turpentine,  which expelled  some lumbrici.   If it arise  from irritation of the
sciatic nerve, it may be cured on this being subdued by cupping and proper
local  treatment.  If, however, it be of a more permanent character than this, the
joint  being firmly fixed, more active measures will be required.   In these cases,
as Mr.  Tamplin has justly observed, a cure may be anticipated,  if there  be any
motion, however slight, in the joint.  In many instances the application of a tin
splint, consisting of two plates, one of which is applied to the posterior  part of
the thigh,  the  other  to that  of the leg, and connected together  by a hinge, and 
DEFORMITIES OF THE HAND.
635
 a screw by which proper extension can be made, will  gradually bring the  limb
 into position.  In other cases, however, in which the muscles are too rigid  and
 unyielding to admit of extension being in this way effected, the  ham-string  ten-
 dons must be divided.   This operation requires to be  performed with care,  and
 due consideration to the anatomy of the parts.   The patient should be laid upon
 his face, and the leg forcibly extended as much as possible by an  assistant; in
 dividing  the inner ham-strings, the  tenotome must be  passed perpendicularly
 downwards on their outer side, but kept close  against them.   In cutting them
 through,  care should be taken to avoid, if possible, the saphena vein and nerve.
 In dividing the outer ham-string, the course of the peroneal nerve must be borne
 in mind, and its section  avoided.   It is needless  to do more than enter the
 caution, to  keep away from the centre of the ham, and from the line in which
 the popliteal vessels run.

                        DEFORMITIES OF  THE HAND.
   A deformity resembling  club-foot has occasionally, though very rarely, been
 met with in the hand.   The contraction may occur in two directions ; either in
 the sense of preternatural flexion, or  in that of  abnormal  extension  of  the
 member.   It  is  always congenital,  and has been  principally described by
 Cruveilhier, Voillermier, and Smith of Dublin.  In most of the cases that have
 been met with, there was a certain amount of deformity of the lower end of the
 radius, with congenital dislocation of the wrist;  and in Mr. Smith's case there
 was an accessory semilunar bone  in  the carpus.  Little, if anything, can be done
 by surgery  for the relief of this deformity, though some  benefit  might possibly
 result from the division of any tendons that were preternaturally tense.
   A  peculiar tendency to contraction, the fingers being drawn into the palm of
 the hand, is occasionally noticed; most commonly this  commences in the little
 finger, and  thence gradually extends to the ring or middle finger, which become
 so forcibly and firmly curved inwards, that their  extension  is  not  practicable.
 It commonly results from frequent and continued  pressure  on the palm  of  the
 hand, as in leaning  on a  round-ended stick  in walking, or in those trades in
 which an  instrument requires to be  pressed into the hollow of the hand.   On
 examining the contracted fingers, projecting ridges will be  felt extending from
 the palm to their anterior aspects;  and on  endeavoring  to  straighten them,
 these  ridges will  be found to become  stretched, and  the  palmar fascia to be
 rendered tense.   The skin covering these  ridges is usually healthy, but some-
 times adherent to  them.  So firmly are the fingers contracted, that by no effort
 can they be extended.
  # The cause of this contraction of the fingers has given rise to a  good deal of
 difference of opinion amongst surgeons.  Dupuytren  appears  to have been  the
 first who endeavored, by dissection, to ascertain its true  character.   He  found,
 on examining a hand that was the seat of this  disease, that after the  removal of
 the skin, which was loose and flaccid,  the contraction  continued as  before, and
 this, therefore, could not be its seat;  but that the palmar fascia, which was  ex-
 posed, was tense  and diminished in  size, whilst, from its lower aspect some
 cord-like prolongations passed up  by the side of the fingers, and that when these
 were divided, the contraction was immediately  removed, the tendons, the  bones
 and the joints being perfectly sound.   He considered these fibrous cords to be
 the digital  prolongations of  the palmar fascia, and  consequently looked upon
 this membrane as the seat  of the disease.   M. Goyrand,  who has carefully dis-
 sected  hands affected in this way, states that these fibrous cords, which he also
 looks upon as the seat of the affection, are not prolongations of palmar fascia  but
 are ligamentous structures  that  extend from  its anterior inferior aspect  to the
sheaths of the flexor tendons, into which they are inserted opposite the second
phalanx;  being an hypertrophied  condition of the subcutaneous  filaments of
nbro-cellular tissue that  naturally exist  in this situation. 
636
DISEASES OF THE EAR.
  The treatment of this deformity consists  in  dividing each tense digital lic_.
mentous prolongation by a subcutaneous incision.  This should be done opposite
the second phalanx, where it is usually most tense ; but, if the other finger-joints
be affected, a separate section may be required opposite each  phalanx.  Sin mid
the skin  be adhtivnt to the fibrous band,  it must be divided with it, and the
finger then extended.
  Contractions about the elbow and  shoulder occasionally, but very rarely, re-
quire  tenotomy.  Occasionally the biceps may be so  firmly contracted as  to re-
quire  the  division of its tendon; in doing this, care must  of course be taken not
to injure the brachial artery.  This may most conveniently be avoided by fixing
it with the fingers of the left hand,  whilst the  tenotome  is slid between it and
the tendon, and the division made directly outwards.
                    DISEASES  OF  REGIONS.


                         CHAPTER  XLVIII.

                DISEASES OF  THE  HEAD AND NECK.

                          DISEASES  OF THE EAR.

   Inflammation of the  external ear,  otitis, or  earache, is  usually a  rheumatic
affection, and is characterized  by intense  pain, generally associated with herui-
crania; a kind  of combination, indeed, of inflammation and  neuralgia.  This
pain is much increased at night, by warmth of the bed, and is generally accom-
panied by throbbing and noises in  the ear.   The treatment, at first antiphlo-
gistic, generally and locally, may advantageously, after a time, give place to qui-
nine and the iodide  of potass, with the external application of aconite.  Occa-
sionally the  affection runs on to the formation of abscess in the meatus externus,
attended by excessively  painful throbbing.  With the  view of relieving this,
leeching, poulticing, and early lancing will be required.
   Otorrhcea, a fetid discharge of a'muco-purulent character, usually occurring in
strumous children, and often associated with enlarged glands under the angle of
the jaw, may be of two kinds;  either proceeding simply from the mucous sur-
faces  and being inflammatory, or it  may be connected with  necrosis of the  pe-
trous  portion of the temporal bone, being associated with disease and destruction
of the tympanum, and necessarily of the internal  ear. In the first case, astringent
injections containing some  of the chlorides in  solution may advantageously be
used,  and will commonly arrest it.   If, however, it proceed from disease of  the
bones, it is  necessarily of a  far more serious character, and the membranes at
the base of  the brain becoming irritated by the extension of the morbid action
to them, convulsions  and  death usually eventually result.  In some of these cases,
phlebitis of  the sinuses and of the cerebral veins ensues, and proves fatal tu  the
patient.
   The external ear is occasionally the seat of special affections.   Thus, in idiots,
hypertrophy of this  structure is occasionally met  with;  and in gouty subjects,
tophi, or gouty concretions, are occasionally deposited in it.   Paget, Bruck, and
Panzetta have described a fibrous tumor that occasionally forms in the lobule of 
DISEASES  OF  THE  NOSE.
637
 the ear from the irritation produced by piercing it, and as " one of the penalties
 attached to the barbarism of ear-rings."  These tumors are of a semi-malignant
 character,  like the warty growths of  cicatrices, and, after excision—which is
 their only treatment—are somewhat apt to return.
   We not  uncommonly find that  the meatus becomes blocked up by accumula-
 tions of wax, dark, indurated, and pipe-like; or forming balls and  masses that
 lie in  contact with  the  tympanum.   These chiefly occur in individuals  of the
 bilioso-phlegmatic temperament, and are a common source of temporary deafness
 amongst young people.  They not only impair the  sense of hearing materially,
 but are very apt to give  rise to noises in the head, and crackling sensations on
 opening and shutting the mouth.   Their presence is best  ascertained by  exami-
 nation with a well-constructed ear-speculum, those introduced by Mr. Toynbee of
 a double convex shape are the most useful.  The treatment of these concretions
 consists in  repeatedly washing out the meatus by the forcible injection of tepid
 soap  and water thrown in with a large syringe; as the fluid regurgitates from
 the tympanum, it will at length bring away the  dark and hardened ceruminous
 masses.
   Polypi are occasionally met with, situated rather deeply on  one side  of the
 meatus; they are usually hard and fleshy-looking, sometimes pedieukted ;  but
 at others situated on a broad base, they produce serious inconvenience by obstruct-
 ing the external ear, and require to  be pulled off by means of a pair of forceps,
 or if too firmly fixed for this, cut  off by means of a pair of scissors; the surface
 from which they spring should then be touched with the nitrate of silver so as
 to prevent  a recurrence of the growth.
   Occasionally the cuticle of the external ear, and that covering the tympanum,
 becomes thickened and indurated, assuming a dull, white appearance,  and then
 may give rise to some amount of deafness.  Under these  circumstances the  use
 of glycerine, as recommended by Mr. T. Wakley,  of the citrine  ointment, or the
 solution of  the nitrate of silver, will be extremely useful in restoring the healthy
 action of the integument of the part.
   It is not my intention to enter into the general pathology of the various kinds
 of deafness, or to discuss the causes of this affection.   It may be  stated gene-
 rally, however, that it may arise from obstructions of the external ear from disease,
 ulceration and perforation of the tympanum from various inflammatory affections,
 chiefly of a subacute and chronic character; of the internal and middle ear from
 paralysis of the acoustic nerve dependent on cerebral lesions, or local paralysis ;
 and lastly, from obstruction  in the Eustachian tube, or from disease of the throat.
 Mr. Toynbee has especially shown that many cases of so called " nervous " deaf-
 ness, together with singing, ringing, boiling and other noises in the head,  are in
 reality dependent upon chronic inflammatory affections of the internal and middle
 ear, and that the treatment  best adapted for their cure consists in  constitutional
 and local means  of an alterative and  antiphlogistic character.

                         DISEASES OF THE NOSE.

   Epistaxis, or bleeding from the nose, is very common in children and in  young
 people  about the age of puberty,  more particularly in  girls antecedent to the
 menstrual period; it may either be of an active or passive character,  but is most
 usually dependent on  congestion of the mucous  membrane.  It may commonly
 be stopped  without  much  difficulty by the use of domestic  remedies, but occa-
 sionally it is so copious, amounting to many ounces, as to exhaust the  patient and
 to require  surgical interference.   In  the majority  of cases the application of
 cold water and ice to the  forehead and bridge of the nose, with rest, and a free
aloetic purge will arrest the bleeding.  If, however, it do not stop in  this way, it
will be necessary to plug  the  nostrils.  In  many cases it may be  sufficient to 
638
DISEASES  OF  THE  NOSE.
plug the anterior nares with a pledget of lint; very commonly,  however, the
posterior nares require to  be plugged as well.   This is best done  by carrying a
long piece of strong whip-cord along the  floor of the nose though  the posterior
                                                     nares into the pharynx, by
                                                     means of Bellocq's sound
                                                     (Fig.  200);  or if  this
                                                     be not at hand, by thread-
                                                     ing  the  cord through
                                                     an  elastic catheter,  and
                                                     carrying  this  into  the
                                                     pharynx, then seizing the
                                                     cord as it appears behind
                                                     the soft palate, and draw-
                                                     ing it  forwards into the
                                                     mouth, at the same time
                                                     that the catheter is taken
                                                     out  of the  nostril.   In
                                                     this way the  string  will
                                                     pass through  the nose,
                                                     round the  back of  the
                                                     soft palate and into  and
                                                     then  out of the mouth.
                                                     To  the  centre  of  the
piece of string that hangs out between the lips, a plug of lint about the size of
the end of the  thumb, should be firmly tied; this is  then drawn up into the
posterior nares by pulling  on the end of the  ligature that  hangs from the nose,
being guided in its passage behind the palate by the fingers introduced into the
mouth.  When the bleeding has ceased, it may readily be withdrawn by means
of the string that hangs out of the mouth.
   The  mucous membrane of the nose  is  not unfrequently chronically inflamed,
especially  in  strumous children;  that  portion  of the membrane  covering the
turbinate bones becoming  thick, soft, and vascular, and  projecting like a broad
fringe from their surface.   It is usually of a bright red color, and covered with
muco-pus.  This swelling at all times produces snuffling and  a peculiar intona-
tion of voice, but increases  in wet weather,  and then  may become so great as
seriously to obstruct the breathing.   The treatment consists in attention  to the
general health ; more especially to the  eradication of the strumous diathesis.
.Much benefit may also be derived by the local application or  injection of astrin-
gents, as a strong solution of the nitrate  of silver applied by means of a camel s-
hair brush, and sulphate of  zinc and oak-bark lotions snuffed up, or injected by
means  of a proper syringe.   In many  instances, when this disease occurs in
strumous children, change of air will effect the  greatest amount of benefit.
   Abscess occasionally forms either on the mucous membrane or on the septum,
and thus may lead to necrosis of the cartilages and bones, with  much discharge
and fetor, separation of these, flattening  of  the  nose,  depression of  its bridge,
and great deformity. These various forms  of abscess, followed by necrosis, are com-
monly  syphilitic,  and then are associated with ulcers and afoul and fetid discharge
which has a tendency to cake upon their surface, forming dark and rugged crusts,
and constituting the different kinds of ozasna.  The septum  may  be the seat of
chronic ulcerations consequent upon the irritation of decayed teeth, producing
disease of the antrum, and escape of morbid secretion from this into the cavity
of the  nose, and this coming in contact with the  septum, produces thickening and
ulceration of it.   The treatment of these conditions must be conducted by the
local application of nitrate of silver, black wash, and the chlorinated lotions; the
general treatment consists usually in the administration of the dilute mineral acids,
the iodide of potassium, and sarsaparilla.  Ulcers and  fissures of a less  serious 
LIPOMA—NASAL  POLYPI.
639
character, though very painful and chronic, often occur at the angle of the ala
and septum, or between the ala  and tip; their  treatment consists  in  touching
them from time to time with the nitrate of silver, or in the  application every
night of the white precipitate or citrine ointment, at the same time that the general
health is attended to, cachexy removed, and the strength restored, by the admi-
nistration of iron, bark, and sarsaparilla.
  Lipoma is a chronic hypertrophy of the cutaneous and subcutaneous  struc-
tures, and of the cellular tissue of the nose, forming a  large  reddish-blue,  vas-
cular-looking,  soft, tremulous, and lobukted mass,  enveloping the end of the
nose, and producing excessive deformity of it.   There  are all degrees of  this
disease, from mere clubbing of the end of  the organ to the formation of a set
of pendulous lobular tumors attached  to it.  The sebaceous glands and  crypts
appear to be  the structures chiefly  implicated in  this disease.   The patient's
appearance may be greatly improved by the removal of these growths.   This
may be done  readily enough by making an  incision down the mesial line to the
alar cartilages, and then dissecting it off these on either side ; especial care, how-
ever, being taken in doing this not to encroach upon the nostril.   This is  best
avoided by directing an assistant to keep his finger in it whilst the dissection is
being prosecuted, so that he may warn the  surgeon of the too near approach of
the knife.  The surface is then left to granulate and cicatrize.
  The nose  is  frequently the seat of lupus and of various forms  of epithelial
cancer ;  many of the deformities of this feature being referable to this affection.
Indeed, lupus may be looked upon as  almost specially affecting this  organ, de-
stroying one or both alae,  the columna, or perhaps the whole of the nose.   The
consideration  of the  nature  and treatment of these  affections in this situation
presents  nothing special;  but that of the  cure  of the deformities induced by
them, which is full of  interest to the surgeon, will be considered  in detail when
we come to speak of the plastic operations that are practised on the face.
   Tumors  of very different structures and composition  are  met  with in  the
nostrils, and to all of these which possess the common characters of being pendu-
lous and  blocking up these passages,  the term polypus is given.   Thus surgeons
commonly speak of the benign, the soft, the gelatinous or mucous polypi, as  well
as the sarcomatous or fleshy,  and the  malignant polypi.   The term,  however,
should properly be confined to a soft  and pendulous  mucous growth, the  fleshy
and malignant polypi being  merely varieties of  fibrous or  encephaloid tumors,
springing from the bones  in  the  nasal  fossae, or from the ethmoidal  and sphe-
noidal cells.
  The true mucous nasal polyp, is a  soft, moist, gelatinous tumor, of a grayish-
yellow color when lodged in the nasal fossae, but when it descends into  the ante-
rior nares, or beyond them, and is exposed  to the  air, it  becomes of a  reddish-
brown or purple tint, and somewhat shrivelled  on  the surface.   It  is usually
lobukted, pedunculated, or bottle-shaped; and not very vascular  except at  the
root, where it is  permeated by largish thin-walled vessels that bleed freely on the
slightest touch.  In structure it is homogeneous, and composed of the elements
of mucous membrane, covered by tessellated and ciliated epithelium, the cilia? of
which may often be seen under  the microscope in  active movement after  the
removal of the growth, beating about the blood-corpuscles and fluid in which it
lies.  These tumors may grow from all points of the surface of the turbinate  and
ethmoid bones, and have indeed  occasionally, though very rarely,  been observed
to project into the nose from the frontal sinuses and antrum.   Most frequently
they grow from the inferior spongy bone towards the outer side of the nostril,
but never take their origin from the septum.  These  polypi are  usually numerous
and of all sizes; as they increase, they commonly extend forwards into the ante-
rior nares, but when of large size, they may be seen  to reach into the posterior
fauces, hanging down behind the palate.
  The  symptoms occasioned  by the  presence of these polypi, depend on their 
640
DISEASES  OF  THE  NOSE.
interference with respiration and speech;  and on the visual  changes they occa.
sion.   The respiration through the affected nostril is impeded, the patient being
unable to blow through it when directed to do so, and his speech is thick and
nasal.   There is snuffling and  mucous discharge  from the nostril, and all these
symptoms are worse in damp than in  dry weather.   On examining  the interior
of the nose, by opening the nostril widely  with forceps, and  then directing the
patient to blow down, the lower end of the  polypi may be distinctly  seen, and if
large, will descend on  a level with, or even beyond the nasal aperture.  By the
introduction of a probe, the size and extent of the tumor, together with the
position  of its  pedicle, may be readily ascertained.   As  it  grows, it impresses
changes on the shape of neighboring bones, producing expansion and flattening
of the nose, inducing  caries of the spongy  bones, and, interfering with the flow
of tears down the nasal duct, occasions a watery state of the eyes, which, together
with the change of shape in the features, and the peculiar character of voice and
respiration, enables the surgeon at once to recognise the nature of his patient's
disease.   Polypi chiefly occur in young adults after the age of puberty; but they
are not unfrequently met with at later periods of life.
   The diseases with  which  nasal  polypi may  be confounded  are, 1st, chronic
thickening of the mucous membrane covering the spongy bones.  From this the
absence  of any pedunculated  growth, around  which  a probe can  be passed,
together with the florid red character  of the thickened membrane, and the fact
of this almost invariably occurring in  strumous children, are  sufficient to distin-
guish  them.   2dly.  From abscess of the  septum,  the  history of the  case and
the fact  of the polypus never being attached to this part  of  the  nose, will esta-
blish the  diagnosis.   3dly.  There is a peculiar  malformation  of the septum con-
sisting in a deviation of it to one side, that  may at first be a little puzzling; but
here the examination of both nostrils  and  the discovery of a depression on one
side of the septum corresponding to the  projection on the other, will reveal the
true nature of the case.   4thly.  The fibrous and malignant tumors of the nostril
will be found to differ sufficiently in consistence and appearance from the ordinary
polypi  to prevent their being confounded with them in many cases;  but yet in
some instances much care will be required  in coming to a definite opinion as to
their true nature.
   Nasal polypi may generally be most readily removed by avulsion, with forceps;
occasionally, but rarely, when  they are very large with a  broad base, and  espe-
cially when extending into
the throat,  they  require                       Fig. 201.
the application of the  lig-
ature.   In removing these
growths   by  the  forceps
(Fig. 201), instruments of
good   length  and  rather
slender construction should
be  used; the  interior of
the blades should  be pro-
perly serrated, and have a
longitudinal groove, so that
the root of the tumor may
be  tightly grasped.   The
patient should be made to
sit  on  rather a low chair,
and as there is generally a
good  deal of  bleeding,  a
towel   should  be  pinned
over his clothes, and a basin placed before him to receive the blood and expecto-
rated  matters.   The  surgeon then having  ascertained by the introduction of a
 
FIBROUS POLYPI — CALCULI.
641
probe, or by means of the blades of the forceps the situation of the pedicle of
the polyp, grasps this  firmly and pulls it  off with a twisting movement of the
hand.  He proceeds in this manner, twisting off rather than pulling away polyp
after polyp, until  the whole of the nostril is cleared, which  may be ascertained
by examination and by directing the patient to compress the sound, and to blow
through the affected side of the nose.   The bleeding, which is often very free,
stops on the application of cold water.  At about  the end of a fortnight  the
patient should  be examined  again, as it  not  unfrequently happens  that small
polypi which had been prevented descending into the  nares by the presence of
the larger ones  now come down and require removal.   These procedures must be
had recourse to from  time to time until all  tendency to fresh  formations of this
kind has ceased.
  The  ligature is chiefly required for those polypi  that pass into  the  pharynx
through the posterior nares.   They may best be tied by passing a loop  of strong
whipcord, by means of a double  canula, through the nose, and  then  expanding
the noose round the tumor in the throat and making it grasp its pedicle, knot it
tightly.
  The fibrous polypi may grow  to a large  size, extending into the throat, and,
perhaps, finding their way from  the  nose  into situations where they  are little
expected.   Thus  they have  been met with in the  pterygo-maxilkry fossa, and
have been known, as in a case recorded by Mr. C. Johnson, to pass  into the orbit
through a hole  in its inner wall.
   Malignant tumors of an encephaloid character occasionally form in the nostrils,
chiefly in children and young people, and, being attended by great expansion of
the bones, with a fetid discharge of bloody matter and disintegrated  portions of
the growths, may end by speedily  exhausting the  patient.  In  such cases as
these nothing effectual can be done in the way of operation.
   Calculi are  occasionally met with in the nasal fossae, where they simulate a
foreign body;  and here extraction may be practised with a pair of forceps.  But
sometimes these rhinolites are situated under the mucous membrane.  In  two cases
I have dissected round calcareous bodies of this kind, ab#ut the size of cherry-
stones, from under the mucous membrane  of the ala of the nostril in children.
  The frontal sinuses, though rarely, are  occasionally the seat of disease.  Ab-
scess may form  here with much pain and expansion of their anterior wall, attended
by the  local signs of inflammation and with
danger  of concomitant  inflammation  of  the
membranes of the brain.   Under such circum-
stances  it may be proper for the surgeon to
consider  the  advisability of removing by a
small trephine  the anterior wall of the sinus,
and  thus giving  exit  to the  retained  pus.
There are  a few cases  recorded in surgical
writings, of polypi springing from these  si-
nuses, and  finding their way down  into  the
nose after producing expansion of it and much
inconvenience.   Here  likewise  the propriety
of trephining  and so  extracting the morbid
mass would have to be considered.
  The cheeks are occasionally the seat of  en-
cysted tumors and cancerous growths, either
springing  from their inner surface, or  taking
their origin as lupoid ulcers on the outside.
The encysted  tumors in this situation may
readily be removed by a little simple dissection.  The cancroid ulcers and tumors
met with here seldom admit  of operative interference (Fig. 202).
 
642
DISEASES  OF  THE  LIPS.
   One of  the most troublesome  surgical affections situated  in  the cheek, is a
 salivary fistula, occurring in consequence of injuries, abscess, or operations, by
 which the parotid duct  has been  opened  so  as to cause a  trickling of saliva
 through the external aperture that has been made into it.  If the fistulous open-
 ing be recent, the lips of the external wound may be brought together  and got
 to close, whilst the internal aperture is free.  If it  be of old date, a seton  com-
 posed of a few threads may be passed into the fistula  from the inside of the
 mouth, so as to allow  the saliva to find  its way along this, whilst union of the
 external orifice is attained by paring  its edges and bringing it together with hare-
 lip  pins.   My colleague,  Mr. Marshall, has succeeded in closing an aperture of
 this kind by restoring the canal by means of a wire heated by galvanism, and
 then getting the external orifice to contract.

                          DISEASES OF THE LIPS.
   The lips frequently require surgical interference.  They may be  the seat of
 tumors of various  kinds,  encysted or erectile, which require extirpation by the
 knife or ligature.   In  dealing with  these, the surgeon must be guided by the
 circumstances  of the individual  case, but  he should, if possible, avoid cutting
 through the whole thickness of the lip, and if compelled to do so, he must act as
 will be described when we come to speak of cancer of this region.   Hypertrophy
 to a great extent occasionally occurs  in this situation.  This is often of an cede-
 matous character,  being kept up  by the irritation  of fissures or cracks; if so,
 these  must be cured,  when the size of the  lip will  gradually diminish  again.
 Sometimes, however, it becomes permanent, continuing  after the cure of the
 fissure;  under these circumstances it may be necessary to excise a portion of the
 lip,  and then to bring the edges together by means of sutures or pins.
   Congenital  malformation of the lips is  of common occurrence.   Contraction
 or even complete closure of the orifice  of the mouth  has been met with at birth;
 such a condition must be remedied according to  circumstances by the skill of the
 surgeon.
   By far the most cornmon malformation in  this situation, is the condition  ter-
 med hare-lip.   This consists of a perpendicular fissure through the upper lip.
 A similar condition has been described in the lower lip, but I have never seen
 such a case, or met with anybody who  has.   In  hare-lip,  the cleft  is usually on
 one  side only; and then it is said  to be single, and  most frequently, so far as I
 have observed, occurs upon the left side.  Not unfrequently there is a fissure on
 both sides of the mesial line; and then the hare-lip is said to be double.  The
 cleft neverpasses  through the mesial line.   When  double, the fissure is deeper
 on one  side than  the other, and usually extends into the nostril, though  some-
 times it stops short of  that.   In  these cases, the nose is usually flattened  and
 expanded, and between the fissures  there is always  a central or median lobule,
 consisting of the  inter-maxillary bones in a  rudimentary condition;  to this  a
 small  triangular piece  of lip is commonly  attached.  In many cases  this is
 pushed forwards, and tilted on its base, so that the  alveolar border projects forwards.
 Sometimes  the projection is so considerable that it  is attached to the tip of the
 nose.
  The cleft in  hare-lip corresponds to the line of junction between the embryonic
 inter-maxillary bones and the superior maxilla.  The fissure when single, may
 be confined  to the lip, but in  the majority of cases it extends to the upper jaw.
In other cases again, the fissure extends back into the  palate; this more frequently
happens when the hare-lip is double,  and in  these cases every variety of palatal
 deformity is met with.
  The cure of hare-lip can only be affected by  a properly conducted operation.
 In the performance of this, the first  point that has to be determined  is the age
 at which it  should  be done.   On this there has  been, and is still, a good deal of 
HARE-LIP.                             643
 difference of opinion.  Surgeons generally are, however, I think, agreed that the
 operation should not be performed during dentition; at all events not during
 the cutting of the incisor teeth, when there is much local excitement and gene-
 ral irritability of the nervous  system; but  they are not agreed as  to whether it
 should  be done before or after dentition.  In support  of the opinion that it  is
 more prudent to wait until  after this period, it is alleged that very  young infants
 are especially liable to convulsions; that  the performance of  operations in them
 is troublesome; and  that  it interferes with suckling.   These statements, how-
 ever, are not carried out by what we meet with  in practice.    I think that there
 is no evidence to show that there is any danger in operating during  early infancy.
 Indeed, I believe that very young children, those but a few weeks or months
 old,  bear operations remarkably well.  I have repeatedly operated at these tender
 ages, not only for hare-lip,  but for hernia, the removal of tumors, nevi, the divi-
 sion of tendons, &c, and have never seen any bad result follow.   Besides this,
 the performance of the operation  is easier at a very early age than when the child
 has reached its first or second year; when its intelligence being more developed,
 it knows what it has to suffer, and screams and struggles more than a very young
 infant does, whenever it sees the surgeon, or he makes an attempt to examine
 the wound or dressings.    After  the operation also, the child will, when young,
 take to  the breast without  difficulty and with the greatest avidity.  At very early
 ages union of the wound takes place with great readiness and solidity, and as no
 time has been given for the rest of the features to become distorted, there will
 not be that permanent flattening  and deformity of the face which is apt to con-
 tinue after the hare-lip is cured if the operation be deferred to a more advanced
 age.  For  these various reasons  I agree with Dubois  and Fergusson,  that the
 operation had best be  done early, and, if possible, at about the sixth  week after
 birth, which may, I think, be considered the time of election for this procedure.
   The operation for single hare-lip is performed  in the following way:—The
 child having been well  pinned in a jack-towel that swathes it tightly, the surgeon,
 sitting  down, places  his feet on a stool  so as to raise  them, and covering his
 knees with a piece of tarpaulin, holds the child's head firmly between them.  He
 then  pares the edges of the cleft by transfixion with a  narrow-bladed  bistoury
 from above, downwards, first on one side, then on the other, taking care that the
 incisions unite neatly and
 cleanly  above  the  upper          F'g-203-                      F _ 2oi.
 angle of the fissure, which
 must be well cut out;  and
 that they extend suffici-
 ently far outwards to cut
 away the rounded portion
 of the  prolabium which
 forms the side of the base
 of the fissure. Care should
 be taken that enough is
 cut away; there is more danger usually of taking too little than too much.  Fine
 hare-lip  pins, made  of soft iron  wire, with  steel points, should then  be deeply
 introduced  through  the lip from one side of the fissure to the other.   At a very
 early age one pin may be sufficient; at a later period two are required.  If two
 are used, the  lower  pin should be introduced  first underneath, or through  the
 cut labial artery, in  such a  way that its pressure may stop the  bleeding from this
 vessel, which is often  rather free.   In passing this pin,  care should be taken to
bring the opposite sides of the fissure well  in contact, so as to be on a level below,
 that  no  irregularity may be left in the prolabium; the twisted suture  is then
 Figs. 203 and 204.—The dotted lines represent the semicircular and  angular incisions, necessary  to
 avoid the production of a central notch.
 
644
DISEASES  OF  THE  LIPS.
applied in the usual way, first  round the lower pin, and then round the upper
one, and  lastly the two are united  by a few cross turns ( Fig. 205).   The  pins
are then cut short, and a piece  of plaster put under their ends to prevent excori-
ation of the skin.  In addition  to the pins and twisted suture, I invariably intro-
duce one point of interrupted suture through the mucous  membrane of the lower
part of the fissure, just inside the mouth; and I  look upon  this as of great  con-
sequence in  order to prevent the notching, which is otherwise very apt to occur,
in consequence of that portion of the incision between the  lower pin and the ed<*e
of the lip being kept open by  the  child in suckling, or  protruding its  tongue
against it.  At the end of about sixty hours, the pin  may be removed by pushing
it through the lip by a gentle rotatory movement, in  such a way that the  cut end
does not tear or lacerate the aperture in the lip.  The sutures may be left on for
two or three days longer;  the lip being supported by a strip of adhesive  plaster,
or by a piece of lint soaked in  collodion, which I have found  to  form a firmer
and  more secure support than  the plaster, and should indeed be continued for
about a fortnight  after the operation, so as to prevent stretching of the  cicatrix
and notching of its lower part.   The point of interrupted suture may be left in
for about six days.  If the fissure be wide, and  the  child restless, so that there
is danger of  the parts being dragged upon during its  screaming or crying, it  is a
very good plan to apply the spring check-compressor, invented by Mr. Hainsby,
and figured in the last edition of Fergusson's "Practical Surgery."
   The operation for double hare-lip is performed  on  the same principles  as  that
for the single form of the disease, viz., of procuring  union by adhesion between
the opposite surfaces.   The difference in the operations consists in dealing with
the intermediate portion of the  lip and  alveolus.  If this portion of the lip be
small it should be cut off, as it would prevent the lateral segments coming into
Fig. 205.
Fig. 207.
^ v
proper apposition ; but if large, it may be well pared on either side and transfixed
by the hare-lip pins, and thus be  interposed between and united to the pared
lateral surfaces.   When the intermediate alveolus is small  and rudimentary, and
more particularly, if it be very prominent, it had better be cut off with a pair of
bone-nippers, and the lip brought together over the cut surface.  Most commonly
there will be  free bleeding from a dental artery deep in  the bone, and which
requires to be touched with a red-hot needle or wire before  the hemorrhage from
it will cease.  If the intermediate portion be large and not projecting, it may be
left, and the edges of the lip brought together over it.   If it be projecting and
large, it should be bent forcibly back;  this is best done by seizing it with a pair
of necrosis forceps covered  with  wash-leather.   If, by any  chance, union by the
first intention  fail, the lip tearing open, the granulating surfaces must be brought
in contact with  one another again, when they will  in all probability cohere as
readily as they would have done  in  the first instance.  Sometimes  it may be
adherent to the tip of the nose, and then requires careful removal (Tim?. 206 and
207).                                                         ^  ° 
PLASTIC  OPERATIONS  ON  THE  FACE.
645
   Ulceration  is not unfrequently met with on the prolabium, frequently of a
 simple character, though chronic, when it will commonly yield to the application
 of nitrate  of  silver and  to proper constitutional treatment, more especially the
 administration of the preparations of arsenic.   Not unfrequently warty growths
 and various forms of epithelial cancer and cancroid diseases appear upon the lips.
 These affections are not  removable  by therapeutic means, and require surgical
 interference.
   Cancroid ulcers of the lip either commence as warty growths, which  gradually
 ulcerate like the ordinary forms of tubercular lupus, or beginning as a crack or
 fissure become indurated, the edges having a tendency to spread, the submaxillary
 glands to become involved, and  the disease  eventually to prove fatal by the pain,
 exhaustion and constitutional irritation induced by them.   These ulcers almost
 invariably occur in  men, affect the lower lip, and are met  with after the middle
 period of life.   Of 10 cases in which I have  operated, 5  were above sixty, and
 2 between  fifty and  sixty years  of age; in  one case only  did  the disease  occur
 under thirty.  This disease is at first entirely local, often being induced by some
 irritation, as by a  rugged, broken  tooth, or by smoking a clay pipe, and when
 removed does  not, I believe, very commonly return.  At least, of the very many
 cases that have been  operated upon at the University College Hospital, I have
 only known one  patient return with the recurrence of the disease, and I do not
 recollect any  case of secondary  affection of this  description  apply to that
 institution from  other hospitals;  I cannot,  therefore, but come to the conclusion
 that the operation for cancer of the lip frequently rids the  patient of the disease.
   When the glands under the jaw are enlarged in these cases, it may be a ques-
 tion whether the operation should be done, but  I think decidedly that extirpation
 of the disease  and removal of the enlarged glands, provided the surrounding soft
 parts are not involved, should be practised,  if the patient be otherwise  in a good
 state of health, as he will thus be placed in a more favorable  condition than  he
 was  before the operation, and will have a better chance of  prolongation  of life.
   When once the true nature of the disease has been ascertained, the  operation
 should be performed with as little delay as  possible;  but before it is done, it is
 well that any very prominent or  broken tooth should be removed, and the  tartar
.cleared  away from the incisors.   The operation requires to  be somewhat  modified,
 according to the  situation and extent of the  affection ; if this be tolerably limited,
 a V shaped cut, extending widely around it,  and carried sufficiently low to include
 any indurated  prolongation of the  absorbents, should be practised; the edges of
 the cut should  then  be  brought together  by  two hare-lip pins with a twisted
 suture, just as in the case of a simple hare-lip.   When the disease occupies  a
 considerable longitudinal extent, but does not dip  down very deeply a slice  of the
 lip should be shaved off,  including the whole of the morbid structure;  and it is
 often surprising, under these circumstances, how  little deformity  will  result, so
 soon as the disease  is removed, the tissues of the lip speedily rising to their
 natural level, and thus preventing any material deformity being left.   In some
 cases the disease occupies a square surface,  and then it is necessary to excise a
 large portion of the lip; when this is done, a considerable gap will be left, which
 requires to be filled by some plastic operation, such as we shall immediately con-
 sider, which may most conveniently  be  done at the time  that the  excision  is
 practised.

                    PLASTIC SURGERY OF THE FACE.
   By plastic or reparative surgery is meant  those processes by which mutilations
 are repaired, and the loss of structure replaced.   As these  operations are princi-
 pally practised  for deformities of the face, we may conveniently discuss them here.
 It has been long known to surgeons that parts of the body  may retain their vita-
lity sufficiently to become again adherent when attached  but by a  very narrow 
646               PLASTIC  SURGERY  OF  THE  FACE.
tongue of tissue, to the part from which they have been all but separated.  This
has often  been observed in cases of injuries of the face  and fingers, portions of
which have been nearly completely severed, and yet have united again on being
replaced.   But  there are even a  sufficient number of cases on  record to show
that certain  parts, when  completely separated, may, after being replaced, again
become adherent.   The most remarkable instances of this kind are those related
by Dr. Hoffacher, and which are  attested by Chelius  and Velpeau.  Dr. Iloff-
acher was officially appointed to attend  as  surgeon at the  duels  which were at
one time frequent among the students at Heidelberg, and, as at these encounters
broadswords were  used, he had an opportunity of seeing a considerable number
of incised wounds, and has related  no less than sixteen cases  in which portions of
the nose, lips, or  chin, had been  sliced off, and being put  on again, contracted
adhesions.  Amongst the  most remarkable  of these, is a case in which the end
of the nose was sliced off by a cut  with the broad-sword, and fell  under a chest
of  drawers; it  was  not  found for  some  time,  but  on being  recovered and
washed, was stitched on, when it became firmly attached.  In  another instance,
a dog that was in  the room snapped up the  detached portion of the organ as it
fell to the ground, but the  nose being immediately  taken  out of the animal's
mouth and  put on again  became firmly fixed !
  In  order that union should  take  place  between parts that have been sepa-
rated  completely or nearly so, and  the rest  of the body, it is necessary that they
be soft and vascular, and more especially that their structure  be of a homogeneous
character,  such  as  is  met  with  in the tissues of the  face;  where no very
large  bloodvessels, nerves,  tendons,  or bone  are found.  It is the same in plastic
operations, which  succeed  best under similar conditions of tissue,  and which are
conducted on the same principle  as an attempt at union in a partially severed
structure.
   Union in plastic operations is effected between the flap of skin that is partially
detached, and the raw surface on which it  is laid  and attached, by primary ad-
hesion.   For this to be accomplished, it is  not only necessary that  the cut sur-
faces  be kept accurately in contact, but  that all foreign bodies, all coagula, &.c,
be  previously removed.   Care must also be taken that there is no compression or
tension put upon the parts so as to  interfere with the maintenance of the circula-
tion through them.   There must also be such a healthy state, both of the part
that is  to be the seat of operation, as well  as of the constitution generally, as
will favor adhesive action.   Hence, if the  plastic procedure is to  be undertaken
for the relief of deformity that results from disease,  it  will be necessary  to see
that all  morbid action has completely ceased in the  part that is to be operated
on; and that the  patient's health  be in a good state, and that he  has been pre-
viously properly prepared by rest, good diet, and a few doses of aperient medicine.
   In performing  these various plastic  operations two methods have been  em-
ployed.   In one, the flap of skin  that  is  intended to repair  the loss of struc-
ture is transplanted from a distant  part, as  the arm for instance.   This operation,
which was introduced by the Italian surgeon, Tagliacotius, and hence commonly
called by his name, has in a great  measure fallen  into disuse, on account  of the
difficulty  of  its execution, and the  great uncertainty of obtaining a successful re-
sult.   The plan that is commonly adopted consists in transplanting the reparative
structure from some part in  the neighborhood of  the  organ to be repaired; the
skin from the forehead, for instance, being  used for the formation of a new nose;
that from the chin for the  restoration of  the lost lip.  This  procedure, which
seems first to have been adopted  by the natives of India in restoring the loss of
the nose, is the method that is now commonly employed  in this country.
   It  is principally for deformities and loss of the nose and lip that plastic opera-
tions  are of much service; they may, however, occasionally be had recourse to in
other situations, as about the  cheeks and eyelids, but seldom with an equal amount 
FORMATION  OF A  NEW  NOSE.
647
of success.   In the practice of this very interesting branch of surgery there is much
opportunity for the  display of manual dexterity, on which, indeed, almost the
whole  success of the  operation depends, and a vast  deal may be done  in appa-
rently the most unpromising cases by management, skill, and patience.   In these
operative  procedures the names of Serres,  Dieffenbach, Liston, and Jobert, de-
servedly take the first rank.
  The only plastic procedures the performance of which can be reduced to dis-
tinct rules, are those for the restoration of a lost nose, rhinoplasties, and for par-
tial loss of a lip, cheiloplasties.   As these operations are commonly practised for
loss of the part from cancroid or syphilitic  disease, especial care must be taken
before  they are commenced, that all morbid action has entirely ceased for at least
a year  or  two, lest the irritation of the operation set it up again, and thus the
new flap be invaded and  destroyed;  I  have more than once seen much disap-
 pointment ensue from want of attention in this respect.

                       RHINOPLASTIC OPERATIONS.
  When the columna and a portion of the septum are destroyed, a large gap is
left at  the nasal aperture, and the nose becoming flattened in consequence of its
tip  falling in, great  deformity necessarily results.   The upper lip also losing that
amount of support which it receives from the columna, becomes pendulous,  pro-
jecting, and thickened at the end, thus adding to the disfigurement.   The re-
storation of the columna is effected from this thickened and prominent  upper lip
which, by  being reduced in size, is rendered far more shapely.  The  operation
consists in  cutting through the whole length of the lip from above downwards
on either side of the mesial  line so as to leave a tongue  about one-third of an
inch in width.   This is then turned  up, and its end being well pared, and the
under surface of the  tip of the nose properly vivified, it is fixed there by means of
a fine hare-lip pin and twisted suture, which should be left in for about four days.
Union  takes place in a few days, but until this  is firm the new columna must be
properly supported  with narrow strips of plaster fixed to the  cheeks on  either
side.   No twisting of this small flap is required, as the mucous surface speedily
becomes  cutaneous, and vice versa.   The division  in  the  upper  lip  must be
treated in the same way as  an  ordinary hare-lip, and  unites without difficulty,
lessening greatly the deformity in this part.
  When one ala only is deficient, the rest of the nose being sound, a flap of  skin
of the  proper shape  to  restore the  deformity may be raised from the cheek and
applied to the edges of the part requiring it, previously pared, and fixed there by
a few points of fine suture.   If  the loss of the substance of the ala be  very  con-
siderable, or if it extend to a part of the body of the  nose, then it is  more effi-
ciently restored by bringing a long  narrow flap from the forehead in  the way  that
will immediately be  described.  In the majority of cases the destruction of the
ala and of the body of the nose is so considerable that other plans than those  just
described are required for the repair of the  deformity.   The  methods that may
be had recourse to are the Tagliacotian and the  Indian  operations.
  The  Tagliacotian operation  consists  in taking the integument  and cellular
tissue required for the repair of the lost organ from the inside of the arm.  Here
a flap of sufficient extent should be marked out and dissected up with its  sub-
jacent cellular tissue, leaving it  merely attached to the limb by a root at its distal
end.  No  attempt at fixing this flap to the nose should be made for at least a
fortnight,  during which time it should be kept upon a piece  of wet lint, and al-
lowed to thicken, granulate, and become  vascular, so as to fit itself  for adhesion
to the new surface to which it is to be applied.  The  remains of the deformed
nose haying then been properly pared  and the flap shaped, they must, after
all bleeding has ceased, be properly adjusted and fixed to  one another by points
of suture.   The arm must then be closely attached to the head  so as to be as nearly 
648
PLASTIC SURGERY OF  THE  FACE.
as possible immovable.   At  the end of about ten  days when adhesions have
taken place, the  connecting  medium may be cut across and the part left to be
supported  by the vitality that it may gain from  the  new surface  to which it is
now attached.   This process is comparatively seldom had recourse to, for obvious
reasons.   The uncertainty of maintaining the vitality in  the flap, the extreme
tediousness of the prolonged constrained position  in which it is necessary to keep
the patient, and  the great difficulty in guarding  against movements of the arm
especially during sleep, and which, however slight and involuntary, would be suffi-
cient to disturb union between the opposed surfaces and occasion the failure of the
operation,  have caused this plan  of procedure to fall into disuse; and it is now, I
believe, universally  abandoned by surgeons in this country, having been replaced
by the more certain procedure of borrowing the skin for the new  nose from the
forehead.
   This, the Indian  operation, a  knowledge of which was brought to this country
by Mr. Carpue, in 1814, is extremely successful in its results, though requiring a
good deal of nicety for its proper execution.  The operative procedures required
by this method are  somewhat complex, and may conveniently be  divided into
three distinct periods : the first consisting in the  dissection of the flap from the
forehead, and its attachment to  its new situation; the second the  separation of
the root of the flap where it is turned down from the forehead, and the formation
of a  proper  bridge  to the  nose; and the  third,  the formation of the columna
nasi.
   In the shaping of the flap care  must be taken  that it is of sufficient size, as
during the after-part of the treatment, it often has a tendency to shrivel, and more
inconvenience usually results from its not  having originally been made large
enough, than the reverse.   The  size adapted to the particular face may best be
judged of  by moulding a thin piece of gutta percha to the  nose, then flatten-
ing it out by dipping it in hot water, and using this as the guide for marking
the outline of the flap upon the  forehead.   This  should be traced with tincture
of iodine, which will not  wash off so readily as ink by the flow of blood, which
is often rather free.   This flap should be of the  size and  shape in  Fig. 208,
taking care that it is rather square at the angles, and not too much rounded off.
It must now be dissected off the  forehead; in doing this  care must be taken not
to remove  the pericranium, but  at the same time to cut the flap as thick as
possible, especially at  its root between the eyebrows.  It must also be but little
handled, and, above all, not pinched, either with fingers or forceps.   The dissec-
tion  should be commenced at the root, so that the outline may not be obscured
by blood ;  and this  part should be left long, in order to admit afterwards of a
very gradual and  easy twist.   In  order to facilitate  this, it is also desirable to
make the incision on the left side a little lower than that on  the  right.   After
the flap has been raised throughout the whole of  its extent, a  piece of wet lint
should be  applied to  the forehead, with a  view of arresting the bleeding, be-
fore the  next step  is  taken.   This consists in  paring the surface and edges of
the stump of the  nose, and removing the integuments from  it in such a way
as to  leave a triangular raw surface.  In  doing this care must be taken, whilst
a good base of attachment is left, not to remove  the parts  too widely, lest the
cheeks, by  separating, have a tendency to gape too much, and the nose to become
flattened out.  The  bleeding  having been arrested by exposure to the air, and
by the torsion or ligature by fine threads of any spouting branch, the flap from
the forehead should  be brought down by a twist from left to  right, and attached
by three points of suture on  either side of the edge of the incision around the
nasal aperture.  A pledget of soft lint, moderately greased, should now be gently
insinuated  under the flap, the lower part of the incision  in  the forehead drawn
together by a point of suture, but not so as to constrict the root in any way, and
the rest of the exposed surface covered with water-dressing.   The patient should 
FORMATION  OF  A  NEW  NOSE.
649
be  put to bed  with  a piece of soft lint laid over the whole of the face, so as to
maintain its temperature, and if it be winter, placed in a  room that is kept well
warmed day and night.  The  diet for the first few days  should be  simple, but
abundant, consisting chiefly of  nutritious slops.
  The dressing must not be disturbed for three days; by this time if all goes
well the flap will be found somewhat tumid, warm, and  sensitive, but pale  in
color.  The plug in the nose will  now require changing, lest it be rendered
offensive by the discharges; its withdrawal and the substitution of another must
be done with the greatest gentleness, the surgeon bearing in mind that any undue
pressure or traction may destroy adhesions  and prove fatal to the vitality of the
flap.   If the sutures produce no irritation, they must be left in till the fifth  or
sixth day, by which time the adhesions will be tolerably perfect, and they may
with safety be cut and withdrawn.   As the adhesions strengthen and the vitality
of the flap improves, it must be elevated by putting underneath it a larger plug
of lint, for which, after a time may be substituted a small  gutta percha tube
moulded to the figure of the inside of the nose.   (Edema of a somewhat solid
character is apt to come  on  in the flap, giving  it a white appearance, but
this is of little  moment, and will gradually subside as the circulation through
it becomes more entirely established.  The flap gradually becomes thicker and
firmer, throwing out  granulations from  its under  surface  which eventually be-
comes clothed  with mucous membrane.   The wound  in  the forehead  must be
dressed like an ordinary ulcer,  and be well touched with  nitrate of silver from
time to time, to insure its contraction.   It usually cicatrizes with great readiness
and leaves  remarkably little deformity.  The next step in the operation is the
division of  the  root of the  flap, which may be done about a month  after  this
has been fashioned, when its vascularity,  through  its lateral adhesions, will be
perfected ;  the  division  of the root is best done by passing a  narrow-bladed bis-
toury under the twist, and  cutting upwards towards the  eyebrows, removing a
wedge-shaped portion of the soft parts  so as to make  a smooth and  proper
bridge.
  The addition of the  columna is now all that is wanted to make the nose
complete.   This must be made at the same time  that the  bridge is fashioned
from the upper lip, and  may be cut and fixed in the way  that has been already
described in speaking of the restoration of this feature.   The columna requires
to be well  supported by means of a  narrow  strip  of plaster passing  from one
cheek to the other, and  usually requires a  good deal of fashioning before it  is
perfect.  Indeed this is the part of the operation that I have always found most
troublesome, and requiring  most attention.   The new nose must be continued  to
be supported from beneath, for  some months after its formation, by plugs of lint,
or small gutta percha  tubes, as it will evince a great tendency to contract and  to
alter in its general outline  and shape, becoming, if the surgeon is not careful,
either  depressed or  dumpy.   The  sensibility of the  new nose is entirely de-
stroyed for a time after the division of the  bridge, but it slowly returns from all
sides, appearing first in the neighborhood of the adhesions between it and the
cheeks, then near the columna, next in the bridge, and thus the organ at last
has its sensations restored; for this, however, several months will  usually be
required, and the part in which it returns last of all is its central portion.   The
annexed cuts give a very faithful  representation of the last  patient on whom I
operated, before and after the restoration of the lost organ (Figs. 208 and 209).
  The principal  causes of  failure  in  the  operation or in the  result, so far  as
concerns the after-appearance of the patient, are in consequence of gangrene  of
the flap, in whole or in  part, taking place from the root being too narrow, too
tightly twisted,  or the flap too roughly handled in its  dissection.  So also if it
be cut too  small and  not properly supported afterwards, the  result will not be
very satisfactory.  Other accidents occasionally  happen; thus erysipelas may 
650
PLASTIC  SURGERY OF TnE FACE.
occur, destroying at once the vitality of the flap, or, coming on at a later period,
when the new nose will slough under  the attack of inflammation, which it  has
not sufficient vitality to resist, as happened in one of Mr. Listen's earlier cases;
Fig. 208.                             Fig. 209.
or it may be destroyed by a return of the lupus which proved destructive to the
old one.   Hemorrhage may also  occur from underneath the flap.   In the last
case operated on by Mr. Liston before his  death, and which was completed by
Mr. Morton, at University College  Hospital, hemorrhage to the  extent of more
than  a  pint took place on the ninth day without any evident cause, from under
the flap, and could only be  arrested by plugging.  Lastly, the operation is not
without  its dangers.  Dieffenbach  lost  two  patients out of six on  whom  he
operated in Paris;  their constitutions, probably, being in an unfavorable state.
   When the nose is depressed and  flattened, in  consequence of  the  loss of the
cartilages,  vomer and septum, though the external parts remain  entire, Dieffen-
bach  has proposed  a plan  for  raising it, by slitting it longitudinally into three
pieces ; dissecting the lateral  ones from the osseous attachments, and then paring
the edges to such an extent that they overlap, and stitching them together, to
bring the whole organ forwards by pushing long hare-lip pins  across its base, so
as to  elevate and narrow its attachments, which are brought more into the mesial
line.   Fergusson has improved this  procedure by not slitting the nose down, but
by dissecting it away from the bones from within the  nostril, and then pushing
long steel-pointed silver needles  across from cheek to  cheek, and twisting their
ends over perforated pieces of sole leather, through which they had  previously
been passed, thus bringing the whole  organ  bodily forwards.  The columna is
next fashioned  in  the way that  has already been described, and the nose thus
completed.

                       CHEILOPLASTIC OPERATIONS.
   The  restoration  of a  portion  of the  lip, that has  been lost  by accident or
disease, is  not so readily effected as that of the  nose, but yet, a good deal may
be done  to restore  the  deformity.   The plan originally introduced  by Chopart
consists, when it is  the lower lip that is  deformed, in  carrying an  incision from
behind the lower jaw, down to the  os hyoides, so  that a square  flap may result,
which is detached  from above downwards.   This flap is then brought up  and
fixed to the pared edges of the remaining portion of the lip by points of suture,
the head being kept properly inclined, in order to prevent undue tension.  After
sufficient union has taken place to preserve the vitality of the flap, its lower 
FORMATION  OF  A  NEW LIP.                 651
attachment may be divided.   The flap should, if possible, not be twisted, though
it is not  always practicable  to  avoid  this.  This operation is  not  usually very
satisfactory  in  its results, as  the new  flap  is apt to become cedematous  and
inverted  at the  edge, or the  flow of saliva may interfere with proper union.   In
those  cases in which  the  greater portion of  the lower lip  has  been excised for
cancerous disease affecting its upper margin, the most successful procedure for
the restoration  of the  deformity, consists in  a modification of the  plan recom-
mended by Serres, and from this I have derived excellent results, as in the  case
which is here represented (Fig. 210).  The  object of the  operation is to raise
the lower lip on a level with the incisor teeth.  This is effected in the following
manner: an incision, about  three-quarters of an inch in length, is made directly
outwards  from  the  angle  of the mouth, on  either  side, into  the cheek;
from  the extremity of this, a cut is carried obliquely downwards on  to the upper

          Kig. 210.                                     Fig. 211.
                                margin of the lower lip, so as to excise the in-
                                cluded triangular  piece;  the lower lip is  then
                                dissected away from  the jaw, from  the inside
                                of  the mouth, and a V shaped piece taken out
                                of  its  centre.  By means of a hare-lip pin on
                                either side, and a  point of suture, the incisions
                                in  the angle of the mouth  are brought accu-
                                rately together, and in the  same way the ver-
                                tical one,  in  the  centre, united  (Fig. 211).
                                In  this way the whole of the lower lip is raised,
and brought more forwards.  If care has been taken, in removing the cancer from
the edge  of the lip, to leave the mucous  membrane  rather  long, which may
always be done, as the skin is affected to a greater extent than it, a good prolabium
may be formed, and the restoration effected with but little deformity.   Care
must  be taken to prevent union occurring between the inside of the lower  lip
and jaw by the interposition of a strip of oiled lint.
  Mr. Syme  has introduced an operation by which the cancerous ulcer of the
lower lip having been removed in a  triangular form, by two incisions  extending
from the angles of the mouth to the chin, the cuts are  carried obliquely down-
wards and outwards, on each side, under the body of the jaw, and  made to ter-
minate  in a slight  curve outwards and upwards.  The flaps thus formed are
detached from their subjacent connexions, and the whole raised upwards so that
the original triangular incision comes into a horizontal line, and is made to con-
stitute the margin of the new lip; the secondary incisions under the jaw coming
together in a vertical direction, in which they are  retained by twisted and  in-
terrupted  sutures.   This operation is fully described in the "Monthly Journal"
for 1847,  and yields, I am told, very excellent results.
  Besides these more  new regular plastic  operations, various other procedures
may be required  for the restoration of deformities of the face, in which the
suro-eon may display much  ingenuity  and  benefit his patient greatly.  The
annexed cuts (Figs. 212, 213) represent a case lately under my care, in which there 
652
DISEASES OF  THE  TONGUE.
was a large aperture by the side of the nose,  with loss of the bones of the nasal
fossae, that was successfully closed by a flap of skin taken from the forehead.

                Fig. 212.                                  Fig. 213.
                        DISEASES OF THE  TONGUE.
  Infants are often said to be tongue-tied, when the frenum linguae is shorter
than usual, causing the end  of the tongue to be depressed and fixed, so that it
cannot be protruded beyond the incisors.   If this malformation be considerable,
suckling and distinct articulation may be interfered with, and then division of
the fold becomes necessary, which may readily be done by snipping it across with
a pair of round-ended scissors.  In  this little  operation,  the  risk of wounding
the ranine arteries that is  sometimes spoken  of, may be avoided by keeping the
point of the scissors downwards towards the floor of the mouth.
  Prolapsus of the tongue has occasionally been met with, either as a congenital
or an acquired  condition ;  it has been described by Lassus and Crosse as consist-
ing either in a  want of power in the retractor muscles or in hypertrophy of that
organ.  In this condition,  the tongue lolls out of the  mouth, is greatly swollen,
of a purplish color, but somewhat dry, with constant dribbling of saliva.   If  the
swelling have existed for a long time, it may give rise to deformity of the  teeth,
and of the aveolus of the  lower jaw, which is pushed  forwards.  In the  treat-
ment of this affection, little can be done unless it be excessive and of a perma-
nent  character, when  excision of a portion of the tongue by knife or  ligature
may be  required.   In children, the ligature would certainly be the safest, as
excision might  be followed  by abundant hemorrhage, not very easy to arrest.
  Glossitis is a rare affection, more  particularly when occurring idiopathically;
most commonly it results from profuse and injudicious salivation.  In this disease
the  tongue  is  greatly infiltrated with serum and blood, becoming immensely
swollen, so as to hang out of  the mouth, with profuse salivation and  inability on
the  part of the patient to swallow or  speak, with perhaps a threatening  of suffo-
cation.  The treatment is as simple as it is efficient; it consists in making  a long
and free  incision along the dorsum of the tongue  on either side of the  raphe,
which gives free and immediate relief by the escape of  the blood and infiltrated
fluids.  I have seen a patient, who was nearly suffocated by the immense  size of
his  tongue, relieved at once, and get  nearly well in the course of a few hours by
such incisions.   Purgatives, especially of a saline character, are  also useful, but
these cannot be administered until after  the swelling has been  relieved  in the
way just mentioned.
 
DISEASES  OF  THE  TONGUE.
653
  Abscess of the tongue, though rare, occasionally occurs.   A  boy was brought
to me some time ago with an elastic fluctuating tumor of slow growth, and about
the size of a small plum, situated  deeply in the centre of the tongue; on punc-
turing it, about half an ounce of healthy pus  was let out, after which the cyst
speedily closed.
  The epidermic covering of the tongue may become the seat of various morbid
changes ;  amongst the most remarkable of which is psoriasis.   In this affection
the tongue is indurated, shrivelled, and dry, having cracks upon its surface, with
patches of a dead-white color, and irregular shape, varying in size from that of
a split-pea to an inch in diameter; this condition exactly resembling psoriasis
of  the palms of the hands,  may occur with or without scaly disease of the
general integument.  I have seen it in both conditions, and have always found
it a most difficult affection to treat.  The preparations of arsenic with Plummer's
pill and sarsaparilla, have, however, appeared  to afford the best results.   In some
instances, it is evidently of  syphilitic origin, and  then  it requires to be treated
on the general principles that guide us in the management of the constitutional
forms of that disease.
  The surface of the tongue occasionally assumes a glazed and warty character,
as if covered with a layer of  boiled sago.   The mucous membrane being cede-
matous, elevated, and papilkted, but at the same  time glassy and semi-transpa-
rent and  without induration.  This condition,  which  is usually of syphilitic
origin, requires the constitutional treatment for that disease.
  Fissures or  cracks  not uncommonly  appear upon  the side of  the  tongue,
usually opposite the molar teeth, sometimes dependent on irritation of stumps,
but not unfrequently on dyspepsia.  These cracks may  in some depraved states
of the constitution extend rapidly, eroding away a considerable portion of  the
side of the organ  in a short time, so as to leave a large and deep sloughy cavity
with much dusky inflammation around  it, with great fetor of the breath, and a
copious discharge of saliva which trickles out of the corners of the  mouth;  the
patient being usually destroyed in from three to six months, by the irritation of
the discharge, the inability  to take food, and  the supervention of hemorrhage.
This disease  which is a combination of sloughing and ulceration, is  best treated
in the early stages by the application of leeches beneath the jaw, and the use of
chlorinated gargles, with a moderate antiphlogistic regimen ; as it advances, the
internal administration of arsenic is useful in some cases, with the application of
the balsam of Peru, either  pure or diluted with the yolk of egg, and the em-
ployment of  gargles composed of  the chlorides and the tincture of myrrh.
   Syphilitic tubercle is not unfrequently met with in  the tongue, as one of the
advanced symptoms  of constitutional  syphilis,  forming an indurated  irregu-
larly circumscribed mass, of a round  shape, situated deeply in  the substance of
the organ, or towards the centre of the tip.   The surface covering the tubercle
is of a dusky red  or  coppery  color;  it rarely  runs  on to ulceration,  though
rhagades and fissures occasionally form around it; there is no fetid discharge and
no destruction of the organ  in these cases.   The treatment consists in  the admi-
nistration of small doses of  bichloride of mercury in sarsaparilla, under which it
will rapidly disappear.
  Various cancerous and cancroid diseases may occur  in  the tongue.  These
affections usually commence with tubercles, or fissures, or as a solid  mass in the
body of the organ.  If as a tubercle or warty growth, it is usually flat, indurated,
and of a purplish-red color, gradually running into ulceration;  if with a fissure,
this from  the commencement  has an indurated base, a foul surface, and an everted
edge.  As the ulceration  extends, a chasm with rugged  sides, a sloughy surface
that cannot be cleansed, and a widely indurated base, gradually forms; there is
great fetor of the breath,  profuse salivation, and  as the disease progresses,  im-
plication of  the mucous membrane  and of the structures of the  floor  of the 
654
DISEASES  OF  THE  TONGUE.
mouth, and of the submaxillary or sublingual glands,  takes  place.  The lym-
phatic glands under the jaw, usually become involved at an  early  period, but I
have known the disease exist for a year  or  two without their becoming inipli-
cated.   Cachexy at last supervenes, and the patient dies from the conjoined
effects of exhaustion, irritation, and poisoning of the system.  In  the  majority
of instances, the disease assumes a cancroid form, but tumors of the tongue may
occasionally occur,  presenting all the characters of scirrhus.   In  one instance I
have seen cancer of the tongue assume a truly encephaloid character :  it was a
case in which the disease had twice been removed,  and recurring a third time,
assumed the character of a large, soft, fungating  growth, with rapid implication
of the floor of the  mouth  and maxillary glands,  death  speedily occurring from
exhaustion.
   The diagnosis of these various forms  of  disease of the  tongue is important.
The foul and sloughing ulcer may be distinguished from all  others by the rapidity
of its progress, its  eroding action, and the absence of all induration at  its base.
Syphilitic ulceration, with an indurated base, commonly closely resembles cancer
of the tongne, so closely indeed, that it is only with  great difficulty that  the
diagnosis can  be effected.   This, however,  may generally be accomplished after
a time by observing that the syphilitic ulcer is elongated, irregular,  and  does not
rapidly extend, the cancerous ulcer on the other hand is of a circular shape, has
eroded edges, and spreads with considerable rapidity.  The  influence also of
treatment will after a time throw light upon the  nature  of the disease,  and  the
scrapings of the cancerous  ulcer when  examined  under  the microscope, will
always reveal its true character.
   The diagnosis between the syphilitic and cancerous tubercle is most important;
here the duration of the disease and the co-existence of constitutional  syphilis
must be  taken into account.  It is also of much moment to attend to the situa-
tion of the tumor, the syphilitic tubercle being almost invariably met with deeply
in the substance of the organ, whilst the cancerous growth is  commonly seated
at its edges or tip.
   In the treatment of cancer of the tongue therapeutic means are utterly  useless;
and  no measures hold  out any chance  of recovery to the patient except  the
removal of the diseased structure.   This may be  effected either by the ligature
or the knife, and should be done as early as possible before glandular or consti-
tutional infection has come on.   When the  free  portion of the tongue only is
diseased  the morbid structure may readily and safely be excised; any hemorrhage
that ensues being arrested by the ligature of the bleeding parts, or  by the intro-
duction of ice  into the mouth.  When  the organ  is more extensively  diseased
it has been proposed to divide the lower jaw, and thus to get a view of the whole
of the  tongue, and  to remove as much as proper, treating afterwards the section
in the bone as a fracture of it.  When, however,  the tongue is very deeply
diseased excision is objectionable,  as the hemorrhage  that  follows may be so
considerable as to be stopped with  difficulty, and, indeed, to require the appli-
cation of the actual cautery for its arrest.   In these deep cancerous affections of
the tongue also, there is usually great enlargement of the  submaxillary glands,
with infiltration of  the  floor of the  mouth and of the neighboring  soft  parts to
such an extent as to render it impossible  with safety or advantage to excise  the
diseased  mass.
  The ligature is the plan usually had  recourse  to, and which indeed,  I think,
is in all cases, except where the tip is alone involved, preferable to excision;  but
though  there  is no risk of hemorrhage when  this means is used, yet it  is  not
without objection on account of the painful  nature of the process and its  tedious-
ness.   Mr. Hilton  has  removed the first objection  by proposing  and practising
the section of the gustatory nerve prior to the application of the ligatures.  This
operation may be done by drawing the tongue forwards and dividing the mucous 
OPERATION FOR  CANCER OF THE TONGUE.         655
membrane and submucous tissue vertically for three-quarters of an inch, opposite
the molar teeth,  over the hyoglossus muscle, and across the upper portion of the
sublingual gland;  much venous bleeding usually occurs, which  embarrasses the
search for the nerve, yet with a little dissection this may be exposed and divided,
when sensation will cease in the whole of that  portion of the  tongue which is
anterior  to the line of incision.   By means of the ligature any portion of the
tongue, however deeply seated, may be securely strangled.   For the purposes of
this operation strong thick saddler's whipcord is the best, as it does not readily
cut through  the  soft  granular tissue of the  organ, as would be the case if the
               small compressed cord usually sold by the  instrument-makers is
     Fig. 214.    used.
                  In removing the cancer of the tongue by ligature, the patient
               should be conveniently seated opposite a strong  light.   The sur-
               geon then passes  a strong silk thread doubled,  through the tip
               of the tongue, by which an assistant draws the  organ  out of the
               mouth; a wooden wedge is next placed between the teeth of the
               upper and lower jaws on the side opposite to that on which  the
               operation is to be performed, and the ligature is then  passed by
               means  of an ordinary nevus needle, or what is often  more con-
               venient, a cork-screw needle curved on the side as well as to the
               point (Fig. 214).  In many cases the plan  described for  liga-
               turing flat nevi will be found the most convenient mode of pass-

                                          Fig. 215.
ing the whipcord round the cancer of the tongue (Fig. 215).   In whatever way
the ligatures are applied, care should always be taken  to pass them through the
healthy tissue of the organ wide of the disease,  and they should then be tied
very tightly, so as to strangle the mass effectually.   Great swelling of the tongue,
followed by profuse salivation and some fetor of the breath attend this operation,
but  the mass, if properly constricted, will slough away in a few days, leaving a
large gap that readily fills by granulation.  When the  disease exists so far  back
in the  tongue that it cannot readily be reached from the mouth, Cloquet, Arnott,
and  others have successfully strangled it by making  an incision in the  hyoid
region, between the  genio-hyoid muscles, forcing the ligatures by means of long
needles through  the base of the tongue, and then drawing them tight through
the aperture in the neck, so as effectually to constrict the diseased mass.
   Begnoli  has of  late successfully extirpated  large portions of the tongue for
cancerous disease of the back of  the  organ, by making an incision  of a semi-
lunar shape, along the line of the  lower jaw from one  angle of the bone to the
other, thus opening into the cavity of the mouth  through its floor, then making
a vertical cut through the centre of this, from  the os hyoides forwards, clearing
the parts  by a little dissection,  and drawing the  tongue through  the opening
down upon the anterior  part of the neck, where the diseased structures may be
ligatured or excised.  The wound is then closed  and  united in the usual way. 
656
DISEASES  OF  THE  JAWS.
By this means the surgeon can reach portions of the organ that cannot be got at
in any other way.
   When, however, the  floor of the mouth  is implicated in the morbid  action
nothing should, I think, be attempted, as it is impossible to extirpate the whole
of the disease, and partial removal of it will  only be followed by rapid recurrence
and increased activity of development.   I do not think that the  enlargement of
the submaxillary glands merely should be any bar to the operation, provided the
disease be limited and the constitution is good, as under these circumstances, the
glands may be excised, as well as the  disease of the tongue removed; or, if they
be not of any very considerable  size,  they may be  left, when  they will perhaps
subside without the necessity of operation, as their enlargement may probably be
dependent upon simple irritation;  or should they continue indurated,  they may
readily be removed at a subsequent period.
   Tumors  of various kinds, encysted, fatty, and erectile,  are met with in  the
tongue, and underneath it in the floor of the mouth.   They require extirpation
by the knife  or ligature, according to  their situation  and size, and  for these
irregular operations  no special directions can  be given.   It must, however, be
borne in mind that if these  growths cannot be reached from the inside of the
mouth, they may be got at by incision through the mylo-hyoid  region, where
there is but a slight thickness of soft  parts between the surface and floor of the
mouth.
   Ranula is perhaps the most remarkable of these buccal tumors.  This disease
occurs as  a globular swelling, semi-transparent, evidently  containing fluid, and
often attaining the size of a walnut or pigeon's egg, situated under the tongue,
pushing this organ upwards and backwards, and consequently interfering with
deglutition and speech.   The walls of the cyst are usually thin, with small vessels
ramifying on them;  its contents are watery  and serous.  Sometimes albuminous
and occasionally cretaceous matters are found intermixed, in some instances even
in large quantity, as much as half a pound of plastery stuff having been met
with in a cyst of  this kind.
   Banula is usually said to be a dilatation of Wharton's duct; but it certainly
appears to me that there is no  proof of  the  disease  being of this nature, and
indeed it is not very easy to understand how so small a duct can be dilated to so
large a size as is occasionally attained  by these tumors, which seem, in some cases
at least, rather to consist of distinct cystic formations such  as commonly occur in
connexion with other secreting glands.  The treatment of  ranula consists either
in passing a seton through its walls, so that contraction may take place in this, or
else in the excision of a large portion of the  anterior wall of the cyst, the remain-
der contracting, until it at last becomes obliterated.
                          CHAPTER XLIX.


                       DISEASES  OF THE JAWS.

                         DISEASES  OF THE GUMS.

  Abscess of the gums is of very frequent occurrence, from the inflammation of
decayed teeth.   Here a free and early incision should be made, which, by giving
exit to the pus, will afford immediate relief.
  Epulis is a tumor  of a fibrous character, springing from the periosteum and
edge  of the alveolus, and implicating the osseous walls, growing up between, 
DISEASES OF THE JAWS.
657
and loosening the neighboring  teeth, which it displaces and  envelopes in its
structure.  It is  most frequently met with  in  the  lower jaw, and commonly
about the molar teeth.   This tumor is red, smooth, and  lobukted, at first hard
and semi-elastic,  like the  ordinary  structure of the  gum,  but after  a time
softening by disintegration, and  ulcerating on the surface, with a  purulent or
sanious discharge; it appears simply to be a  circumscribed hypertrophy of the
gum.
  The treatment of epulis consists in the removal of the whole of the mass and
of that portion of the alveolus  from which  it  springs.   As it evinces a great
tendency to reproduction, it must not simply be shaved off the bones, but a por-
tion of the osseous structure must be removed as  well;  unless this point be
attended to, the growth will to a certainty be reproduced.  In performing the
operation, the first thing to be done is to extract a  tooth  contiguous  to  and on
either  side  of the tumor;  a cut must then be made  with a saw through the
alveoli of  the teeth  that have been removed, down to a level with the base of
the tumor.   In doing this care must be taken not to cut too near the remaining
teeth, lest the alveoli be opened and their support lost.   If the tumor is large it
may be necessary to saw deeply, but the base of the lower jaw should in all cases
be left intact, the whole  of its substance not being sawn through, so that, though
a considerable portion of  bone be  removed, yet the length of the jaw may be
preserved.   For this  purpose Hey's saw should not be used, it  is a niggling
instrument, difficult to manage in this situation; but a straight  and stiff-backed
saw, with as deep a blade as the mouth will  conveniently admit, will be found
most useful (Fig. 176).   The epulis, included  between two vertical  cuts, may
now be removed with  cross-cutting forceps, and the bleeding stopped by placing
a plug in  the wound and compressing it against the teeth of the upper jaw by
means of a bandage passed under the chin.   Should there be a spouting dental
artery, it may be necessary to apply a red-hot wire in order to  arrest its bleed-
ing.   The  cut surface will  speedily  granulate, and the cavity fills up with fibrous
tissue.
  Cancerous ulcers and  fungous growths from the alveolar processes, malignant
epulis, as they are called, occur in the same way as  the  last; but they are soft,
purplish, very vascular,  grow rapidly, and are speedily reproduced after removal;
they principally, I think, occur  in  males advanced  in  life.  The same opera-
tion requires to  be practised for these diseases as for the simple epulis, and as
there  is usually much hemorrhage following their removal, a red-hot iron must
be applied  to the bleeding surface.

              DISEASES OF THE  ANTRUM AND UPPER JAW.
  Our present knowledge of diseases of the jaws, and of the operative procedures
necessary for their removal, is chiefly due to the labors of Gensoul and of Liston.
Mr. O'Shaughnessy also, who appears to have had many opportunities of witness-
ing these  affections  amongst the natives of India, has added much  to our
acquaintance with their pathology and treatment.
  The antrum may be the  seat of fluid accumulations or of solid tumors.  Dropsy
of the antrum from accumulation of mucus within this cavity occasionally occurs.
As the aperture  leading from this cavity into the nose is a little above its floor,
there  may  be a  natural  tendency for the fluid  secreted here to accumulate to
some  extent before it is discharged.   If, however, this aperture be from any
cause  blocked up, the secretion may increase  to so great a degree as to occasion
serious inconvenience by its outward pressure.  In cases such  as these, the
accumulation of  fluid  has been known after a time to expand the  walls  of the
cavity; and in this way the floor of  the orbit or the  roof  of the mouth  may be
caused to  bulge, the  nasal cavity may be encroached upon, and the cheek ren-
dered round and prominent—an indolent semi-elastic tumor forming in  it and 
658
DISEASES  OF  THE JAWS.
protruding it outwards, and giving rise to the egg-shell or parchment crackling
on pressure.   The treatment in these cases consists in making an  opening into
the cavity of the antrum with a strong perforator through its most expanded and
thinnest part, and leaving a plug  of lint in the aperture, so  as to allow the dis-
charge to escape freely.  The shape of the cheek maybe restored by the gradual
pressure of a spring pad or double-headed roller.
   Suppuration may  take  place  in the antrum, being usually  excited by the
irritation of a carious  molar tooth,  or by some injury of the face, and occasioning
perhaps  much pain, with  throbbing or  lancinating  sensations.  The pus, as it
forms, will sometimes escape into the nose through the duct, and then may keep
up constant irritation, with much fetor in the nostrils; in other cases, it escapes
through the socket of a tooth into the mouth; and in other  instances again, its
exit being prevented, it gives rise to enlargement of  the cheek, the soft parts of
which become brawny and inflamed, and the bones expanded, so that at last they
are thinned to such an extent, that, as in dropsy of the cavity, they crackle when
pressed upon.  Any portion of the wall of the cavity—the orbital, buccal, palatal,
or nasal—may thus be expanded, and  the lachrymal duct being commonly ob-
structed, the eye on the affected side becomes watery.
;, The treatment of this condition  consists in the extraction of any  carious tooth
seated in the neighborhood of the  antrum, or if they be all sound, in the removal
of the second molar, the fangs of which come in close relation to, and frequently
perforate the bottom of the cavity.  In  this way an  exit should be given to the
matter;  but should it not discharge itself, the antrum may be opened through
the alveolus,  or through the canine fossa  under the cheek, provided it be  much
expanded in this situation, so that its cavity is easily reached.  It is well not to
attempt to perforate in the site of teeth that have been extracted for some length
of time, as here  the bone becomes  unduly consolidated, and I have  consequently
seen failures  in reaching the cavity occur.  The matter that is discharged is often
very offensive, or it may be thick  and pasty from the absorption of its watery
parts.   After the aperture has been  made, the cavity  should be  syringed out
with tepid water, and its shape gradually restored by pressure.  '
  Tumors of various kinds spring from the upper jaw, taking their origin either
from its surface, from the interior of the antrum, or  from  the pterygo-maxillary
fossa.  Those that grow from the surface of the bone, are  either some of the
various forms of epulis that spring from its alveolar border, and must be treated
as already described, or they are exostoses growing from  the outer surface of the
bone, projecting perhaps up into the orbit, and requiring removal with the saw,
bone-nippers, or gouge.  In doing this,  care  must be taken  not to destroy the
nasal process of the bone, lest the  lachrymal  sac be opened.
  The tumors that spring from the cavity of the antrum or from the  posterior
part of the upper jaw are of very various kinds;—fibrous, cartilaginous, osseous,
fatty, fibro-plastic, erectile, and encephaloid growths may all  be met with in this
situation. In the museum of University College, which is very rich in specimens
of these tumors, most of the above varieties will be found.  The fibrous tumor is
perhaps the most common; it  principally occurs in elderly people, and may attain
a very considerable bulk.  The encephaloid  comes next in order of frequency,
and the osseous  and enchondromatous occur, but are extremely rare.  The osseous
tumors are remarkable as occasionally appearing to set up a spontaneous attempt
at elimination, by necrosis taking place in them.   These various growths are
most commonly connected with, or spring from, the mucous membrane of the
antrum,  and  in  growing gradually expand and dilate the walls  of this cavity,
pressing the bones outwards, thinning them, and  giving rise to a considerable
outward projection of one side of  the face.   The tumor thus formed  is usually
smooth, round, or oval, slightly lobed perhaps, more especially  if of a fibrous
character, and has in many cases  a tendency to hang downwards, so as to over- 
          SUPPURATION  AND  TUMORS OF  THE  ANTRUM.      659

lap the lower jaw to a certain extent; at the same time it encroaches  more or
less upon the other cavities lying in the vicinity of the antrum.  Thus, it pushes
down the palate, causing considerable swelling in  the roof of  the mouth; dis-
places the alveolar processes and teeth, giving rise to irregularity in their outline;
and when encroaching upon  the orbit, occasioning stillicidium  lachrymarum, or
even impairment of vision.  As the tumor enlarges, it obstructs the nasal cavity,
and stretching back into the pharynx, interferes with respiration and deglutition.
When  it is of an encephaloid character, obstruction  of the nasal fossa will  be
found to be one  of its  earliest signs; and  the  integuments will be observed
speedily to become involved,  the gums  implicated, and  the submaxillary absor-
bent glands enlarged.
   In the diagnosis of these tumors there are three principal points to be attended
to:—1st,  to distinguish them  from  fluid  accumulations; 2d,   to  determine
whether the growth is simple or malignant; and, 3d, to ascertain its seat.   In
making the diagnosis from fluid  accumulations in the antrum, the history of the
case, and the uniform enlargement  of the cavity without the tumor  projecting
externally beyond  any part of its walls, may enable the surgeon to determine that
it is not of a solid character. But  in  many cases this is not  sufficient, and it
becomes necessary to have recourse to an exploratory puncture  by means of the
perforator,  through one  or other  of the more thinned and expanded parts already
indicated.   This should never be omitted in cases of doubt, for  it  has happened
even to so good  a  surgeon as Gensoul, that after making incisions through the
cheek with a view of extirpating the tumor, the bones were found to be expanded
by an antral abscess, and that, consequently, the operation had been  undertaken
unnecessarily.
   In determining whether the growth be of a simple or malignant character, the
surgeon will experience much difficulty, so long  as  it is  confined to the cavity
of the antrum;  but when once it has perforated and got beyond its walls, this
point is  easily solved.  Whilst  the tumor  is still confined within the antrum,
much light may however be thrown  upon its nature by attention to the rapidity
of its growth; the greater this is, the more reason there is to suspect its malig-
nant character.  But though attention to this sign is of value, yet too much im-
portance must not be attached to it; for though, as a general rule, the fibrous
and cartilaginous  tumors may increase less  rapidly than  the malignant, yet it
may happen that these  attain a very great bulk in a short  space of time.  With
regard to the age of the patient, that is of  comparatively little value in a diag-
nostic point of view.   I think, however, that as  a general rule, simple tumprs
most frequently  occur in the  young,  whilst the malignant forms of the  affection
are commonly met with at the middle or advanced periods of life.  It is of much
importance, even in a diagnostic point of view, to examine the condition of the
submaxillary glands.  When the disease is malignant, they become enlarged and
indurated,  at a very early period.  In a case lately under my care, the malignant
character of a tumor whilst  still in  the antrum, was determined  by the fact of
there being a long chain of indurated lymphatic glands, lying under the angle of
the lower jaw, where they had become secondarily affected by absorption, before
the bones had been perforated by the growth.  When once a malignant tumor
has got beyond the cavity of the antrum, and is thus relieved from the  pressure
of its walls, it grows with great rapidity, insinuating itself extensively  amongst
the bones of the face and skull, by  creeping through the foramina and fissures,
encroaching greatly on  the nasal cavity and orbit;  implicating  the integuments
of the cheek and  soft structures within the month, and throwing  out sprouting
masses in these  several situations, which present all the  characters of the true
malignant fungus.                          m
   A point of very great importance in relation  to operative interference  is to
determine whether the tumor springs from the cavity of the antrum, or takes its 
660
DISEASES  OF  THE  JAWS.
origin behind the superior maxilla in the pterygo-maxilkry fossa.  In the former
case the nasal or palatal walls of the antrum are expanded, and the line of teeth
rendered irregular.  In the latter the maxillary bone will be found to be simply
pushed ,bodily forwards, there  being little  if any deformity in  its outline, the
line of teeth not being displaced, or the walls of the  antrum,—palatal, nasal, or
orbital, expanded.   Yet it must be borne in mind that the difficulty of the diag-
nosis is greatly increased, as happened in a very interesting case recorded by Mr.
Hewett, by the fact that a tumor though not originating in the antrum, may pass
into the orbit, through  the spheno-maxilkry fissure, and may  make its way for-
wards amongst the bones of the face, partly by creeping through, and partly by
displacing them.
   In the treatment  of tumors of the  antrum, nothing  can  be  done except to
extirpate the growth;  and it is consequently of great importance to distinguish
those forms of the disease in which an operation can  be undertaken with safety,
and with a fair chance of success, from those in which none should be performed.
When the tumor, springing from the antrum, is of a simple character, the disease
should be removed, together with the whole of the superior maxilla; the tumor,
whatever size it has  attained, being generally encysted, and the bones expanded
around it;  so that it is well bounded, and does not implicate neighboring parts.
Here, as Liston justly observes, no  nibbling  or grubbing operations should be
done, but free excision of the whole mass practised.   When the tumor springs
from the pterygo-maxilkry fossa pushing the bones of the side  of the face for-
wards, I think it is doubtful whether the surgeon ought to interfere, as the base
of the skull may be  implicated to such an extent that the patient may die a few
hours after the operation, as I saw happen in a case of Listen's.  When once a
malignant growth of this part has passed  beyond  the osseous boundaries of the
antrum, it should not be interfered with.   So long as it is contained within this
cavity, where indeed it is often impossible  to ascertain until after removal the
true nature of the  affection, it may be excised, provided the glands in  the neck
be not greatly enlarged.   If they are much  implicated, even  though the walls of
the antrum be  not perforated, I think it  is safer not  to interfere,  as a cure by
operative procedure  must be hopeless.  Whenever  the soft structures of the
cheek are involved so as to require partial excision with  the tumor, no operation
should be done, as the disease will probably have become constitutional, cannot
be completely extirpated, and will speedily  recur in the cicatrix.
   The operation of the excision of the upper jaw together with the malar bone
for tumor of the antrum, was first performed by Gensoul in France, and by Lizars
in  this country.   It may conveniently be  done in  the following way :—The
central incisor on the diseased  side having  been extracted, the  point  of a bis-
toury should be entered opposite the external angular process of the frontal bone,
and carried with a semicircular sweep into the  angle of the  mouth.   From the
upper end of this incision, a cut about one  inch in length may be  carried along
the  zygoma.   Another incision is made from  the nasal process of the superior
maxillary bone, down to the side of  the nose, round the ala, which it detaches,
and through the centre of the  upper lip into the mouth.   The flap thus formed
is dissected upwards until the margin of the orbit is  reached, the soft ;parts are
then carefully separated from the floor of this cavity, and the infra-orbital nerve
dissected and drawn upwards with a curved copper spatula, which protects them
and the globe of the eye.  The next step in the operation consists in the division
of the bones.   This may best be  done with strong cutting pliers;  the zygoma
should be first cut across, the external orbital  angle  next divided, and then the
internal angle cut through by putting  one blade of the  forceps  into the nostril
and the other into the orbit.   The palatal arch must next be cut across by notch-
ing it deeply with a  Hey's, or a narrow-bladed saw;  and then passing the pliers
into the mouth and nose, cutting through the line of the groove and the alveolus 
      TUMORS  OF, AND OPERATIONS ON  THE  LOWER  JAW.   661
                                                            i
of the incisor that had  been extracted.  The whole mass having  thus had its
osseous connexions separated, is depressed, drawn forwards and  reachTy removed
with the bistoury by the division of a few remaining soft parts.   In the early
stage of the operation, during the incisions through the cheek, there is often a
good deal of hemorrhage; this may be arrested by pressure, or by the ligature
of any vessels, such as the facial, that bleed with great activity.  However much
the soft parts may be stretched, no skin should ever be removed, as it will even-
tually contract.  In  the later  stage of the operation  after the removal  of the
tumor there is not so much hemorrhage  as  might be expected,  though some
branches of the internal maxillary will require ligature.  By an operation  such
as this,  the whole of the superior maxillary and malar bones  may, if necessary,
be removed, and the large cavity that is left between the eye and mouth, having
some lint introduced into the bottom so as to support the parts  in  the orbit and
the cheek, may be allowed to granulate; the cheek being replaced and retained
in situ by a few points of  twisted  suture evenly introduced through the  line of
incision in it, and in the upper lip.   After cicatrization is complete the deformity
resulting from such a procedure will be far less than might at first be anticipated.
   In some cases the malar bone and floor of the orbit will be found to be sound.
When this is  the case they should both be left, and with this view, after the
cheek has been turned up,  as just  described, a deep groove should be made with
a  narrow, straight-backed  saw, below the orbit directly across from the  nasal
process  of the maxillary, and the outer edge of the malar bones.   The removal
of the growth may now be effected by cutting  through  the nasal process  with
the forceps,  and then applying them  to the  horizontal groove made below the
orbit, after which the palatal arch  may be divided  as already directed.
   Mr. Fergusson has in some cases succeeded in removing tumors of considerable
magnitude by a single incision through  the cheek, from  the angle of the mouth
upwards and outwards; and in other cases by slitting open the upper lip in the
mesial line,  and then carrying the knife along the side of the base of the columna
into the nostrils, by which  simple incision this distinguished surgeon states, that
sufficient relaxation of parts  can be obtained to  excise the greater portion of
the superior maxillary bone.

                      DISEASES  OF THE LOWER JAW.
   The lower jaw is not unfrequently the seat of necrosis, which may arise either
from some constitutional cause, from  local injury or irritation, or from the specific
action of the fumes  of phosphorus.  In this disease we must wait until the bone
has become  loosened, and  then by incisions through the gum, or through the
structures of the lower part of the cheek, or under and along the lower angle of
the jaw, reach the diseased bone and  extract this; separating, if necessary, any
part that may still be adherent by means of cutting pliers.
   Tumors not  unfrequently  spring  from the lower jaw.   Like those in the
superior maxilla they may  either  be  simple or malignant.  Amongst the simple,
we most commonly  find the fibro-cystic.   Fibrous tumors are also occasionally
met with, and more rarely osseous and enchondromatous growths.   The malignant
tumors  are principally of an encephaloid character.  These various  growths fre-
quently occur, in early and middle life, and usually spring from the diploe, between
the two tables of which the bone is composed.    They project into  the mouth
and on  to the side of the  neck, forming large, rounded, uniform,  or imperfectly
lobed masses.   Occasionally malignant diseases spring from the neighborhood of
the bone, and, without invading its structure, envelope it so as to give rise to an
appearance of morbid implication  of it.
   In the cystic and fibro-cystic tumor of the jaw the  growth is expanded into
cysts having more or less solid matter intermixed, partaking of the character of
epulis.   These cysts are of various degrees of thickness; some being thin and 
662
DISEASES OF THE JAWS.
membranous, others having the walls partly composed of fibrous tissue, and others
again having expanded bony lamellae largely entering into their composition, so
that on pressure they occasionally  communicate  the  semi-crepitant sensations
peculiar to the cystic expansions of the osseous structure.   The fluid contained
in these cysts is a viscid liquid, usually semi-transparent, yellowish, or bloody.
   In the  lower, as in the upper jaw, it is of great  importance to diagnose the
simple from the malignant affections, as in the latter form of disease an operation
is rarely justifiable, the soft tissues around the bone being usually implicated to
such an  extent  as not to  admit of removal,  and consequently of the full  and
complete  extirpation of the  disease.  The malignant tumors  may generally be
readily detected by the rapidity of their growth, their  pulpy or elastic character
and infiltration  of  neighboring parts, with  implication of the  sub-maxillary
glands.
   The treatment of tumors of the lower jaw depends in a great measure upon
the character of the  growth.   In cystic tumors of moderate size, with thin walls
and but little deposit of fibrous  tissue  around the cysts,  the best mode of treat-
ment consists in cutting down on the expanded portion of bone, opening the cyst
by means  of the antrum-perforator, small trephine, or cutting pliers, according to
its size and the thickness of its walls;  letting out the fluid contained within, and
then by introducing a plug of lint get  it to granulate from the  bottom, and gra-
dually to contract.  When the cysts are so large  that they have  destroyed the
integrity of the bone, or when they are' associated with a large quantity of fibrous
tissue, so  as to constitute true fibro-cystic tumors, excision of the diseased bone
must be  practised.   This  also is  the  only plan  of treatment  that can  be  had
recourse to in other affections of this bone.
   The operation of  excision of a portion of the  lower jaw for tumor  of that
bone was  first performed by Dupuytren.   As the growths for which this opera-
tion is performed are usually situated  between the symphysis and  angle of the
bone, seldom extending beyond the middle line, the operation is generally limited
to one side of the face.  In  some instances, however, the tumor  may encroach
so far that it may be necessary to remove more than the half of the bone;  and
in other cases again, though of very rare  occurrence, the whole of the bone has
been disarticulated.
   When the tumor is of small size, and is situated  about midway between the
symphysis and angle of the jaw, it may be  reached by  making a semilunar
incision of sufficient length under the  lower edge of the  bone,  dissecting up the
flap thus formed, then carrying the knife cautiously on the inner side of the jaw,
so as to detach the mucous  membrane of the mouth and  the mylo-hyoid  muscle
to a sufficient extent.  One of the teeth on either side of the tumor having been
previously drawn, the jaw must now be deeply notched through their alveoli  into
its base with a narrow strong-backed saw, and cut through with pliers.   After
the fragment of diseased bone, with the attached tumor has  been removed, a
silver cap should be fitted  upon the teeth on  the  two portions  of bone that are
left;  or they should  be tied together with strong silver wire so  as to prevent the
displacement that would otherwise occur in the smaller fragment.   Union takes
place after a time by fibrous tissue, which becomes sufficiently dense to make the
jaw strong and useful.   In those cases in which the tumor encroaches upon the
angle and ramus of the jaw it is better to remove  the bone at the articulation on
the affected side, for if the articular end  including the coronoid process be left,
it will be  displaced  forwards and upwards by the  action of the  temporal and
external pterygoid muscles, and be a source of much  inconvenience and irritation
to  the patient,  unattended  by any  corresponding utility.   In these cases the
removal of one lateral half of the jaw will consequently be required,  and the
operation  may be performed in the following way:  The point of a strong bistoury
or scalpel should be  entered  immediately behind  the articulation, carried down 
CLEFT PALATE.
663
the posterior margin of the ramus behind the angle, and under the body of the
bone beyond the anterior  limits of the tumor, where it must slope gradually
upwards, terminating at some distance from the lips, which  should not be en-
croached upon; the convex  flap thus formed is dissected up, and the facial artery
and any other branches requiring ligature tied.   The knife is then carried behind
the jaw in front of the tumor, and one of the incisor teeth having been extracted
before  the operation commenced, a saw should be applied  to the bone in this
situation, and  its section finished by means of the cutting  pliers;  the  surgeon
then dissects under and around it; in this situation a scalpel,  curved on the flat,
will be found useful, keeping the edge of the knife close to the bone and tumor.
When  he  has cleared  the tumor and ramus, he depresses the  body of the bone
forcibly with his left hand,  in order more readily to divide the attachment of the
temporal muscle to the coronoid process.  This having been done, the only part
left is the disarticulation, which is best  effected by opening the joint from  the
front, whilst the bone is well depressed and twisted somewhat  outwards, the edge
of the  knife being kept close to its neck, scraping the bone so as to avoid wound-
ing the internal maxillary artery, if possible;  when  any remaining attachments
having been cut through, the disarticulation is effected.  In depressing the bone
to get  at the temporal  muscle and  the joint, care must be taken not to use too
much force, lest it happen that the ramus gives way, having  been weakened  by
the disease; a good deal of trouble being consequently experienced in removing
the fragment left behind, which can only be done by seizing it with necrosis for-
ceps,  thus dragging it forwards, and then  dividing the muscle and  capsule.
Should the internal maxillary artery have been divided, it must be ligatured;  or
the termination of the external  carotid, where the vessel divides into the tem-
poral and internal maxillary, tied :  any other branches that bleed will necessarily
also require the ligature;  and  then the cavity having been lightly filled with
lint, should be left to granulate; the cheek being kid down and attached along
the line of incision by hare-lip pins and twisted sutures.  A kind of fibrous tissue
forms in place of the jaw that  has been removed,  and comparatively little de-
formity results.   When the disease of the bone extends beyond the symphysis,
a thick ligature should be passed through the end of the tongue, which must  be
drawn forwards by an assistant, lest on the division of the insertion of its muscles
into the lower jaw it be forcibly retracted into the pharynx, and thus occasion
suffocation.
                            CHAPTER  L.

                     DISEASES OF THE THBOAT.

                              CLEFT PALATE.

  Various degrees of congenital deformity may occur in the palate and uvula;
thus, the uvula"alone  may be bifid, or the cleft may extend through the greater
part or the whole of the soft palate;  or, the hard palate may be divided as well,
and, lastly, the separation may extend forward  to the integuments of the face,
giving rise to the complication of hare-lip.  The soft palate and uvula are most
frequently cleft without the hard palate being divided; but,  in some cases, the
lip and the hard palate are fissured without the soft one being cleft.   These mal-
formations necessarily give rise to great inconvenience, by interfering with de-
glutition, and rendering the speech nasal and imperfect.  During the swallowing
of fluids, especially, there is a tendency to regurgitation through the nose, though
this is occasionally prevented by the approximation of the  edges of the fissure. 
664
DISEASES  OF  THE  THROAT.
   In the treatment of these malformations, the first question  to  be determined
 is the age at which the operation should be performed.   As the success of the
 operation depends in a great measure upon the patient remaining perfectly tran-
 quil  and steady during the necessary procedures, which are  of a tedious and
 protracted character,—upon his assisting the surgeon by opening his mouth, and
 not struggling on the introduction of the instrument,—and, after the operation,
 in  making as little  movement as possible in speech or deglutition for some days;
 it is  usually considered expedient not  to interfere with  this malformation until
 the patient has attained the age to understand the necessity of remaining quiet,
 and to be able to control his movements ;  but yet  some  recent observations by
 Fergusson and Sedillot have shown that the  necessary  operation may be done
 successfully  on young children.
   The  operation for the cure of a cleft in the soft palate may be said to have
 been introduced by Boux; for although several  attempts at the  cure of this
 deformity had been made by surgeons before  his time,  yet he was the first to
 establish staphyloraphy as  a distinct operation.   Many modifications of Boux's
 plan  have been  practised by Graefe, Warren,  and others, in order to render it
 more easy of execution and certain in its results.   But it is to Fergusson that is
 due the great credit of introducing a  new principle of treatment in the opera-
 tion—viz., the application  of myotomy  to it, and thus paralysing the movements
 of the muscles of the palate.   Fergusson found that the great cause of failure in
 these cases  was the mobility  of  the  parts, and  the  traction  exercised by the
 muscles, principally the levator palati,  and  the pakto-pharyngeus on the line of
 union; in order to  obviate this, he  conceived the happy idea of dividing these
 muscles.   Before Fergusson laid  down the principles of this operation, various
 cuts had been made in the palate by different surgeons, with a view of taking off
 the tension after the sutures were tied,  more especially two parallel incisions, one
 on  either side of the line of union  ; these, however, were done almost at hap-
 hazard, and in an empirical way, without the recognition of any distinct principle
 being involved.
   In the  operation, as performed  by Mr.  Fergusson, there  are four distinct
 stages.   In  the first, the muscles  of the palate are divided, by passing a curved
 lancet-ended knife through  the fissure behind the  velum, midway between its at-
 tachment to  the bones and the  posterior margin, and about half-way between the
 velum and the end  of the Eustachian tube ;  by cutting deeply with the point of
 the knife in  this situation the levator palati is divided.  The uvula is then seized
 and drawn forwards, so as to put the posterior pillar of the fauces on the stretch,
 which is to be snipped across, so as  to divide the  pakto-pharyngeus.  The next
 step in the operation consists in paring  the edges of the fissure from above down-
 wards by means of a sharp-pointed  bistoury.   This is best done by seizing the
 lower end of the uvula, putting it on  the  stretch, and cutting first on  one  side
 and then on the other, leaving the angle  of  union" to be afterwards removed.
 The patient  should  then be allowed to remain quiet, and to gargle the  mouth
 with  cold water or ice, so as to stop the bleeding.   When this is arrested the
 surgeon proceeds to  the next step, that of  introducing the sutures; this may be
 done  by means  of a nevus needle,  armed with a moderate sized thread, being
 passed from below upwards  on  the left side of the fissure, about a quarter of an
 inch from the margin; the thread  should  now be  seized with forceps, and one
 end of it pulled forwards through the fissure.   This may again be  threaded in
 the needle and passed through the opposite side of the fissure from  behind for-
 wards through the  right side; as the point of the needle appears, the  thread
 should again be seized and the needle  at the same time withdrawn ; the suture
 is  then tied  by means of the surgeon's knot, and in this way from  two to four
sutures  may be passed, according  to the extent of the fissure,  tied tightly, and
the knot cut close.   The patient must next be put to bed, and every care taken
to avoid any  movement of the  palate.   He should be restricted to a small quan- 
DISEASES  OF  THE  UVULA  AND  TONSILS.          665
tity of fluid but nourishing food for a few days, and should be directed to swallow
this with as Jittle effort as possible, and indeed should not be allowed anything
solid until complete union has taken place.   All  coughing, spitting, or swallow-
ing of the saliva should be interdicted.  The stitches should be left in for several
days, and indeed need not  be disturbed  so long as they produce no irritation.
They usually require  removal by the  eighth  or tenth day, but  occasionally may
be left with advantage for some time longer, until they excite irritation, or until
union is perfect;  they should then be cut across with  scissors  and drawn out,
the upper one first, the middle next, and the lower one last.   Should there be
any aperture left in  the palate, where union has not taken place, this may be
closed by touching it with a stick of nitrate of silver.
   The voice in these cases does not usually at once recover its natural tone after
the operation, although in some cases  it does so; but at the end of a month or
six weeks the patient may be put through a course of instruction with  a view
of regulating the movements of the tongue  and  the actions of the  soft  palate.
Mr. Skey in his  " Operative Surgery," makes some good remarks as to the mode
of instruction, to be adopted in these cases, to which I would refer the reader.
   Fissures of the hard palate usually require to be closed  by  means of obturators
made of gold, vulcanized India-rubber, or ivory.  Dr. Warren  has  proposed to
close the fissure  here by dissecting the soft tissues from the palatal arch between
the margin of the cleft and the edge of the  gum, and then uniting them in the
middle line  by means of  stitches in  the  same way as in  fissured palate.   This
operation has not I  believe been hitherto successful in this country, and indeed
been but little practised, but yet it deserves attention, and holds out a prospect
of eventually proving successful in cases of this kind.
   The uvula occasionally becoming elongated, and  hanging  down into the pha-
rynx so  as to touch  the epiglottis and  sensitive mucous membrane in its neigh-
borhood, gives rise to a tickling or spasmodic cough which can  only be cured by
removing the pendulous body.  This  little operation  may  be  readily done by
seizing the end of the uvula, with a pair of polypus forceps,  and snipping across
its roots.   Of late I  have been in the habit  of using a pair of
"vulsellum  scissors" (Fig. 216), which I have constructed for
the purpose, by which  the  uvula is  cut off  at the same mo-
ment that it is seized, thus rendering the operation easier and
less irritating to the  patient.
   The tonsils are not  unfrequently  the  seat of disease, be-
coming inflamed or  permanently enlarged.   When inflamed
they become swollen and red, with much pain in the side of the
neck  and ear, increased by any attempt at swallowing; there
is usually rather a profuse secretion of saliva, and a good deal
of swelling under the angles of the jaws; the tongue is much
coated with thick pasty mucus, and  the voice  is  thick  and
nasal.   The  treatment  consists  in  the application  of  leeches
under the jaw, of fomentations, the inhalation of the steam of
hot water, and low diet, which  need scarcely be enforced, on
account of the difficulty and pain in swallowing.   If the mouth
can  be opened, much  relief may be given  by scarifying the
tonsils with  a probe-pointed  bistoury, and if abscess form, it
should be opened early, which may most  readily  be done  with
a gum-lancet.
   The tonsils not unfrequently become chronically indurated
and enlarged, sometimes as the result of repeated  attacks of in-
flammation of these parts, but in the majority of instances in-
dependent  of any inflammatory mischief, though when  once
enlarged these organs  are  constantly  liable  to  inflammatory ^
attacks.  Hypertrophy of the tonsils most commonly occurs as a strumous disease
 
666
DISEASES  OF  THE  THROAT.
     in  scrofulous children, who have a tendency to congestion of the mucous mem-
     brane of the nose, and to enlargement of the lymphatic  glands of the neck.   In
     such cases as these the enlargement of the tonsils may gradually subside  as the
     child grows  older and stronger, and the treatment should be directed to the im-
     provement of the general health and strength, by means that are ordinarily had
     recourse to in the management of strumous affections; the internal use of iron
     and the local application of the tincture of iodine or of nitrate of silver being oc-
     casionally serviceable.  In  the majority of instances, however, the disease  will
     not be influenced by any therapeutic  means that may be adopted; and as the
     enlargement, continuing or  increasing,  gives rise to difficulty in  respiration, and
     thus -interferes with the due arterialization of the blood in the  lungs, and impairs
     the child's speech,  it becomes necessary to remove the  enlarged growths.   This
     may conveniently be done  by means of the ordinary tonsil-guillotine: the ring
     of the instrument being passed over the tumor, the cutting blade is  pushed for-
     wards, and thus a slice of  the projecting part of the growth is removed.   In
     some cases not  a  little difficulty is  experienced in  getting the tonsil fairly into
     the ring of the  instrument,  more particularly if the  child is unruly; this may be
     obviated by drawing it through with a vulsellum  or double hook, and  indeed in
     some of the machines sold  for the  purpose a kind of prong is  attached,  which
     being fixed into, draws forwards the tonsil before it is sliced off.  In performing
     this operation,  especially in children, it is most  convenient for  the  surgeon to
     stand behind the patient, as he can thus look better into  his  mouth and has
     more command over the head.  Should a guillotine not be  at  hand, the tonsil
     may be  removed  by seizing it with a vulsellum, drawing it forwards, and then
     taking off a  slice  with a  probe-pointed  bistoury, the base of the blade of  which
     should be wrapped  round with a piece of  plaster, to  prevent its wounding the
     tongue.   In excising the tonsil in this way, care must be  taken to  cut  down-
     wards and upwards  towards the mesial line, and on no  account to turn the edge
     of the knife outwards lest the internal carotid artery be endangered.

                            DISEASE OF  THE PHARYNX.
        Inflammation of the pharynx of a diffuse erysipeloid character, with low fever,
     not unfrequently occurs; it is best treated by the application of a strong solution
     of nitrate  of silver, the use  of emollient gargles, and the internal administration
     of ammonia, with bark, stimulants  and support.   If it have a tendency to run
     into sloughing action, the internal administration of the mineral acids, with bark
     and  stimulants, the  nitrate of silver  lotion  and chlorinated  gargles  are useful.
     Sometimes abscess forms in the substance of  the velum, and then requires to be
     opened with the knife that is delineated at page 335.
        Abscess occasionally  forms in the  cellular tissue behind the pharynx, the
     posterior wall of which is  consequently pushed forwards so  as  to occlude the
     posterior  nares, giving rise to a peculiar nasal intonation of voice;  it also may
     interfere with breathing  by pressing upon the upper part of the larynx.  This
     kind of abscess is often  connected with disease of the bones at the base of the
     skull, or of the upper  cervical vertebrae.   In  many  cases, if left to itself, it
     would burst through the mucous membrane into the  mouth, but in others it comes
     forwards under the  sterno-mastoid muscles into the forepart of the neck.   By
     exploring the pharynx with the finger, which may readily be done, tension and
     fluctuation through  its posterior wall  may easily be made out.   In these cases,
     the treatment simply consists in letting out  the  matter by puncturing the tense
     membrane covering it.  This may be done by means of a sharp-pointed bistoury
»    properly protected,  or the  ordinary abscess knife.   The  pus let out is usually
     offensive,  even though the bones be not affected.
        Tumors are occasionally  met with in the post-pharyngeal cellular tissue, giving
     rise to the same swelling, difficulty in respiration and deglutition, and lateral pro- 
STRICTURE OF THE (ESOPHAGUS.
667
jection, as occurs in abscess of this region.   These growths are mostly cancerous,
and speedily prove fatal.   Polypi in  the pharynx usually come  down from  the
nasal cavities, but sometimes spring from the inside of this canal on one or other
of its margins.   They are usually, when truly pharyngeal, of a malignant charac-
ter, and grow with  great rapidity.   The  uses of the  part are necessarily inter-
fered with, and death may eventually result from obstruction to deglutition and
respiration.   Cancer of  the pharynx of an epithelial  character has occasionally
been met with.   This form of the disease, which is of rare  occurrence, does not
differ from similar growths elsewhere.

                     DISEASES OF THE CESOPHAGUS.
   All diseases of this mucous canal have a tendency to Occlude its passage, and
hence are commonly described as strictures  of it.  In some  instances the con-
striction of the oesophagus may be of a purely nervous or spasmodic character;
but in  the majority of instances it is the result either of fibrous or  cancerous
degeneration of the walls of the canal, or of the projection of malignant growths
into its interior.
   The spasmodic stricture usually occurs in hysterical  women and not unfre-
quently results from local irritation  occurring after the removal of a fish-bone or
some such body from the canal.   It is often  chiefly seated in the constrictors of
the pharynx.  In it the  symptoms  are usually intermittent, the patient experi-
encing difficulty in swallowing certain articles of food, or at particular periods
of the day, whilst at other times deglutition  is  perfect.  In many instances it
appears simply tp be a  variety of the  hysterical globus.   In the treatment of
this affection, the patient must be  put upon  an  anti-hysterical plan,  with cold
douches and electricity  to the neck,  and  the  occasional  introduction  of  the
bougie to blunt the sensibility of the part.
   Organic stricture of the oesophagus  usually occurs  either at  the commence-
ment or end of  the canal, most frequently  at the former, opposite the  cricoid
cartilage.   The patient first complains of difficulty in  deglutition, he  finds that
a portion of the food that  he has apparently  swallowed, returns into  his  mouth
after a  time, and that he is obliged at last to confine himself to slops.  On exa-
mining the oesophagus by means of a bougie, the  surgeon  will find a part that
appears to  be constricted, and at which the point of the  instrument is either
arrested altogether or passes with difficulty.   After a  time the patient gradually
becomes cachectic,  and a painful and  distressing death will  at  last occur from
slow starvation, or from the irritation occasioned by the formation of abscess around
the seat of disease.
   In the treatment of organic stricture of the oesophagus care should be  taken
that the patient  is principally kept  upon nutritious  slops, or upon meat that
has been well chopped up, as larger fragments are apt to  become impacted at
the seat of constriction.   Means should at  the same time  be  taken to  dilate
the stricture.  If it be of a fibrous  character, such a plan of treatment will be
of use; if cancerous, it is useless to attempt its  dilatation,  and upon the whole,
I think it better  not to irritate the disease by pushing instruments through it.
In introducing bougies  into the strictured part of the oesophagus, there is often
a good  deal of difficulty in getting the point of the instrument into the nar-
rowed portion of  the canal.  This  is more  particularly the case when the con-
striction commences suddenly; the oesophagus, as is frequently the case, being
dilated  into a pouch-like sac above it, in which the food is  apt to lodge and  the
end of the instrument to be arrested, and at the bottom of which a narrow orifice
exists,  leading into the lower portion of the canal.  In  these cases much patience
and care may be required in overcoming the difficulty.  In a patient who  had a
strictured oesophagus  of this kind,  who had  not swallowed food for nine days,
and who was  consequently  nearly exhausted by starvation, I succeeded, after 
668
DISEASES  OF  THE  THROAT.
much difficulty, in getting a No. 5 gum-elastic catheter into the stricture, through
which nutriment was injected  into  the stomach.  In  this  case  much benefit
was afterwards derived by gradually dilating  the  stricture, which was  done on
the same principle that has been introduced by Mr. Wakley in the treatment of
urethral strictures,—by getting a narrow instrument through the constriction, and
then slipping  a  larger one  over it.   I first  introduced a long  narrow bougie
through the stricture as a guide, and then slid a gum-elastic  tube, well rounded
at the end, over this; and  although  the  patient eventually died of cancerous
degeneration of the  oesophagus, with abscess, he was by these means kept alive
for many months, enabled to  swallow food, and put  in  a state  of comparative
comfort.   It is needless to observe that, in the treatment of stricture of the oeso-
phagus by bougies, no force should  be employed, lest by any accident the walls
of the canal be perforated, or the constriction  be dependent on the pressure of a
tumor or  of an  intra-thoracic aneurism.   Indeed, it is well in all cases of diffi-
culty of deglutition dependent on lesion of the oesophagus, that the thorax should
be examined,  with a view of ascertaining whether such disease may exist, before
any treatment by dilatation is  undertaken.  In cases in which the stricture has
become impermeable, the patient must necessarily speedily sink, exhausted by
starvation.  Sedillot seems  to think that, under such  circumstances, it would be
justifiable to lay open the stomach,  with the view of introducing food directly
into that organ.   This plan, however, appears to be  somewhat too heroic to be
adopted in practice.   The consequences of such an operation  would probably be
to save the patient the horror of a lingering death from starvation, by more speedily
terminating his existence.

                        DISEASES OF THE LARYNX.
   Inflammation of the larynx principally occurs in adults, from exposure to cold,
to the infection of  erysipelas, or to the general occasioning  causes  of  the low
forms of inflammation;  it differs essentially from the croup of children,  which is
attended by an albuminous exudation, and spreads downwards into the bronchi;
whilst in laryngitis,  there is no effusion of plastic matter, and the disease is con-
fined to the  larynx itself.   Laryngitis may not only be  of an acute or chronic
kind, but it likewise presents two distinct varieties, according to the parts affected,
the  cause from which it arises, and the condition  of constitution  in which it
occurs; in one, the  true acute laryngitis, the  inflammation is  chiefly seated in
the mucous  membrane and  cartilages; in  the other  the cedematous  laryngitis,
the affection chiefly  occurs in the submucous  cellular tissue, within and around
the larynx.
   In all inflammatory affections of the larynx, whether acute or chronic, there is
great danger to life; the rima glottidis, that narrow chink through which all the
air destined for respiration must enter, becomes readily occluded, and asphyxia con-
sequently results.  This may happen either by the swelling of the lips of the glottis,
from the effusion of plastic matter within or upon them, or by the occurrence of
spasm in the larynx.  Indeed, there is always more or less spasm conjoined with
all the inflammatory affections of this part of the air-tube, and this spasm being
superadded  to already existing mechanical occlusion, commonly proves fatal.  It
is of importance to  bear in mind that death may occur in these cases,  although
a  considerable portion  of the  cavity of the  larynx  continue  free.  Thus Dr.
Cheyne states that there is always in croup at least three-eighths of the cavity of
the larynx open for  the  transmission of air, and  that death  must  consequently
result from  some other  cause  than mere mechanical obstruction.   This freedom
from permanent occlusion commonly occurs in cases of laryngitis, and the imme-
diate cause  of death in the majority of instances appears to be spasm, conjoined
with defective arterialization of the blood; which, becoming dark and poisonous, 
ACUTE  AND  (EDEMATOUS  LARYNGITIS.           669
causes congestion of the lungs or brain, and  thus  low pneumonia and convul-
sions.
  In acute laryngitis the symptoms are those of local inflammatory action of an
acute kind, conjoined with those indicative of interference with the proper admis-
sion of air to the lungs.   The cartilages and the mucous membrane are the parts
principally inflamed, and but little effusion  takes place under the mucous mem-
brane ; hence the symptoms  are not always indicative of such early or intense
interference with respiration,  as is met with in  the cedematous form of the disease.
In acute laryngitis there is pain and tenderness on pressing upon  the larynx,
more especially about the pomum adami.  The voice at first is harsh and rough,
then stridulous or sonorous,  with difficulty in deglutition;  dyspnoea then  comes
on, the  lips becoming livid,  the features  pale, and  bedewed with  perspiration,
the eyes watery  and blood-shot, and the  respiratory muscles being called into
violent action, the nostrils are dilated, gasping efforts at breathing, and sudden
fits of increased difficulty in inspiring come on;  at  the  same time the pulse
becomes feeble,  though  it continues rapid, and unless efficiently relieved, the
patient will speedily sink.  When it proves fatal, the acute usually runs into the
cedematous form of laryngitis.
   The treatment in this  disease  should be actively antiphlogistic.  No time must
be lost, otherwise  the patient will fall into  a  hopeless state of  asphyxia.   Free
bloodletting, the application of an abundant supply  of  leeches to the larynx, and
the administration of calomel in large  doses,  with antimonials,  must be  had
recourse to.  If notwithstanding the administration of these remedies, the diffi-
culty in respiration continue to increase, the windpipe must be opened  before
the lungs  and brain become irretrievably  engorged.   It  is no easy matter to
determine when  it is no longer prudent to  trust to active antiphlogistic treatment,
and when operation should be had recourse to. Indeed the determination  of this
point may be considered as one of the nicest questions in surgery.  As a general
rule it may be stated, that if notwithstanding  the antiphlogistic means above in-
dicated,  the dyspnoea get gradually more urgent, then  no time should be lost in
the performance of  the  operation, for however short a  period the disease may
have existed.  I can truly say that I  have seen several cases  lost by delaying
the performance of  this operation, but  never one by opening the  windpipe too
early.   Indeed if the opening be even made somewhat early, I do not think that
much,  if any, harm results,  as  the  larynx  is thereby set  at rest; and on the
laryngitis being subdued by the continuance of proper treatment, the aperture
which simply served as a breathing hole may  be allowed to close by granulation.
   In cedematous laryngitis,  the disease is seated chiefly, if not entirely,  in the
submucous cellular tissue, and frequently comes on in the course of chronic affec-
tions of  the larynx.   It may, however, be of a distinctly erysipelatous character
occurring as the result of exposure to infection, or to atmospheric vicissitudes.
In fact, in many cases it appears to be at times epidemic, and in its pathological
conditions  resembles closely  phlegmonous erysipelas  of the part; the mucous
membrane becoming red, pulpy, and swollen, and the cellular tissue lying beneath
it infiltrated with semi-puriform plastic matter.   In this form of the disease, the
fauces are reddened, dusky, and swollen;  there is much and early dyspnoea, the
voice becomes hoarse, rough,  and speedily extinct, with much difficulty in  deglu-
tition, and on passing the finger over the  back of the  tongue, the  epiglottis will
be felt rigid and  turgid.  There may be some degree of tenderness about the
larynx, but the  local symptoms, which are  less acute, are attended by a greater
amount of dyspnoea than in the  active form  of laryngitis.  In cedematous laryn-
gitis there is also a good deal of spasm associated  with the local turgescence.
These spasms sometimes come on early, and  carry off the patient at once, and are
very apt  to be brought on by speaking or swallowing; but as the  disease advances,
dyspnoea supervenes, with great  restlessness, a quick, small pulse, and convulsive 
.670
DISEASES  OF  THE  THROAT.
breathing, the countenance  being pale, sunk,  and clammy, and the  eye  dull.
Stupor at length supervenes  which speedily terminates in death.
   The cedematous infiltration in this form of laryngitis is principally confined to
                  the submucous cellular tissue around  the epiglottis, at the
                  margins of the  glottis, and to that which lies at the back of
                  the thyroid cartilage.  In these situations the tissue is distended
                  with sero-plastic fluid, of an opalescent character, so as almost
                  completely to occlude the rima glottidis (Fig. 217).  It is a
                  pathological fact of much importance that this effusion never
                  extends below  the true  vocal cords;  being limited  at this
                  point by the direct adhesion of the mucous membrane to the
                  subjacent fibrous tissue, without the intervention of any cellu-
                  lar membrane.
                     It is of great importance to make the diagnosis between the
                  two forms of laryngitis.   In the acute variety of the  disease,
                  antiphlogistic treatment is of great moment; in the oedema-
                  tous form it is comparatively  useless, for here effusion  sets in
                  early, and nothing is left for the surgeon but to open the air-
                  passages, so as to give the patient  breathing-room, whilst  the
                  disease is  being subdued.   In making the diagnosis, the epi-
                  demic character of the affection, the absence of  much pain in
                  the larynx, and the dusky-red and swollen  fauces point to the
cedematous variety.   Then also the effect of antiphlogistic treatment should be
taken into account.   If,  after its active employment, no alleviation  of the symp-
toms occurs, it is only reasonable to suppose that the obstruction to breathing is
owing rather to a purely mechanical obstacle than to simple inflammation.
   The treatment of cedematous laryngitis must be antiphlogistic, though the con-
stitution  will  not usually  bear any  very active measures of this description.
Leeching under the  jaws and over the larynx, the administration of antimonials
and salines, will  be  especially serviceable.  In many cases, scarification with a
hernia knife or probe-pointed bistoury about  the root of the epiglottis, the sides
of the glottis, and the back of the thyroid  cartilage, will be found the most ready
means of unloading the infiltrated  mucous membrane.   In these cases it is, how-
ever, especially necessary to open the windpipe before it is  too late, and the lungs
become engorged.  After the proper employment of  the means that have been
indicated and  their failure, the less delay there is in opening the air-passages the
better.   The operation adds but little to the patient's danger, but the increased
risk is immense if it be delayed to too late a period.
   If the  cedematous  laryngitis become chronic, sloughing and putrid suppuration
of the submucous cellular tissue may occur, as in phlegmonous erysipelas of other
parts of the body, and the patient  may die partly from asphyxia and partly from
typhoid symptoms, with putridity of the breath and mouth.  In these cases, the
administration of stimulants  and  tonics, more particularly port wine and bark,
with free sponging of the part with a strong solution of nitrate of silver, will be
urgently  required.
   The larynx  is liable to various chronic diseases of a serious character, some of
which are incurable, leaving  a permanent  impairment of voice, or alteration in
the use  of the larynx.  These affections  present great variety, and as many of
them are attended by loss of voice, they are  included under the general term of
aphonia.   In  many cases  this affection results  simply from cold in relaxed and
debilitated subjects, or after long exercise of the voice in persons not accustomed
to public speaking.   This affection  commonly  occurs  amongst clergymen, and
hence is  familiarly known as  the clergyman's sore throat;  it is also of frequent
occurrence amongst  singers, but  may be  met  with among  all classes  of the
community.   Aphonia commonly appears to depend upon  chronic  inflammation
 
APHONIA — CHRONIC  LARYNGITIS.
671
of the mucous membrane of the rima glottidis, but is more especially dependent
on disease of that extensive mucous surface which stretches from the base of the
epiglottis over the back of the thyroid cartilage.   In many instances it may also
extend into the interior of the larynx, and at last may implicate the vocal cords.
In  all  these situations  the membrane  is reddened  and  inflamed, ulcerated at
points, and secreting a  thin and  acrid  mucus.  In other instances again, the
disease  implicates the soft  palate, the  back of the nares, and the neighboring
parts;  and in  these cases the morbidly inflamed surfaces will be seen to  secrete
a thick puriform fluid, which usually hangs in a broad streak down one  side of
the posterior wall of the pharynx.
   The symptoms of this chronic  irritation  of the  mucous membranes in these
situations consist of habitual  tickling or spasmodic cough, a veiled or hoarse
character of voice, with, perhaps, at last, complete extinction of it, so  that it
cannot be raised above a whisper.   At the same time there is usually  a  feeling
as if  there was  some constant cause of irritation in the throat, attended by a
desire to cough up and expectorate.   As the disease  advances, the expectoration
becomes more  and more puriform,  the cough increases, the patient emaciates, is
affected with night-sweats, and at last sinks from what is called laryngeal phthisis.
When the posterior nares and the  neighboring parts  of the pharynx are affected,
the symptoms  are not so severe, though  they may eventually become so by the
extension of the disease  downwards.
   These  affections  are  very frequently mistaken  for chronic  bronchitic,  or
catarrhal attacks.  From the first they may be  distinguished by the absence of
all auscultatory signs in the chest, and examination of the pharynx will prevent
the disease being  confounded  with  an ordinary catarrh.  This examination,
however, requires to be  properly done, so that a full view may be gained of all
the parts  engaged in the  morbid action.   This is best obtained by seating the
patient opposite a good light, and  then, depressing the root of the tongue at the
same time that it is drawn  forwards by means of a  proper tongue-depressor or
spatula, directing the patient to inspire.  In order to examine the mucous mem-
brane at the back of the pharynx, and in the neighborhood of the posterior nares,
the velum may be raised by any convenient instrument.
   The treatment of these various chronic inflammations of the mucous membrane
of the pharynx and larynx requires to be conducted by the topical application of
a solution of the nitrate of silver,  which may almost be  looked upon as  specific
in these diseases.  The great value of topical medication  in these affections has
been principally pointed out by American surgeons, amongst whom the names of
Dr. Horace Green and J. Warren may especially be  mentioned.   The  nitrate of
silver may be applied in various ways, on  sponges, in powder, or by injection.
The mode of application that  is the simplest and most effectual, consists in
depressing the tongue with a proper spatula, and then passing a  throat-sponge,
consisting of a small piece of this material firmly attached  to a curved whalebone
stick (Fig. 218), and saturated  with a solution of nitrate  of silver, to  the  parts

                                     Fig. 218.



    /                 —


that are diseased, so that the liquid may be applied to the whole of the affected
surfaces.  This solution should vary in strength from half a drachm to  a drachm
of the  salt to an ounce of distilled water;  most commonly, the  latter strength
will be most useful.   This plan  of treatment has been much  practised of late
years in this country, and with considerable success in a large number  of cases. 
672
DISEASES  OF  THE  THROAT.
Some of its advocates, however, not content with curing in this way disease that
is visibly seated in the throat, pretend that the morbid action extends down the
trachea into the bronchi, and that it is necessary to follow it in these  situations.
They accordingly speak of sponging and mopping out those parts of the air-tube,
and of applying the caustic solution to them, as if this were a proceeding that
could be adopted  with  as little difficulty as passing the sponge into the nares.
I  cannot believe,  however, that  this practice, though commonly spoken about
and professedly employed, is ever  in  reality carried out.  Any one acquainted
with the physiology of the larynx knows how acutely sensitive it is, and  how in
its normal  state it resists the  introduction of  any foreign  body by the  most
violently spasmodic fits of coughing; and any  surgeon who has seen the effects
resulting from the fair and complete inhalation of  a drop or two of a solution of
the nitrate of silver in a morbid and irritable  condition of this tube, must feel
sure that no sponge saturated with a solution of this caustic could ever have been
thrust down between and beyond the vocal cords.   But not only does physiology
and ordinary experience  tend to disprove the possibility of such a procedure, but
repeated experiments,  both on the living and on  dead subjects, have led me  to
the conclusion that it is utterly impossible to pass  a whalebone, whether  curved
or straight,  armed with a sponge, beyond or even between the true  vocal cords.
I have frequently  endeavored to do  this  in cases of cut throat, in which, the air-
tube having been laid  open, the passage  of the sponge  could  readily have  been
observed, and in which the facility of doing so would have been greatly increased
by the larynx being no longer subservient to respiration; but in no one instance
have I succeeded in passing the sponge so as to make it appear at the external
wound.   In the dead-house, also,  I have  repeatedly endeavored  to  pass the
curved whalebone tipped with sponge into the  trachea, but have never yet suc-
ceeded  in  doing  so by  employing  those manipulations  which could  alone be
practised on the living subject, or indeed by any ordinary degree of force.   From
the repeated observations I have made upon this point, I have  no  hesitation  in
expressing my conviction that the sponge has  never been passed, in the living
subject, beyond the true vocal cords; though I  believe it is possible that in some
instances, and, with the  requisite dexterity, it may for a moment be introduced
between the lips of the  glottis so as  to  apply the solution freely to those parts,
not, however, without  inducing  the  most intense  and  spasmodically suffocating
cough.   I  have little  doubt that in those cases in which the sponge has  been
supposed to have been passed between and beyond the  vocal cords, and in which
the operator speaks of having felt the constriction exercised by these in its entry
and exit, it has in reality not entered  the larynx  at all,  but has  been  passed
behind this tube into the oesophagus, the constriction being produced by its pas-
sage beyond, the  projection of the  thyroid  and cricoid cartilages, and that the
caustic solution has been applied to the mucous  membrane in this situation,
instead  of to that lining the interior of the air-passages.
   In  some  cases the  introduction  of  the sponge  to the tender and inflamed
pharynx produces increased irritation and even excoriation.  Under these circum-
stances the nitrate of silver in powder may be conveniently employed, or its solu-
tion may be injected.
   The inhalation of the nitrate of silver in powder is most conveniently done by
mixing it, in proper proportion with some innocuous, impalpable powder, such as
ground and dried sugar.   The strength may vary from one part of the nitrate of
silver to twelve, sixteen,  or twenty of the  sugar.  A small quantity of the powder
so prepared should be put into  the  end  of a thick glass tube, which has  been
bent nearly at right angles,  about one inch from  its extremity.  The surgeon
placing  his finger over the orifice of the straight part of the tube, carries the bent
end behind the tongue, over the epiglottis;  he then directs the patient to make
a sudden inspiration, and at the moment of  his doing so takes away his thumb, 
CAUTERIZATION  OF  THE  LARYNX.
673
so as to allow the powder to be drawn out of the tube and into the  air-passages
along with the current of inspired air.   In this way the nitrate of silver may,
in some cases, be very  conveniently applied to the whole of the affected mucous
surfaces without the irritation produced by the friction of the sponge.
  The injection of the solution of the  nitrate of silver  may most  conveniently
be done by means  of  the instrument that is here delineated  (Fig. 219), and
which I have had constructed for this purpose.   It consists of a silver tube, per-
Fig. 219.                               ^
forated at the end and having a small piston moving in it with a sponge attached
to its lower surface.  The instrument is charged by dipping the end in the solu-
tion, and then drawing-back the piston-rod.   It is then passed into the pharynx,
or between the lips of the glottis, and the fluid injected into the air-passages or
upon the inflamed surfaces in  a number of fine streams by pushing down the
piston  and compressing the  sponge.   By means of this  laryngeal syringe  the
nitrate of silver can be applied to any part of the pharynx, without irritating the
tender mucous membrane by the contact of a  rough  body, and by applying its
nozzle  to the lips of the glottis, the fluid may be readily thrown down into  the
interior of the  larynx with  the  greatest certainty and  ease.   In those cases in
which it is wished to apply the solution of the nitrate of  silver into the air-pas-
sages, I far prefer using this simple instrument to the ordinary sponge, the mere
pressure of which  upon a tender mucous surface may be a source of irritation.
When  the mucous membrane  behind  the  velum  or  of  the  posterior nares is
affected, the solution may readily be injected against these parts by turning the
end of the instrument upwards, and then injecting it directly on to the affected
surfaces.  In whatever way the caustic is used, its application should be repeated
about every second or third day, in order to insure its full effects.   In some in-
stances, however, advantages may be obtained by using it every day.   In  others,
again,  a longer interval is required than that just stated.
  In  the more  advanced forms of chronic disease of the larynx, the mucous
membrane  becomes  infiltrated with plastic  deposits, which also form upon  its
surface in the shape of vegetations, and at last run into ulceration, with much
narrowing of the rima, and muco-puriform discharges.  These diseases are often
of a syphilitic origin, and after continuing for some length of time give rise to
hoarseness, cough, shortness of breath, a pale, pasty and cedematous look about
the face with diffused  eyes  and constant difficulty in  breathing.   Under these
circumstances there is a constant tendency to acute inflammation supervening on
the chronic laryngeal  disease, and the affection commonly proves fatal  by the
induction of oedema glottidis, often coming on with great rapidity.
  Necrosis of the cartilages of the larynx not unfrequently happens in the more
advanced forms of this affection, attended with all the signs,  constitutional and
local, of the so-called laryngeal phthisis, and by the expectoration of large quan-
tities  of fetid puriform sputa,  often streaked with blood, and occasionally con-
taining masses  of the  necrosed and  disintegrated cartilage.   In many cases
abscesses form outside the tube, and after much irritation and distress open exter-
nally, and not unfrequently they are met with to such an extent as to undermine
and disorganize  the greater portion of the tissues of the anterior part of the neck.
Where they correspond to the necrosed patches of cartilage they give rise to aerial
fistula, through which the bubbles of air escape during respiration.
  In the treatment of  the more severe diseases of the larynx, the daily applica-
tion of nitrate of silver will be found of  great benefit.   It should be freely
                                     43 
674
DISEASES  OF  THE  THROAT.
applied to or injected upon the  mucous membrane  about the  epiglottis, within
the lips of the glottis, and more especially that loose  and filamentous tissue which
is extended over the back of the thyroid cartilage, and which is commonly the seat
of much chronic irritation  and the chief source of the muco-puriforni discharge.
At the same time the internal administration of the bichloride of  mercury with
sarsparilk will  often be found of great service, more particularly in those cases
in which the disease is  of a syphilitic character;  the patient being kept in a
regulated temperature, not  allowed to exert his voice, and avoiding all  laborious
exertion.   Whenever-acute inflammation supervenes in these  cases, with a ten-
dency to oedema about the  glottis, the patient should be narrowly watched, as he
may readily be carried off by the sudden swelling of the lips of the rima, or the
supervention of spasm.   In such cases as these, the air-passages  may require to
be opened to allow of respiration to be carried on, and this operation  must not
be delayed until such time as the patient falls into an asphyxial condition.
  Nervous affections of the larynx occur both in children and adults.   In chil-
dren this affection, commonly called spasmodic  croup, comes on  suddenly and
runs its course with great rapidity.  The child is seized, often without previous
warning, with difficulty in  breathing,  uses  violent efforts  to inspire,  becomes
black in the face and convulsed, and may die before anything can be  done  for
his relief.  In other instances again he gapes and gasps  a few times, and even-
tually recovers himself with a long deep-drawn whooping inspiration.   In such
cases as  these  the treatment at the time of the fits, consists in  dashing cold
water  in the face, in exposing the  body to a  current of cold air,  and  in using
friction to the extremities.    If asphyxia occur, artificial respiration  must be kept
up either through an opening made in the windpipe, or by the mouth.
  In the adult these spasmodic affections of the larynx may come on either from
pure hysteria,  or from irritation  of the laryngeal nerves  by the pressure of
tumors or aneurisms upon them.   In other instances again they appear to arise
from the presence of some local inflammatory  mischief about the glottis.  In
the hysterical form of the affection the ordinary remedies for  hysteria, together
                        with cold douches, will  be  of essential  service.  In
                        some cases, however, the  obstruction to  respiration is
                        so great that  the surgeon may almost think it  necessary
                        to have  recourse to  operation.   When the  disease
                        arises from irritation to the trunks of the nerves, such
                        a procedure  is seldom justifiable, as  the occasioning
                        cause is usually in itself of a fatal character.
                            Tumors  or polypi occasionally form in the larynx.
                        They  are commonly  granular, or  small cauliflower-
                        looking  bodies,  though they  occasionally attain  the
                        size of  a  hazel-nut  (Fig.   220).  They necessarily
                        interfere with respiration, and at last may  give rise
                        to asphyxia by obstructing the  cavity of  the  larynx.

                      OPERATIONS ON THE WINDPIPE.
  The windpipe may require to be opened either to allow of the formation of a
temporary breathing aperture, in consequence of the  obstruction of the larynx from
causes that are speedily removable; or the air-passages may require to have a per-
manent aperture established in them in those forms of chronic laryngeal disease
in which the obstruction depends upon  such organic alterations of structure as
are not remediable.   Amongst the conditions that require the temporary opening
of these passages may be mentioned all acute  inflammatory affections of the
larynx, together with the various  nervous or spasmodic  diseases of this organ;
so also certain  traumatic conditions may require this operation, as  the  impaction
of masses of food in the gullet  inducing asphyxia  and not admitting  of imme-
 
OPERATIONS  ON THE  WINDPIPE.
675
diate removal, the presence of foreign bodies in the air-passages, and oedema of
the glottis from wounds of the thyro-hyoid membrane.
  The establishment of a permanent  aperture  in  the  air-passages is especially
required in chronic diseases of the larynx, attended by thickening of the mucous
membrane, abscess, or necrosis of the cartilages, and in fact  such conditions as
do not admit of removal; so also in polypi of the  larynx, a permanent  opening
below the obstructed point may be required.
  It is a question  whether  the  windpipe should be opened  in  cases of croup.
Were croup merely a disease of the larynx it would doubtless be proper to per-
form the operation; but it has been incontestably shown that in  this affection
when it  is severe, the inflammation is not confined  to the larynx but  extends
down the bronchi even to the lungs, which become engorged and affected so that
death very commonly results from this cause as much  or more than from the
laryngeal disease.   Hence opening the larynx alone will not suffice in saving life
in the majority of  instances, as the  child will  die of broncho-pneumonia after
these passages are  opened.   A serious objection also to the performance of this
operation -in croup is the difficulty attending it; the struggles and screams of the
child by increasing the tendency to spasm interfere materially with the surgeon's
attempt to open  the windpipe.  Indeed  I have  known  one  case  in which  the
bleeding was so profuse as to  prove  fatal.  But although, as a general rule, I
fully agree with Porter in strongly reprobating  this practice  in  croup, yet cases
are doubtless occasionally met with, in which the disease is so clearly limited to the
larynx—the respiration  being free throughout the lungs  and  bronchi—that  the
surgeon  may feel  himself justified in  endeavoring to  save the  little  patient,
struggling against  overpowering asphyxia, by opening his windpipe.   In two or
three cases, to which I have been called by other practitioners, I have considered
myself justified in doing this,  though in  no instance have I as  yet succeeded in
eventually curing a child by this operation ; and I think that the  general expe-
rience of surgeons in this country is unfavorable to its performance.   Trousseau,
who strongly advocates  tracheotomy in croup, has  published  a large  number of
successful  cases in favor of  this proceeding.   But I think it may fairly be
doubted  whether an operation was really necessary in many  of  these instances,
and whether the children  might not have  recovered under ordinary medical
treatment.
   When it has been determined to open the windpipe  for  acute disease, more
especially supervening, on chronic laryngeal  affection, the less delay there is in
having recourse to operation the better, as the patient may  at  any moment be
seized with spasms and be carried off.  The operation also ought to be completed
even though  the patient has apparently  expired  before the  windpipe has been
opened, when resuscitation may be effected by artificial respiration.   When  life
hangs on so slender a thread as it does in extreme cases of laryngeal obstruction,
the first touch of the knife  may cause a spasmodic seizure  that  may give rise to
apparent death.   It has twice happened to me to operate under such circum-
stances, and in both cases to be fortunate enough to  save  the patient's life.   In
one case to which I was called about five years  ago by my friend Mr. E. Baker,
the patient, an elderly woman, was apparently dying from the  supervention of
acute upon chronic laryngeal disease.   I lost no time in making an incision into
the crico-thyroid membrane, but  at the first touch of the knife she sunk back
apparently dead.   I  immediately completed the operation, and  introduced a
large silver tube, through which the lungs were inflated, when in the course of a
few minutes, the action of the heart  recommenced, and the  patient eventually
recovered.   She has never,  however been able to breathe without the silver tube,
which she wears in her windpipe up to  the  present time.   In  another case to
which I  was hastily summoned by my friend Mr.  Tweed, I found  the patient, a
young woman, in  the  last  stage of asphyxia from acute disease of  the larynx. 
676                   DISEASES  OF THE THROAT.
I immediately proceeded to operate, with the assistance of my then house-sur-
geon, Mr. Lister.   As the  patient's  neck was short and thick,  and the veins
excessively  turgid, there was profuse hemorrhage on the  first incisions being
made; whilst waiting a minute or two until this  would cease before opening the
windpipe, the  patient fell  back and apparently  expired.   I lost  no time in
plunaing the scalpel into the crico-thyroid membrane, and cutting down through
the cricoid cartilage, so as to make a free aperture into the air-passages.  On
endeavoring to set up artificial respiration, I found the  chest clogged with in-
spissated mucus, which prevented the entrance of air into the lungs; the life of
a fellow-creature being at stake, and dependent on the  immediate and full esta-
blishment of artificial respiration, I felt there was only one thing to be done, and
that was to empty the chest of the matters that loaded it, and that this must be
done instantaneously.  I accordingly  applied my lips to the wound  and  sucked
out three or four mouthfuls of blo6d and mucus, when I  had the satisfaction to
see that air could be got to  enter the  lungs.   By keeping up artificial respiration
for some time,  the heart began feebly to act,  the  face to become less livid, and
the circulation to be re-established; the patient eventually  did well, and is now
alive and in good health.
   In opening  the windpipe, the surgeon has  the choice of two situations, in
which he may make the aperture,—either  in the crico-thyroid  membrane by
laryngotomy,  or in some part of the trachea by tracheotomy.  Besides these two
established operations, some surgeons have performed a third,—laryngo-tracheo-
tomy, by opening the membrane and dividing  the cricoid cartilage with the
upper rings of the  trachea.
   Whichever operation  is  performed, so soon as  the  windpipe is  opened the
patient is seized with an attack of spasm  and convulsive cough, often attended
by much struggling and  distress, during which  the whistling occasioned by the
passage of  the air through the  new passage is very loud and marked.  The pa-
tient, however, soon recovers himself,  and  then  breathes  naturally and easily,
the signs of asphyxia disappearing.
   Laryngotomy is an easy operation, the crico-thyroid membrane is almost super-
ficial, and  may readily be reached by making a vertical  incision  in the mesial
line, between  the  sterno-thyroid muscles, about an inch in length, and then a
cross cut through the membrane with an ordinary scalpel.   The air-passage having
thus  been  opened,  a silver  tube, curved on the  flat, may be  readily introduced
and retained by tapes round the neck.   The only troublesome result that can
occur in this operation is the wound of a small arterial branch, the inferior laryn-
geal, that crosses the membrane, but  the hemorrhage from this would readily be
arrested by pressure or ligature.
   Tracheotomy consists in making an opening into some part of the trachea, by
exposing the tube and cutting across  one or more of its rings.
   In performing tracheotomy the patient's  shoulders should be supported with
pillows, and his head be thrown as much back as practicable.  An incision about
an inch and a half in length should then be  made with a scalpel directly in the
mesial line from the cricoid cartilage  downwards.  After  dividing the  integu-
ments any veins that present themselves should be avoided as carefully as possi-
ble, being held aside with a blunt hook.  By using the point of the scalpel to a
limited extent, and dilating the deeper portions of the incision with its  handle,
the trachea may at  last be reached; it must then be opened by pushing the point
of the knife, with  its back turned towards the  sternum, between two of the
rings, and cutting upwards, through about three  of them.  The tube must  then
be introduced and retained by tapes round the neck.
   This  operation is often attended by extreme  difficulty, and not unfrequently
with a  considerable amount of  danger.  The  difficulty in exposing the  tube 
DIFFICULTIES  IN  TRACHEOTOMY.
677
increases greatly as the  incisions approach the sternum, and  are far greater in
stout short-necked persons than in those of a different development.
  There are three situations in which the trachea may be opened/ either above,
underneath, or below the isthmus of the thyroid body, which  usually crosses the
air-tube opposite its third or fourth ring.   Above the isthmus  the trachea is com-
paratively superficial, and is  not  covered by any venous plexus, nor does  any
other source of difficulty present  itself to the surgeon.  Where  the  isthmus
crosses the  trachea this tube is overlaid by a venous plexus as well as by the
glandular structure.   Below the thyroid gland the air-tube is overlapped by the
sterno-hyoid and sterno-thyroid muscles and by the inferior thyroid veins, which
are of large size, together with some tracheal branches from the inferior thyroid
artery; and not unfrequently an irregular arterial branch ascends in this situation
in front of  the trachea to supply the thyroid body.   The carotid arteries also are
in close relation to the vessel on either side, and opposite the  episternal  notch it
is crossed by the left carotid and by the innominata, which vessel has been seen
by Mr. Maeilwain to cross the tube at the very point where tracheotomy is usually
performed.   A glance at  these important relations will suffice to indicate  the
difficulty that must, in many cases, occur in exposing and opening the  trachea.
This difficulty is greatly  increased when the veins of the neck have become turgid
in consequence  of the pulmonic obstruction.   It will also be seen that the tra-
chea is less covered, and may consequently be much  more readily reached above
than below the isthmus of the thyroid  gland; and though  some  surgeons, as
Velpeau, for instance, have recommended the  opening to be made in the lower
part of the  tube, the greater number advise that it should be entered  in its upper
part, though the incision  may, if necessary, be carried  downwards as low as, or
even through the isthmus.
  The difficulties  occurring in tracheotomy are chiefly referable to two causes;
the risk of profuse hemorrhage, and  the difficulty in  opening the air-passage.
The hemorrhage in this operation may occur either  from arteries, veins, or the
thyroid gland.  Arterial hemorrhage is less frequent and troublesome than  the
bleeding from other sources.   When it occurs it chiefly happens from the wound
of some anomalous branch, or from that of the small tracheal vessels.   Desault
has, however, mentioned a fatal case in  which death arose from a wound of the
carotid.   The arterial anastomosis of the isthmus of the thyroid body may, if
this part be enlarged, occasion some difficulty in the performance of the opera-
tion, but the main source of danger  unquestionably proceeds from  the venous
bleeding.   Not only are the plexuses of veins of large size, more  particularly
where they cover the  lower part of the trachea,  but as has already been observed
they become immensely gorged by the asphyxia that necessitates the operation.
Hence, when wounded,  the bleeding  may be so abundant as  scarcely to be con-
trollable, and may  retard very greatly the after-steps of the  operation.   Many
surgeons of authority in these matters, advise that the windpipe should not be
opened so long  as the bleeding is abundant, lest the blood entering the  bronchi
and lungs through the aperture, asphyxiate the patient.  I think, however, that
in many cases the  best way to arrest this hemorrhage is by opening the  trachea,
and thus enabling respiration to go on, for,as the lungs unload themselves  the
bleeding will cease.
  Another  difficulty in tracheotomy sometimes consists in opening the tube after
it is exposed.  In consequence of the convulsive breathing of the patient,  the
sterno-mastoids  are put upon the stretch, thus increasing considerably the  depth
of the wound in the neck, and at each short and gasping respiration, the air-tube
is rapidly pumped or jerked to and fro, approaching to and  receding from  the
surface in such  a way that the scalpel cannot be thrust into  it with  safety.  In
order to do this with  the least risk, a  sharp-pointed hook should be passed
between two of the rings, and the tube being thus fixed,  opened  by cutting 
678
DISEASES  OF  THE  THROAT.
upwards.  I have found it advantageous in cases of this kind to open the trachea
with a cutting-hook, such as is  here represented (Fig. 221).   By means  of an
Fig. 221.
instrument of this kind, the trachea is first fixed and then divided without dan-
ger to the patient.  The danger from hemorrhage, and  the difficulty in opening
the trachea, are  much greater  in  children than in adults.   Before the age of
puberty, this tube is deeply-seated, covered with a quantity of loose granular fat,
containing many veins, and  is of small size, so that a slight deviation of the
incision  to one side or the other may readily lead the  surgeon  astray, and into
dangerous proximity with the carotid artery.
   After the trachea has been  opened, the next point  is to introduce, in cases
requiring it, a proper tube.  In doing this, some little difficulty may occasionally
be experienced,  owing to the elasticity of the sides of the incision in the wind-
pipe, in consequence of which one of them is apt to get doubled  under the end
of the  instrument.  This  may be avoided by  holding one edge aside with the
forceps, whilst the tube is slipt under the other.
   My friend and late house-surgeon, Mr. H. Thompson, has lately recommended
a very simple and most  ingenious mode of opening the  trachea, by which the
dangers and difficulties of  the old operation,  such as  have just been  described,
are in a great measure avoided.  This operation consists in making the puncture
at once into the windpipe by means of the tracheotome as here depicted (Fig.
222), which serves at the same time as a guide to the tube into- the opening.
Fig. 222.
By means of this instrument a puncture is made transversely through the skin
and cellular tissue, and between the first and second rings of the trachea, so that
the cartilages are  not injured.  When the  blades  have been  introduced they
should be  held  there by the left hand, and  the screw in  the handle  gradually
turned, so that the separation of the blades may dilate the contiguous structures
until the aperture is sufficiently  large to allow a tube to be introduced.
   Mr.  Thompson states that the proper point for introducing the instrument may
always be determined by feeling for  the projection of the cricoid cartilage, and
defining  its lower border clearly with  the finger.  The point of the instrument
should then  be introduced transversely in the mesial line a quarter of an inch
below this cartilage,  when it will enter the space between  the  first and second
rings.  The screw is then to be  turned, the blades expanded, and the tube intro-
duced, as above described.   This operation  is certainly the safest, the  easiest,
and most speedy mode of opening the trachea, and appears to be a very great im-
provement  upon the ordinary methods of performing tracheotomy.  It is not,
however, applicable  to  children, nor  would it,  I think,  be desirable to have
recourse  to it in those cases in which the trachea requires to be opened  for the
extraction of foreign bodies from the windpipe, as the vertical incision tends to
facilitate its escape.
   On comparing tracheotomy as ordinarily performed, with laryngotomy, I think
there/can be little doubt that the surgeon should give the preference, in all cases 
TRACHEOTOMY — TRACHEA-TUBES.
679
where it is practicable, to the latter operation, on account of its greater simplicity,
safety, and rapidity, though in these respects it appears  to be equalled by the
method introduced by Mr. Thompson.  In all those cases in which the obstruc-
tion to respiration is dependent upon inflammatory effusions into the submucous
cellular tissue, whether it be dependent upon idiopathic or erysipelatous laryn-
gitis, or upon the irritation and inflammation excited by swallowing boiling water
or the stronger acids, the swelling, for reasons  that have already been mentioned,
never extends below  the true vocal  cords; hence an opening  into the crico-
thyroid membrane will always be below the seat of obstruction.   An objection it
is true has been urged to laryngotomy in  these cases, that it does  not allow of
the patient wearing a tube without much irritation  being induced.  This, how-
ever, I have not found to be the case  in  my  practice.   I have  at  present two
patients under observation, in both of whom I introduced a silver  tube in  this
situation a considerable  time back, and in whom no special  irritation  has been
occasioned by it.  In one case the tube has been worn for five, and in the other
for nearly two years; the larynx in both instances having been nearly completely
occluded by chronic disease.  When the windpipe requires to be opened for the
extraction of a foreign body, tracheotomy should be performed  in  preference to
laryngotomy, as the latter operation does not admit of sufficient space for its ex-
pulsion or extraction.
   In  children  tracheotomy is almost always  a  tedious and often  a dangerous
operation, the exposure of the trachea requiring very careful dissection and much
time being often lost before it can be punctured owing  to the free hemorrhage
which usually occurs.
   Laryngotomy on the other hand, can be performed with but little delay.  The
crico-thyroid membrane can be quickly exposed, no parts of importance lying in
the line of incision; and the bleeding is in general  but trifling, not  nearly so
abundant as when  the incision is made more towards the root of the neck, and
very soon ceases sufficiently to allow  an  opening to be made into the air-tube;
hence, when time  is of importance, as it almost invariably  is in those cases of
croup  in  children  that  require operation, I should prefer the high to the  low
operation.
   It is a practice with some surgeons not to open the windpipe until  all, or nearly
all, the bleeding has ceased.  But it appears to me that in this way much valua-
ble time may be consumed,  and the patient be  exhausted by a tedious and pro-
longed  operation, and by the loss of an  unnecessarily large quantity of blood.
The hemorrhage in these operations  is almost  entirely of a venous character, and
is, in a great measure, dependent on the distension of the veins of the neck that
occurs in asphyxia, as the result  of the accumulation  of  blood in the right cavi-
ties of the heart consequent upon the obstructed circulation through the lungs;
and the bleeding will continue so long as that obstruction remains unremoved.
But as the respiratory process is re-established, this obstruction to  the  pulmonic
circulation diminishes, the cardiac cavities become unloaded, the venous tumes-
cence of the neck  subsides, and  the hemorrhage proportionately lessens.   This
I have repeatedly found in asphyxia artificially induced in animals, and have
more  than once seen in the human  subject in cases in which it has become
necessary to open  the windpipe  at once, without waiting to arrest  hemorrhage.
Hence, I think, that except in those instances in which an arterial  twig or large
venous trunk has  been wounded, and which must  of  course  be  secured, the
occurrence of bleeding, though tolerably smart, need not deter the surgeon from
opening the  windpipe;  as  the relief afforded to respiration will induce a corre-
sponding diminution in the  venous turgescence of the neck, and in the consequent
flow of blood from the wound.
   Trachea-tubes should be of such  a calibre throughout as to admit of respira-
tion being carried on through them without any effort on the part of the patient. 
680
DISEASES OF THE THROAT.
Many of those that are to be met with in the instrument-maker's shops; though
very wide at the mouth, are far too narrow and contracted at the lower aperture
to allow a free and  unimpeded passage for the air of respiration, being made
very conical in order to admit of easy introduction, and  to occlude completely
the opening in the windpipe, so as to prevent the entry of any blood by the side
of the tube.  The disadvantage attending this mode of construction  may in a
great degree be remedied by having a longitudinal opening like the large eye of
a catheter cut in the side of the tube, immediately above the inferior aperture.
   One  great difficulty that  the surgeon has to meet in cases of tracheotomy or
laryngotomy is to keep the  tube from being  clogged and obstructed by mucus.
It is  usually stated that the tube may be kept clear by the occasional introduc-
tion of a feather, of a piece of sponge fixed to a stick, or a bit of lint wrapped
round a probe.  In this way it is true  that the frothy or spumous mucus that
collects in the tube may be readily enough cleared away;  but this simple means
will in  very many cases be found to be quite ineffectual in removing another
kind of mucus that  in certain conditions rapidly accumulates  to a considerable
extent within  the tube.  On  examining a trachea-tube that has been worn for
but a few hours, it will be found  that its interior becomes gradually lined by a
coating of dry, gummy, and very tenacious mucus, which is so firmly adherent
to the metal as to render it necessary before the tube can be properly cleaned, to
detach this lining by means of a penknife, or pointed probe; or, what is better, by
pouring boiling water through the tube.  This tenacious  mucus collecting, as it
does, in largest quantity at the inferior aperture, and at the curve of the trachea-
tube,  may block up its  calibre to a very great and dangerous extent, whilst the
mouth of the tube appears to be perfectly pervious and free, and though feathers
and pieces of stick, armed with sponge or lint, have been introduced from time
to time; but these, passing over  this dry mucus, are quite  unable  to  detach it
from  the side  of the tube,  and merely bring away the sputa  and more frothy
mucus.
   A very simple  and effectual means has been deyised by Mr. Obre, of Lisson
Grove,  to remedy this inconvenience.   It consists in the trachea-tube being
made of uniform calibre throughout, and having an interior tube accurately fitted
to it, and projecting  about one-eighth of an inch beyond the lower extremity of
the outer tube.  It is in the  projection of the internal tube beyond  the lower
end of the external one  that  the great utility of this contrivance consists.  If the
two tubes are of the same  length, or still more, if the innermost tube be the
shorter, a plug of mucus may be left  at  the end of the outer canula, on the
withdrawal of the inner tube.   But if this be the longer  of the two, the end of
the outer tube will be effectually cleared every time it is withdrawn, which may
                           be done as often as any mucus collects,     Fig. 224.
                           without in  the  slightest degree dis-   >_^^v
                           turbing the patient.  The two  tubes  /J[^\L
                           are fixed by means of a button,  at-   a   A   \]
                           tached  to the edge of the outer one. I  \T) / ¥\ J J
                           have found it convenient to have  the  \\rr^SkJjJ'
                           ordinary set of  three  trachea-tubes   x^-^F
                           made in this way, the internal tube be-     y^f
                          ing the largest, the middle the next in     I  |
                           length, and the  external the shortest.     I J
                           By this arrangement the smaller tra-     MJJ
                           chea-tube is made to serve the purpose     W
of the internal canula.  When used for laryngotomy,  these tubes  may conve-
niently be  curved on  the flat, their longest  diameter  being lateral instead of
antero-posterior, thus adapting themselves  to the form  of the  aperture in  the
crico-thyroid membrane.
 
        TUMORS OF  THE PAROTID — THEIR  EXTIRPATION.     681


                       DISEASES  OF THE PAROTID.

  Parotitis or mumps  is a common affection, especially in children, though  it
not unfrequently occurs in adults.   It  usually arises from cold  and wet, and  is
frequently infectious.   Both sides of the neck are usually affected, and the swell-
ing, stiffness, and pain are often considerable, though it very rarely happens that
suppuration occurs unless it be in  the  lymphatic glands of the neighborhood.
Metastasis,  though of rare occurrence,  has been described as occasionally hap-
hening to the testicle or breast.  The treatment for this affection is of a simple
character, the application of hot fomentations and leeches if it be severe; the
administration of saline purgatives and, as the affection is on the decline, frictions
with camphorated oil will hasten its resolution.
 "  Tumors of the parotid itself are not so frequent as morbid growths situated
upon or in  the vicinity of this gland, yet occasionally they occur either upon  it
or consist in an actual transformation of its structure.  The tumors usually met
with here  are of a fibrous nature and often encysted; they are  hard, deeply at-
tached, but yet movable on careful manipulation; round, and often attain a very
great size, up to  that of a cocoa-nut even; the skin covering them is thin but
not adherent, and not unfrequently a network of veins covers the mass.  These
growths frequently send prolongations under the lower jaw, and then occupy the
whole of  the space  between its  angle and  the mastoid process;  when firmly
bound down, they involve the bloodvessels  and  nerves in this important region,
coming into relation  with the styloid process and its muscles, and even pressing
upon the  pharynx.  In consequence of the large size that these  tumors may
attain, they have a tendency to produce atrophy of the parotid, and often by inter-
fering with the cerebral circulation occasion various congestive  symptoms about
the brain.   In some cases the  parotid  may undergo  cancerous  infiltration, the
tumor then presenting  the  characters and running  the  course  of the ordinary
forms of malignant disease.
   It is  of importance to effect the diagnosis in their early stages between the
non-malignant and the malignant  varieties  of this  affection.   In the fibrous
tumor there is always mobility,  and although  the attachment may be  deep, the
skin is not involved, and the outline of the  mass  usually well  defined, square,
and somewhat lobukted.  In the scirrhous growth there  is no mobility, but the
mass is solidly fixed, its outline is ill-defined, the skin of a reddish  purple color,
brawny, and presenting the  usual  characters indicative of subjacent malignant
action.
   In the  treatment  of these tumors, extirpation is necessarily  the only course
that can be adopted; and this should not be attempted if the disease  be malig-
nant in its characters;  for as it  would be impossible  to get  away its deeper
attachments, its growth to a certainty would easily return.   In removing tumors
in this situation,  the superficial incisions should be made free, and either longi-
tudinal or crucial, so that the whole mass may be fairly exposed.  The edge  of
the knife must then  be directed against it, and the  dissection carried on  from
below upwards, so that one division of the bloodvessels may be sufficient.  After
the tumor has been well loosened by the division of investing fasciae and struc-
tures, and  it is  surprising how movable it becomes  after this  has been done,
though it  may previously appear to  have been incorporated solidly with the sub-
jacent tissues, it should be taken  hold of by the hand or a large double hook,
and drawn well forwards whilst the  deep dissection is  being carried on.   In
prosecuting this, the  surgeon must especially guard against wounding the external
carotid artery and the  portio dura  nerve, which are especially exposed to injury.
In many cases the division of these structures cannot be prevented, as they are
incorporated in the mass that is undergoing removal.  The  hemorrhage  under
these circumstances would of course  be abundant, but may immediately be arrested 
682
DISEASES OF  THE  THROAT.
by the ligature of the divided artery;  indeed, in most cases the bleeding is pro-
fuse, owing to the unavoidable section of nutrient vessels and of large subcutaneous
veins, but may generally be readily arrested by ligature and pressure.  After the
extirpation of some small tumors of a fibrous or encysted character lodged in  the
substance of  the  parotid, there is often  a great  tendency to copious secondary
hemorrhage,  requiring pressure, or even the application of the actual cautery for
its arrest.  Excision of the parotid itself is  occasionally spoken of, but is very
rarely if ever done.  I believe that in most, if not all, the cases in which it is
stated that complete removal of this gland  has been accomplished, tumors over-
laying and compressing it have been mistaken for it.  It is evident that a diseased
parotid could not be removed without the division of the external carotid and  the
portio dura.
  Besides tumors in the parotid region, fibrous  and encysted growths are  not
unfrequently met with in the submaxillary space, and in  the  posterior triangles
of the neck.   In these  situations they may occasionally attain a  considerable
size, though  they seldom extend  very deeply.   Hence  when the  integuments
and superficial  structures covering them are divided, the growth may be insulated
with  sufficient facility,  its fixity being  in a  great measure  due to its being
bound  down  by the investing fascia rathef than to its having contracted deep
adhesions.
  A peculiar cystic  tumor,  the hydrocele of the neck,  has been  described by
Maunoir and Phillips.   The  disease usually  appears  in the  posterior inferior
triangle, forms a largish bladder-like tumor, unilocular in some cases, multilocular
in others; filled  with  a yellow or chocolate-colored sero-albuminous fluid and
may attain so large a size as to interfere  with deglutition and respiration;  the
skin covering  these growths is not discolored,  but thin and expanded.   The
treatment consists in the introduction of a seton after the tumor has been tapped.
  Enlargement of the lymphatic glands of the neck either terminating in chronic
induration or abscess, is of such common occurrence as to constitute perhaps  the
most frequent form of glandular enlargement.   The tumors thus formed, present
nothing peculiar in their progress or treatment when occurring in this situation,
except that when abscess forms it should be opened early by a small incision, and
in such a direction, corresponding to the natural  folds of  the skin, as to leave as
little scarring as possible.

                              BRONCHOCELE.
  The thyroid  gland is subject to various chronic enlargements which commonly
go by the name of bronchocele.  It may be simply hypertrophied, and may then
attain a very considerable size; in some cases forming  an  immense lobukted
tumor on the forepart of the neck, such as is met with in various districts of this
country and of the continent, in which the disease is epidemic.   In the majority
of instances,  these tumors are, however, of but very moderate size,  commencing
at first as a mere fulness and uniform or rounded enlargement of the isthmus, or
of one of the lateral lobes of the thyroid gland;  and gradually increasing until
perhaps  by the pressure  of the  growth, confined  between  the  sterno-mastoid
muscle and the deep structures of the neck, respiration and  deglutition become
seriously affected.   There  is a remarkable connexion  between  tumors  of the
thyroid gland of  this kind, and a general anemic condition  of the  system.   In
London nothing is more  common than to find  a certain degree of bronchocele in
pale or bloodless women or girls;  indeed so frequent is this  coincidence  that it
is almost impossible not to regard it in the light of cause and effect.  Mr. W.
Cooper  has  pointed out the fact,  that great prominence of the eyeballs is
frequently associated with these conditions.
  In some cases cystic tumors are met with in this gland, either associated with
general hypertrophy of  it,  or occurring independently  of  this.  These  cysts, 
TREATMENT OF BRONCHOCELE.
683
which may be single or numerous, usually contain a dark bloody-looking fluid,
and have often cauliflower-like  excrescences  projecting into  their interior.   In
some instances pulsation has been observed in a bronchocele.  This may either
be communicated by the artery lying beneath it, or be owing to the very vascular
character of the tumor itself.   In either case, when  confined to  one lobe only,
care must  be taken not  to  confound the beatings with carotid  aneurism, a
mistake that  I  have known to occur, and  the diagnosis  of which has been
adverted to at page 519.
  The treatment of bronchocele must vary according to the size and character
of the tumor; when  small, and associated with anemia, and of comparatively
recent formation, it is  best treated  by improving the general condition  of the
patient by  the administration of iron internally, aspecially the iodide, with the
external  application of the iodine or iodide  of lead ointment.   When of large
size, its absorption  cannot, I think, be expected to occur by these  or any other
means, and the question then  arises as to the propriety of having recourse  to
operative interference.  The excision of the tumor is seldom to  be  thought of;
its vascularity is so great, and the arterial supply that it receives from both .sets
of thyroid  arteries so abundant, that any attempt at extirpation  must generally
be attended by such profuse hemorrhage as necessarily to prevent the completion
of the operation.  Cases have, it is true, occurred to Boux and others, in which
large bronchoceles have been successfully extirpated;  but these operations must
be looked upon  as altogether the exception in the treatment of the  disease; and
cases are certainly not often met with in which a surgeon would  think it proper
to undertake so serious a procedure for an affection that is not necessarily mortal.
In the event of its being thought desirable to operate, the better* plan would be,
after exposing the tumor, to enucleate it as much  as possible with the handle of
the scalpel, ligaturing carefully all the vessels divided as they were cut.
   The ligature of the thyroid arteries has been practised by some surgeons, and,
it is stated, with a certain degree of success.    The difficulties and danger of the
operation, the uncertainty of its results, and the readiness with which the arterial
supply would  be forwarded to the tumor from other sources, have  caused it  to
be but little resorted to by surgeons of the present day.   The introduction of a
seton across the tumor is occasionally attended by beneficial  results.  This ope-
ration, however, is not unaccompanied by danger; a patient on whom it was being
performed  in  the neighborhood of London a few years  ago, having lost his life by
the puncture  of a vein at the root of the neck, into which air was spontaneously
admitted.
   In some instances the  employment of pressure has been of use, especially in
conjunction with the iodine inunctions ; though it is not easy to apply this means,
and any considerable degree  of it can necessarily not be borne, on account of the
increased difficulty of respiration that is thus occasioned.  In fact, the compres-
sion exercised upon the tumor by the sterno-mastoid muscle in some of these cases
is occasionally so  considerable, that it becomes necessary to divide its tendon
subcutaneously, in order to relieve the trachea from the constriction to which it
is thus subjected.  When the tumor is chiefly of a  cystic  character, the fluid
contents may  be drawn off by tapping, and an endeavor may be made to get the
cvsts to close  by inducing inflammation in them by the injection of tincture of
iodine. 
684
DISEASES OF THE BREAST.
                            CHAPTER  LI.

                     DISEASES OF THE BBEAST.

   These affections when occurring in the female, are  of great interest to the
surgeon, not  only  on account of their great  variety, but from the difficulty of
diagnosis attending them and the importance  of determining the question of ope-
rative interference in connexion with them.
   The mammary gland is subject to certain anomalies as to development. Thus,
in some  instances, it  has been found to be altogether wanting.   Sir A. Cooper
and Froriep both relate instances in which this structure was not developed, and
in which the ovaries were also deficient.   A  more remarkable anomaly consists
in the development of a number  of supernumerary breasts.  Birkett has collected
fourteen reported cases, in which there were more than two breasts; more fre-
quently there is but one supernumerary gland, sometimes two, and occasionally,
though very rarely, three have been met with, constituting quintuple mammas.
Supernumerary nipples  have likewise been found to occur;  two to each breast
have  been met  with, each communicating with the gland, and passing milk.
Most  frequently the supernumerary breast is situated somewhere in the neighbor-
hood  of the normal gland, as on  the anterior part of the thorax; and where  four
are developed they have been  found placed in two parallel rows one above the
other.  Occasionally they have been met  with in very strange situations;  thus
they have been seen on the outer part of the thigh, in the groin and on the back;
and children have even been known to have been suckled by these abnormal breasts.
   Diseases of the breast seldom occur before puberty, being most frequently met
with either during lactation, when the functions of the gland are in a high degree
of development,  or towards the termination of menstrual life when the actions of
the organs are necessarily influenced by the changes that are taking place in the
uterine system.  Before puberty, the breast occasionally, but rarely, becomes the
seat of inflammation and abscess, in all probability accidentally so, these  changes
taking place in it in the same way that they might in any other part of the body.
More  serious  disease has, however, been met  with in the mammary gland, even
at this very early age.   Thus, Mr. Lyford has recorded a case of cancer of the
breast in a girl of eight.   As the period of puberty approaches, the breast often
swells, becomes  hard, knotty, and  somewhat  painful, indicative of some com-
mencing change in the generative system.  In other cases again a precocious hy-
pertrophy may take place, frequently attended with severe neuralgia in the part.
When puberty occurs the breasts naturally enlarge, and often become tender, and
occasionally one  undergoes a certain degree of hypertrophy, increasing greatly in
bulk beyond the  other. These various changes, though exciting alarm in families,
cannot be regarded as of any serious importance, and seldom require more  than
the simplest surgical treatment.
   Neuralgia of the breast, occasionally occurs to so severe a degree as to consti-
tute a positive disease, either in  girls or at a more advanced period of life, when
it not unfrequently complicates  other more  serious affections of this organ.  It
is especially apt  to occur in young, delicate, unmarried females of the hysterical
temperament, though it is often  met with  in  strong, ruddy-looking women,  who
are perhaps subject to neuralgic pains in the back, and in other situations.   Most
commonly the catamenia will be  found to  be  irregular, and uterine congestion,
inflammation, or ulceration, will  be discovered on examination; indeed  of  late,
since  the attention of the profession has been drawn to these affections, I  have
scarcely ever failed to detect one or other of these conditions in the  uterus  in
cases  of irritable breast. 
        NEURALGIA  AND  HYPERTROPHY OF THE BREAST.     685

  In neuralgia of the breast the mammary gland may be of its normal size and
consistence, but in some instances the whole of it is more or less indurated and
hypertrophied.   There is  always much general pain and aching deeply in  its
substance, with cutaneous  tenderness of its surface,  and lancinating or radiating
sensations that extend into the axilla and  down the arm.   These painful sensa-
tions are commonly increased before the menstrual period, and not unfrequently
alternate in opposite  breasts.   The diagnosis of this affection from the more
serious mammary disease may usually be effected by attending to the superficial
and radiating character of the pain, to the temperament of  the woman  in whom
it occurs, its shifting seat,  and the absence of any positive signs of disease in the
breast.
  The treatment consists especially in attention to  the  condition of the  uterine
organs.   Unless this be done in a proper way the disease will prove to be exces-
sively rebellious and troublesome to manage.   By using the speculum, however,
when necessary, and removing any uterine irritation that may be found  by pro-
per remedies, this  affection will yield  with far greater readiness than  by any
other  plan of treatment.   At  the same  time anti-hysterical  constitutional
remedies may be employed; the preparations of iron administered, when  neces-
sary ; and  the  local pain  relieved by the application of belladonna and opiate
plasters,  or inunctions with atropine  ointment.
   Simple  hypertrophy  of the  breast not unfrequently occurs,  associated with
very severe neuralgia of the organ.   An increase of size, such as naturally takes
place during pregnancy, between the fourth and the ninth months, will occasionally
commence,at puberty, and go on until  the organ attains an enormous bulk.   In
some cases the breast  has  been found to weigh as much as twenty pounds after
death; and after removal,  a  breast of this kind,  taken from  a young  woman
under thirty, has weighed no less  than twelve pounds,  being entirely composed
of its normal tissues, greatly hypertrophied.   In these cases of hypertrophy, both
breasts are usually affected, though one  is commonly more so than the other.
When first this morbid condition commences, the breast preserves its usual shape,
though it is increased in bulk, but as it enlarges it gradually projects forwards,
drawing  down the  skin of the shoulders, of the sides of the chest, and  even of
the back, and  hanging  downwards, until, as in a case  mentioned by Berard, it
has been known to  reach to the knees.   The treatment of this affection is very
unsatisfactory.   The general  health must be attended to, and an endeavor may
be made to excite lactation, and thus to  unload the vessels of the breast by the
employment of galactogogue remedies.  I do not think that amputation of the
organ should be performed in these cases, unless the growth attained so great a
size as to render life a burden.  The lobular hypertrophy of the breast, described
by Sir A. Cooper, as occurring chiefly in  unmarried women between thirty and
forty years of age, and which  appears on manipulation to be composed of several
solid but movable masses, that after a time begin to diminish in size, until the
breast at last atrophies, and is in a great  measure  absorbed, seems to me to be
rather a species of the chronic mammary tumor than of pure hypertrophy.
  The lacteal  secretion is occasionally the cause of abnormal conditions in  the
breast; thus the milk may appear at unusual times, a twelvemonth, for instance,
after weaning; it has occasionally been known to be secreted in children, and in
some remarkable instances in men.   In other instances, again, after  parturition,
there is a total absence of milk, either owing to want  of development  in  the
gland, or to debility on the part of the mother.   The opposite condition  will  oc-
casionally occur, and an excessive flow of milk may continue in hysterical  females
after the child  has  been weaned.   In such cases as  these, the galaetorrhcea may
be checked by the  employment of tonics,  the administration of acids, &c.
  It may happen during lactation that one of the lactiferous ducts becomes ob-
structed, either by its becoming obliterated  by inflammation or occluded by the
deposit in it of a small concretion,—a lacteal calculus.   In either case the walls 
686
DISEASES OF  THE BREAST.
of the duct may be expanded, so that at last it constitutes a moderate-sized cyst,
fluctuating on pressure,  and evidently containing fluid.  In  some  cases the
lacteal tumor has been known to attain an enormous size.  A M. Walpy has re-
lated a case in which he drew off  ten pounds of milk  by tapping a collection of
this kind.  These tumors may exist for a considerable time.  Dupuytren records
an instance in which it  had existed for ten months, and Cooper one of a year's
duration.   In these chronic cases the milk  usually  undergoes changes; be-
coming creamy, thick, and oily, and in some instances would appear by the ab-
sorption of its watery parts to leave a solid residue.  In other instances, again, the
milk appears as if diffused through the substance of the  gland and its ducts, con-
stituting a spongy semi-fluctuating tumor.   Velpeau has pointed out that these
lacteal deposits undergo a series  of  changes, somewhat similar to  those that
take place in the blood that has been  extravasated,  becoming absorbed in whole
or part in some instances, in others left fluid, and in others becoming encysted.
  In  these  cases the readiest mode  of getting rid of the tumor is, as Sir  A.
Cooper advises, to make an oblique puncture from the nipple towards it, by means
of a trochar and canula, so that a fistulous track may be left, along which the
milk is discharged, and  thus got rid of, the child being at the same time weaned,
so that the secretion may cease.   In  some cases after weaning, the milk may be
diffused into  the substance of the  gland or collected into masses of curd, form-
ing hard nodules, which give a good  deal of trouble, and may eventually go  on
to some of the forms of inflammation  that will  immediately be described; these
swellings  are usually best got rid of by frictions with somewhat stimulating em-
brocations, such as camphorated oil, &c, by which  their absorption is promoted.
   Inflammation of the  breast may occur at  any period of life, but is usually as-
sociated with that change in the function of the gland which occurs during lacta-
tion.   It is commonly met with during the first month or two after  the birth of
the child, and seldom occurs during weaning.  The inflammation may affect any
one of the constituents of which the  breast  is  composed, and may be  limited to
this;  thus it may occur in the nipple,—in the subcutaneous cellular tissue lying
between  the  skin and the gland,—in  the gland itself, or in that extensive plane
of cellular membrane upon which  the gland rests, and  which intervenes between
it and the pectoral  muscle.   But although  the inflammation commonly affects
these different parts, yet in many cases  the whole of the breast appears to be
affected,  and no distinct implication of any special tissue can be made out.
  Inflammation of the nipple and areola usually  occurs at an  early period of
lactation  in  delicate women,  and especially during their first pregnancy.  It
commences  in the follicle of the part,  accompanied  by superficial  ulceration,
abrasion,  fissure, and cracks, with  oozing  of a  small quantity of thin, sero-puri-
form  fluid, great pain  during suckling, so  much so indeed  as  to prevent the
proper continuance of  this act; and  is usually accompanied  by a good deal of
constitutional irritation.   In some instances  the  fissured state of  the nipple
would appear to  precede  the setting in of inflammation; in other cases again,
the inflammation is the primary  condition.   Wrhen the areola and  nipple  are
inflamed, these parts become conical, red, and swollen, with much pain, owing
to the density of the subcutaneous tissue in  this situation.  When this disease,
commonly called cracked nipple, has  set in, most relief is afforded by the appli-
cation of the nitrate of silver to the bottom of the fissures, and over the inflamed
surface.   This application, though painful at the time, gives the patient after-
wards more complete ease than any other with which I am acquainted.  In some
instances the application of  the  citrine  ointment, and in other and slighter
cases that of collodion is useful.  When inflammation  exists, with  superficial
abrasion,  but without any distinct crack, the employment of astringent  applica-
tions, such as the tincture of myrrh  and  of catechu, borax and honey, or spirit
and water may be useful.   In these cases also  a leaden nipple-shield may be 
 CRACKED NIPPLE — ABSCESS  OF AREOLA — MILK ABSCESS.   687

employed with advantage, and the state of the infant's secretions should be care-
fully attended to; the occurrence of aphthous ulcers in the mouth being followed
with especial frequency by the disease in question.
  Abscess of the areola  not  unfrequently  occurs in suckling women, with the
ordinary signs of local inflammation,  terminating in circumscribed  suppuration.
The treatment consists in the  application  of warm poultices  made with  lead
lotion, and lancing the part  early.   In  doing this, care  should be taken  that
the cut be made from the centre of the nipple towards the circumference of the
areola, so as not to cut the lacteal ducts.
  Inflammation of the  cellular tissue upon and behind the mammary gland,
and of the  gland itself,  rarely occurs, except as the result  of the irritation  of
lactation; and as it  commonly terminates  in suppuration, is usually called milk
abscess.
  Inflammation, followed by  abscess of the subcutaneous  cellular  tissue of the
breast, though commonly occurring during  lactation, is more frequently met with
than any other form  of inflammation in this region  at other periods of life, more
particularly about the age of  puberty.   Its symptoms are those of simple phleg-
monous  inflammation of these structures,  differing in no way from abscesses  of
this kind in other situations,  except that it is always distinctly circumscribed.
   When inflammation occurs in the cellular plane which lies between the mamma
and the pectoral muscle, it diffuses itself  over  the whole of this cellular layer,
and almost  invariably runs into abscess with considerable  rapidity, giving rise
to  great pain  in this situation of a deep heavy and throbbing character, much
increased by moving the arm and  shoulder, attended by swelling, oedema, and a
slight red blush upon the skin.   The breast becomes  prominent, is conical and
projecting, the whole organ being pushed forwards  by the pressure from behind;
the subcutaneous veins become engorged, and at last abscess forms.   It  is not
always  easy in these cases  to  determine whether  suppuration has taken  place
or  not, the  depth at which  matter forms  rendering  it impossible in the  early
stages to detect fluctuation until it approaches the surface; its presence may, how-
ever, be suspected by the occurrence  of deep-seated throbbing pain, oedema, and
some superficial  redness.  The abscess at last points at some part of the margin
of  the  gland, usually at its  lower and outer side, where the  matter seems  to
gravitate;  after a time, however,  it will commonly appear at other points of the
circumference of the gland,  beyond  which it always  extends, though it seldom
if ever perforates the structure.   I  have,  in more than  one instance, seen a
series of four or five  apertures, forming a large  circle around the margin of the
gland.   It very commonly happens that the  apertures through which the pus
discharges itself through these situations, degenerate into fistulous  canals, by no
means easily closed.
   Inflammation of the gland itself is not of such frequent occurrence  as either
of  the other forms of abscess;  when  the whole  of the organ is affected, it  gives
rise to great  swelling of the breast, with  severe  aching  and  lancinating pain,
and much constitutional  disturbance,  usually of an irritative type.   Not unfre-
quently one lobule only of the gland  becomes inflamed, and then the local signs
are proportionately limited, and occasionally cease.   As Velpeau has pointed out,
one lobule after another may become  inflamed, so that a succession of abscesses
form in different parts  of the gland.   As the inflammation  advances to  sup-
puration, the skin is reddened, assumes a dusky hue, becomes glazed, has a pecu-
liar greasy  appearance,  and  pits  on  pressure.  When matter has formed, the
tension of the superficial parts with  oedema and perhaps deep-seated fluctuation
determine its presence.
   In the treatment of inflammation and abscess of the breast occurring during
lactation it must be borne in mind that we have not a sthenic inflammatory con-
dition to deal with, but that  the disease  almost invariably occurs in pale delicate 
688
DISEASES  OF  THE  BREAST.
women, commonly  of a strumous habit  and weakened  by recent parturition;
indeed the  affection appears to be rather an inflammation of an irritative and
congestive,  than of a  sthenic  character.  It  is  therefore obvious  that anti-
phlogistic means of an active nature are not admissible ; and the best plan of treat-
ment appears to consist in keeping up the strength of the patient by proper consti-
tutional support, at the same time that the local inflammation is checked by topical
antiphlogistic measures.   The first thing to be done is to  prevent the occurrence
of suppuration;  if this can be accomplished, which is, however, rarely the case,
much will  be gained.   In order to  effect this, the breast should  be  supported
in a sling, so as to lessen congestion in it, and the arm at the same time should
be fixed  to the side in order to prevent traction of the pectorals and movement
of the sub-mammary cellular tissue.   If the patient's strength is  good, leeches
may be applied; in the majority of cases, however, they will not be required, but
warm evaporating lead lotions or the assiduous application of chamomile or poppy
fomentations may be substituted in their stead ; at the same time the milk should
be drawn off by means of a breast pump or sucker, the child being put  to the
unaffected breast or weaned,  and  an occasional saline purgative administered.
when suppuration is impending, the application of fomentations may be continued,
the patient being allowed a more liberal supply of nourishment, with a moderate
quantity  of malt liquor;  and so soon as matter  can be felt, it should  be cut
down upon  and let  out by an  aperture in  the  most dependent position.  It is
of great  importance that  the matter should be let out early, and by an opening
into the  lowest part of the abscess; if it  is not, it burrows deeply, diffusing
itself through the cellular tissue under, beyond,  and around the gland, and open-
ing at several points, leaves long fistulous tracks perforating the breast in various
directions.   When  suppuration  is  going on, the patient's strength must be sup-
ported with tonics, the mineral acids, bark and  quinine.   Porter  must be liber-
ally allowed, and plenty of nourishment given.  The sinuses that  are left may
usually be got to close by attention to the  state of the general health;  should
they not  do so,  however, the  employment of pressure and the use of stimulating
injections may, in time, accomplish this.   In the event of their  proving rebel-
lious it has  been proposed to slit them up, but this is an unnecessarily severe
practice,  and may, I believe, in all cases be dispensed with.
   Chronic or encysted abscess of the breast, is  a  disease of great importance,
inasmuch as it  simulates closely various  tumors  in this  situation; so much so,
indeed, that it is only with extreme difficulty that the diagnosis is effected in
some cases.   It may commence either as the result of acute lacteal inflammation,
but more commonly without  any distinct cause  ;  as the  consequence, probably,
of a very chronic and gradual engorgement of the cellular tissue in this region.
An indurated indolent swelling forms,  and  this may gradually soften  in the
centre, but fluctuation may for  a long time be very indistinct, and  even absent,
being obscured  by the thick wall of plastic matter that is thrown out around the
collection of pus.  It is owing to the deposition  of this dense mass of limiting
fibrine that the encysted abscess  is commonly developed as a hard and apparently
solid lump.  It is  in  general  not  very  distinctly circumscribed, and  of but
moderate magnitude, after a time remains stationary, or but slowly increases with
but little pain during a  space of many months; and is not unfrequently attended
with retraction  of the nipple.
   The diagnosis of  this form  of abscess is of great importance, inasmuch as it has
not unfrequently been excised for tumor of the breast.  I am acquainted with at
least seven instances in which this mistake has been committed.   Such an error
may, however, commonly be avoided by observing that the  abscess commences
during lactation; that although it is of slow formation and without pain it is  not
distinctly circumscribed, but gradually fuses in an  irregular manner into the
neighboring  tissues; that it  is not freely movable, but rather incorporated with 
TUMORS  OF  THE BREAST.
689
adjacent parts; and that elasticity, or even fluctuation may be commonly felt at
one part of it.   Should there be much doubt in the case, the introduction  of a
grooved needle by giving issue to the pus, will always determine its true nature ;
indeed this simple means of diagnosis should never be  neglected in  all cases  in
which there is reason to suspect  the possibility of the apparent tumor  of the
breast being in reality an abscess.  The cure of  these encysted abscesses  of the
breast may most conveniently be effected by making a puncture into them, and
then passing a seton across them in a perpendicular direction; the inflammation
thus excited in the tumor will speedily lead to its being softened down, and
eventually disappearing.

                         TUMORS OF THE BREAST.
   The study of the various tumors of the breast, more especially in  a diagnostic
point of view,  is of the first importance to the practical surgeon; for though it
might be supposed that it would be easy, if not to recognise the  minuter shades
of pathological  difference between  morbid growths  so superficially situated  as
those of the mammary gland; at all events to diagnose the malignant from the
non-malignant affections of this organ; yet in practice nothing is more  difficult
in many cases :  and it  not only requires  great experience, but also an intimate
acquaintance with the  special course and symptoms of each particular disease, to
come to  a correct  conclusion as to its nature.   Even with all the light that
experience and a careful examination of the characters of the tumor may throw
upon the nature of  the disease, it will be  impossible for  the surgeon to avoid
occasional errors in his diagnosis.

                         NON-MALIGNANT  TUMORS.
   Mammary tumors may be of a simple or a malignant character.   The recogni-
tion of the  different varieties of simple  tumor that  affect the  breast gland, is
principally due to Sir A. Cooper; and this department of surgical pathology has
of late years been much extended by the researches of Mr. Birkett.  The  non-
malignant  tumors of  the  breast comprise the  chronic mammary tumor, the
different varieties of cystic growth, the painful tubercle, hydatid cysts, and various
forms of fibrous, cartilaginous, and osseous growths.
   The chronic mammary tumor is perhaps  the  most common variety of these
benign structures.  It usually occurs  as the result of blows, squeezes, or lacteal
irritation, and is almost invariably met with in young women under  thirty years
of age ; seldom  if ever occurring at a later period than forty; usually in persons
otherwise hearty;  and most  frequently  in those  of a sanguineous  nervous
temperament.    This tumor is generally of small size, though occasionally it may
attain the bulk of the fist.   On examination after removal, it appears irregularly
lobukted, and its cut surface will be found to present a bluish or grayish-white
color, which after exposure to the air assumes a rosy tint,  and on pressure drops
of a thick creamy fluid will often be seen  to exude.   Under the microscope it
has been found, by Mr. Birkett, to consist of imperfectly developed  hypertrophy
of the glandular tissue; the terminal cells of which are filled with epithelial
scales.
   This tumor usually commences as a small, movable, finely nodulated  growth,
attached by a  pedicle to one side of  the mammary gland;  it is hard and  incom-
pressible,  often appears isolated, and not generally painful; it increases  slowly,
and without discoloring the skin or becoming attached to  it, and is  often many
years in attaining  a moderate size.   These tumors are frequently  mistaken for
cancerous growths, and the diagnosis is often as difficult as it is important; though,
in many cases, the otherwise good health of the patient, the mobility of the mass,
the absence of all implication  of the skin or glands, the want of hardness and of
a circumscribed character, will usually indicate its true nature.
                                     44 
690
DISEASES  OF  THE  BREAST.
    The treatment consists in attention to the general health, and the employment
  of local  absorbent  remedies.   In this way tumors  of this  description  have
  occasionally disappeared;  in some instances they have  been known  to become
  spontaneously absorbed after marriage or during pregnancy.  If obstinate,  their
  dispersion may be facilitated by the occasional application of two or three leeches,
  followed by inunction of the iodide of lead ointment; and  the  internal adminis-
  tration of Plunimer's pill,  and  the compound decoction of aloes.  In addition to
  these means, the employment of compression will be found especially serviceable •
  this may  be applied either by means  of Arnott's slack air-cushion, or by using a
  pad to which a spiral  spring is attached, and which being  compressed  by a
  proper arrangement of bandages across the chest will keep up steady and  con-
  tinued pressure upon the tumor.   I have employed this kind of apparatus, which
  is far less expensive  and  cumbersome than the air-compressor, in several cases of
  mammary tumor with great advantage;  it was, I believe, first introduced by M.
  Tanchou, who is a decided advocate of the pressure plan of treating these affec-
  tions.   The advantage attending it is  that it can be used  in conjunction with
  absorbent ointments, which cannot be used with the air-bag, as the grease enter-
  ing into their composition destroys the macintosh cloth of which it is made.   In
  this way absorption  may not unfrequently be secured;  and  I  am disposed to
  think that not a few of the so-called cases of cancer of the breast that have been
  reported as having  been  cured by  pressure, were, in  reality, instances of the
  chronic mammary tumor in which absorption had been  brought  about  in  this
  way.   Should the growth attain too great a magnitude to admit of absorption by
  the means that have just been recommended, its excision must be  practised.   In
  doing this it is not necessary to remove the whole of the breast, but  it will be
 quite sufficient to extirpate the  tumor itself.   This  should be done by means of
 an incision that radiates from the nipple as from a centre, so that the lactiferous
 ducts may not be unnecessarily cut across.
 m It occasionally happens that the chronic mammary  tumor becomes the seat of
 intense  neuralgic pains of a very severe and paroxysmal character, attended with
 very considerable cutaneous sensibility, constituting the form of disease that goes
 by the  name of the painful mammary tumor.   This condition  most frequently
 occurs in early life, and in women of an  irritable and  delicate  constitution  : it
 is commonly associated with disorder of the uterine functions, the pain increasing
 at the catamenial periods, and appearing to be essentially owing to the implica-
 tion of some of the twigs of  the intercosto-humeral nerves in the disease  The
 treatment  of this affection  must have special  reference to  the removal of  the
 neuralgic condition.   This  is commonly best effected by the  internal administra-
 tion ot alteratives and tonics, more particularly of the preparations of iron and
 zinc, and by the inunction of belladonna or aconite  ointments into the affected
 breast.   In many cases the application of a few leeches, from  time to time, will
 lessen  the  neuralgia more effectually than any other plan of treatment; and in
 others  again, pressure will  be found serviceable.  If all other means  fail, exci-
 sion of  the tumor may in  this, as in the last case, ultimately  be found necessary.
   tystic tumors of the breast are amongst the most common  of the non-malig-
 nant affections of this organ.  They may occur in three  distinct forms: either
 as a single unilocular cyst; as  several of  these cysts occurring together; or, as
 the cysto-sarcomatous  tumor,  in which the cystic development appears to  be
 superadded to a structure analogous to that of the chronic mammary tumor.
   Ihe single or unilocular cyst of the female breast, described  by Sir B. Brodie
 as the sero-cystic tumor, and by Sir A. Cooper  as a  variety of  hydatid tumor,
 usually occurs in  the  form of  a small thin sac, about the size of a filbert, con-
 taining  a clear  serous fluid,  imbedded in the glandular substance of the breast,
and movable under the skin; most commonly more than one  cyst of this kind
is present  in the breast, though as one attains a greater development than  the 
             CHRONIC  MAMMARY AND  CYSTIC  TUMORS.         691

others, the smaller ones may readily escape detection.  These cysts, when single
and small, always contain a clear serous  fluid, but  as they increase  in  size, or
become multiple, their  contents may assume  a  greenish, brown or blackish
tinge.   They may continue for a great length of time of small size, but in other
cases, again,  they gradually increase until they contain several ounces of serum.
Sir B.  Brodie is of opinion that they are  originally formed by  a dilatation of  the
lactiferous tubes, and refers to  a preparation in which this position can be demon-
strated.  The diagnosis of the affection may usually be readily effected by feeling
the globular elastic cyst  or cysts under  the skin; the mammary gland being
movable, and not adherent to any of the adjacent  structures.  In those cases,
however, in which the tumor  lies deeply, the diagnosis may  not  so readily be
made, more especially from some of the cystic forms of cancer to which  I shall
by-and-by have occasion to advert.
   Unilocular cysts of the breast  occasionally attain an immense size, at the same
time that their  walls continue  thin and supple.  In some of these instances,  the
fluid continues  to the last of a truly  serous character; in other cases, however,
it becomes more or less glairy  or mucilaginous, and  hence Velpeau has described
this variety as the sero-mucous cyst.   In  other cases, the walls of the cysts have
been known to  undergo calcareous degeneration.  When these cysts attain a very
large size, their walls being thin, and the skin covering them tense,  they may
become translucent, and  thus constitute a true  hydrocele of the breast, resembling
in many respects similar serous tumors that form in the neck.
   In the majority of instances, as has already  been  observed, no material change
takes place in the cyst, except perhaps, its gradual increase in size; but in other
instances, peculiar changes occur in them, in consequence of which they  become
filled up by a dense,  solid growth springing from their interior, at last undergoing
ulceration, and  giving  rise to a series  of  destructive changes.  The pathological
phenomena that accompany these changes have been ably investigated  by Sir B.
Brodie.  He finds that, in the first instance, one or more membranous cysts, con-
taining serum,  are formed in the breast;  the fluid gradually becomes darker in
color, and opaque; after a time, a fibrous excrescence, of a  lobukted or  foliated
form, springs up into  the interior of the cyst, gradually displacing  and occa-
sioning absorption of the contained fluid, and, at last, filling up the whole of its
interior; and then coming in contact with the capsule by which it  is compressed,
or with which it may be  firmly incorporated, the whole tumor is converted into a
solid mass in which the remains of the cysts still continue  to be perceptible.
Sir B. Brodie thinks there is  reason  for  believing that a growth  of a fibrinous
substance takes place from the outer side of the cyst  as well,  thus adding to  the
general size of  the  breast.  If one of the larger cysts be laid  open, or if  the
pressure of the intra-cystic growth cause  inflammation and ulceration  of  its cap-
sule, this may at last be perforated, and a fungous mass will  sprout through it,
presenting  many of the ordinary symptoms of a malignant growth, being irre-
gular,  dark-colored,  bleeding  readily, and increasing rapidly in  size.   When
such changes as these have taken place, the tumor assumes a formidable eharacter,
and will rapidly prove  fatal by the induction of exhaustion and hectic.  Tumors
of this description, composed of cysts having intra-cystic growths sprouting from
their interior, may attain an immense magnitude and  weight.  They have been
met with of six, eight, or even twelve pounds  weight, but the largest with which
I am acquainted is one recently removed by Mr. Fergusson, which had attained
the dimensions  of three adult  heads, and weighed eighteen pounds.
   The  various forms of cystic tumor that have just  been described,'when asso-
ciated with the  development of fibrinous  intra-cystic matter, constitute forms of
the so-called cystic sarcoma.   Another variety of this disease, however,  is   not
unfrequently met with, in which the sarcomatous or solid  element of  the tumor
preponderates over the cystic part of the  growth.   In these cases the tumor will 
692
DISEASES  OF  THE  BREAST.
be found to be  composed  of a  dense,  white,  lobukted, or foliated structure,
closely resembling that of the chronic mammary tumor, and consisting either of
imperfect hypertrophy  of the breast-gland,  or of the  deposit of  a fibrinous
material.  This mass is studded throughout with a number of small  cysts, vary-
ing in size from a pin's head  to a hazel-nut, and usually containing  clear fluid.
If some of  these cysts  increase out of proportion to the  rest, the  tumor will
assume more of the true cystic character.
  This form of cystic sarcoma usually occurs in women from thirty to thirty-five
years of age, as the result of injury or as the  remote consequence of some in-
flammatory action during lactation.  On examining abreast affected in this way,
it will be found that the  tumor, which may be either confined to one lobe, or im-
plicate the whole of the  gland, is hard, heavy, and  solid to the feel;  on careful
examination, however, its surface may be felt to be finely nodulated;  and, occa-
sionally, a larger  cyst than usual may be found  projecting, which is  recognised
by its elastic feel  and globular shape.  The disease  is slow in its growth and does
not implicate the  adjacent cntaneous or cellular  structures; hence, the tumor is
movable on the pectoral muscles, and the skin is unattached to it.  The axillary
glands, also, are not enlarged, at  least not to any material extent.   The nipple
will always be found to be normal  in its shape, and not depressed.
  The treatment  of these various forms of cystic and sarcomatous growths varies,
according to the  size of the cysts, and  the quantity of solid matter deposited
inside and around them.   When  the cysts are small, the fluid contents may be
let out  by puncturing with a grooved  needle; but a cure  cannot  be  effected in
this way, as  the  fluid readily reaccumuktes.   In  such cases as these, Sir B.
Brodie has found considerable advantage in the application of stimulating embro-
cations, more particularly of one composed of equal parts of camphorated spirit
and weak spirit, with one-eighth part of liquor plumbi.   In other cases, blister-
ing and the application of the tincture of iodine, may be serviceable.  Should,
however, these plans of treatment  produce  no good effect, it may be necessary to
remove the whole of the breast affected by the disease.   Such an operation, how-
ever, should  not  be undertaken in the early stages, as the tumor may continue
for many years without  seriously troubling or  endangering the patient, and may
perhaps eventually undergo atrophy or absorption.  If, however, it show a dispo-
sition to increase, to become troublesome by its bulk, or painful, it should then
certainly be  extirpated, and this operation may always be performed with a good
prospect of success, inasmuch as the disease is not malignant, and does not tend
to contaminate the constitution.   It is  a  remarkable  fact, however,  which has
been adverted to  by Lawrence and  Brodie, that even though the whole of the
breast  be extirpated, a similar affection occasionally recurs  in the cicatrix, re-
quiring subsequent operation; and then, perhaps, being permanently  eradicated.
This must either  be owing to some portion of the cystic structure having been
left in the first operation, or to the development of new cysts in the  site of the
former;  but to which cause it is referable is  still uncertain.  A still more  re-
markable circumstance  connected with these  tumors is, that after their removal
a recurrence of cancer will occasionally take place in the cicatrix.   Of this fact,
which has been remarked by Mr.  Paget, I have seen two  instances in my own
practice, which have been published in the "Lancet"  for 1852.
  Besides these  tumors, the breast is  occasionally the  seat of  other morbid
growths; as  for instance, fibrous, osseous, and  cartilaginous  masses  have been
met with in  this situation.   All these affections, however, are of extremely rare
occurrence, and when they form it is almost impossible to determine  their true
nature until after removal.  Their extirpation is usually practised on account of
the obscurity attending the diagnosis, and the fact of their commonly being mis-
taken for cancerous growths.
  Sir A. Cooper  describes a scrofulous tumor of the breast, the precise  nature
of which is not very apparent  from the account given by that surgeon.  It is not 
CANCER OF THE BREAST.
693
improbable, however, that it  is of a tuberculous character; and Velpeau states
that he has found tubercles occurring in the breast in two  forms.  In  the first,
principally deposited in the skin and subcutaneous cellular tissue; and in the
other, of a fibro-tuberculous character, affecting the gland itself.
  Hydatids of the breast are of rare occurrence, and have been principally de-
scribed by Sir A. Cooper, and  cases have been related by Graefe and others.
These hydatid tumors arc so excessively rare and obscure that their true nature
would not in all probability be suspected until after removal.   They present the
ordinary characters of a deeply-seated cyst, with fluctuation and some induration
round the globular swelling, and an absence of pain.   In such a case as this, an
incision into the tumor will cause the escape of the acephalocysts, and  the ulti-
mate suppuration of the cavity in which they lodged, which will gradually cica-
trize.   In some rare cases, tumors containing  foetal remains have been  met with
in the breast; these cases, however, are rather matters of surgical curiosity than
of practical importance.

                  MALIGNANT TUMORS OF THE BREAST.
  All the various forms of cancer  have been  met with in the  breast;  scirrhus,
however, occurs with  far greater frequency  than any of the other  varieties.
Occasionally the encephaloid form of the disease  is  met with, but colloid very
rarely occurs; indeed the only case of colloid of the mammary gland, with which
I am acquainted, is that in a preparation in  the  University College  Museum.
Cancer of the breast, whatever form it assume, is  invariably primary; it may
affect one  lobe only, or be infiltrated into the whole gland;  and it may commence
in the nipple or in the skin covering the breast.    Most frequently only one side
is affected, but in some cases both mammary glands are implicated.
   Scirrhus is that form of cancer which is commonly met with in the  breast; it
may occur in several ways, either as affecting the  nipple, as being deposited in
the form of an intra-mammary tumor, or as infiltrating the whole substance of
the organ.   It most commonly commences as a circumcisted tumor of small size,
at first perhaps smooth and round, hard and indolent in its character, with little
or no pain; it is readily movable, may  be  situated  in one  lobe, and  attached
perhaps to the rest of the gland by a distinct pedicle.  As it increases  in size, it
becomes hard, knobbed, and irregular, perhaps presenting a finely granular feel,
and becoming fixed to the gland and subjacent parts.  When the disease begins
as scirrhous infiltration of the  breast,  the gland is from the first  hard, rugged,
irregular,  nodulated, and heavy;  often somewhat square in  shape,  and early
accompanied  by adhesions to subjacent parts.   In other cases again, the develop-
ment of the scirrhous  mass is accompanied  by a  corresponding atrpphy of the
mammary gland, which becomes shrivelled and disappears entirely.    In  some
instances  rather large cysts may form in connexion with these  scirrhous masses.
In a woman, whose breast I lately removed, for what was  supposed to be cystic
sarcoma, but  proved after the  operation to be a scirrhous tumor, the mass con-
tained  several cysts as  large as cherries, filled with  dark or greenish  fluid, and
projecting from its surface.   It was the presence of these detected before the
operation that led to the suspicion of the growth being of a cystic non-malignant
character.
  As the swelling increases in size, it has a tendency to become more fixed to
the subjacent parts, becoming adherent to the  pectoral muscles, and incorporated
with the  cellular tissue at the border of the axilla.   The tumor also begins to
form a  distinct external projection, becomes more  irregular in shape, is the seat
of severe pain, more particularly at night, and is usually covered by a  plexus of
blue and dilated veins.   The ordinary symptoms of cancerous cachexy now begin
to set in,  and the disease then makes still more rapid progress.
  The  tumor may in some cases remain for a great length of time without impli- 
694
DISEASES  OF  THE  BREAST.
eating the  skin, but most commonly after it has existed for a  few months this
tissue  becomes  more or less involved in  the morbid action.   Instead of being
loose  and movable  over the surface of the tumor, it  will be  found, on  being
pinched up between the fingers, to dimple at one part, where it may be felt to be
attached by a kind of cord-like process to the  tumor beneath it.   After a time,
that portion of the skin which first became fixed in this way, acquires a reddish
or purplish color, and is covered with thin, scaly, epidermic desquamations, and
becomes permeated by a number of small ramifying vessels.  A crack or fissure
eventually forms in this; a small  exudation of a mucous fluid takes place, which
dries into a scab; under this, ulcerative action sets in, which  speedily assumes
the ordinary  characters  of a scirrhous  ulcer, having hard, elevated, and everted
edges, a grayish-green  or foul surface, and discharging a quantity of very fetid
pus.  In some cases ulceration may take place at  several points, and thus the
whole  surface of the breast become converted into one immense chasm, which
may even extend up into the axilla.
   The skin, when affected, often  assumes  a red, glazed, hard,  and  brawny
character, being shining, and  as  if greasy upon  the  surface,  having its pores
enlarged, and enveloping the side of the  chest in a kind of stiff, solid casing,
attended usually by much pain, considerable  oedema of the arm, and an aggra-
vating form  of constitutional cachexy; ulceration at  last takes  place in this
hardened mass, and then speedily  destroys the patient.
   The pain is in many cases but trifling in the early stages of the affection, so
much so indeed, that it is the tumor, often accidentally noticed, that first excites
alarm; as it increases, however, the suffering becomes  severe, more particularly
at night, is greatly aggravated by handling the diseased  mass, and chiefly extends
up to the shoulder and  down the  arm.   The pain  usually becomes most severe
about the time when the skin is first implicated; but as the  cutaneous infiltration
goes on,  it gradually lessens, owing probably to the  destruction of the cutaneous
nerves.
   Betraction of the nipple commonly commences about the same time that the
skin is implicated;  it appears to be owing  to the glandular substance becoming
involved in the mass of the tumor, and thus  giving rise  to shortening of the
lacteal ducts, in consequence of which, by the projection forwards of the general
mass of the breast,  the  nipple appears to be completely buried.   This sign has,
I think,  received more importance than it deserves  in  connexion with cancer, as
it  does not  occur in all  cases of malignant disease,  and is occasionally met with
in simple mammary tumors.
   The axillary glands usually become enlarged early in the disease, and on close
examination a kind of indurated cord may be felt extending in the course of the
absorbents, from the edge of the pectoral to the axilla.   After a time  the supra-
clavicular glands may  likewise become implicated.  In fact, the  whole of the
glandular structures in  the vicinity of the shoulder undergo cancerous infiltra-
tion.   When this is the case, the pressure that  is exercised upon the  axillary
vein commonly occasions oedema of the arm and hand.  The glandular infiltration
usually increases rapidly after the  skin has become  implicated.
   As the scirrhus  extends, it gradually affects the subjacent  muscles, cellular
tissue, the ribs, and at last the pleura, commonly giving rise eventually to hydro-
thorax or secondary visceral deposits.   In  many instances,  however, the disease
proves fatal by the induction of  exhaustion.   The constitutional cachexy is in
many cases not very distinctly marked, until after the skin has become involved;
but then it rapidly increases, more especially when ulceration takes place.  Indeed,
the cancerous degeneration of the  skin may be  looked upon as an epoch of pecu-
liar importance in  scirrhus of the breast, as it is  at  this period that the pain
increases, that the lymphatic system becomes infected, and that the constitution
becomes distinctly poisoned. 
                CAUSES  OF  CANCER  OF  THE  BREAST.             695

  The duration of life after the occurrence of scirrhus of the breast, varies
greatly, so much so that the disease may be considered as assuming an acute and
chronic form.   The acute variety principally  occurs  in  ruddy  and plethoric
women, and commonly proves fatal in  a few months.  In those who are of a more
feeble  and  delicate  constitution, the disease, as a general rule, takes a  slower
course.   Sir A.  Cooper  states that the disease, on an average, is from two to
three years in growing, and from six months to two years in destroying life, after
being fully formed.  In this estimate,  which  is probably correct, Dr. Walshe
agrees, so that the  average duration of life in cancer of the breast would probably
be about three years.  As a general rule the progress of scirrhus is slower in old
people, in whom it occasionally gives rise to a kind of atrophy of the breast, with
shrinking and induration  of  the tumor.  There are many instances on  record,
however, in which cancer of the  breast has existed for a far longer period than
has just been mentioned, for ten, twelve, or even, as in a case related by Sir B.
Brodie, for twenty-five years.
   After removal, scirrhus of the mamma presents considerable variety in  appear-
ance.  In the majority of instances it occurs as a peculiarly hard, knobbed
and irregular mass, creaking under the knife when cut, and presenting on section
a grayish or bluish-gray semi-transparent surface, traversed in various directions
by bands of a more opaque character, and  exuding on pressure a thin reddish
juice.  In many instances masses of an opaque character and yellowish tint, may
be seen in  the midst of the tumor.  These, which look like tuberculous deposits,
consist in reality of fatty degeneration of the scirrhous, structure.  In other cases
again, on pressing the tumor, small drops of a thick creamy  fluid  will  appear to
exude at various points.  This appears  to be the inspissated and  altered secre-
tion of the gland retained  in the ducts.  Cysts are  occasionally,  though rarely,
met with in scirrhus of the  breast;  these  are  usually small and contain clear
fluid, being deeply imbedded in the substance of the  tumor; in other cases again,
they may be large and globular, and  filled  with a bloody or  dark-green  liquid.
The microscopial characters of scirrhus of the breast,  are such as are represented
in Fig. 98.
   Encephaloid  of the mammary gland  is by no means of such common occur-
rence as  scirrhus, but yet all the varieties of this form of cancer have been met
with in the breast, and the fungus haematodes has been seen to spring from the
bottom of cystoid growths previously  developed  in this region.  Encephaloid of
the breast may sometimes acquire a considerable size, thus, Cruveilhier relates a
case in which the tumor weighed nearly twelve pounds.   The structure of this
disease does not differ from that of the same affection in other situations; both
the hard and the soft varieties may be met with, and in some advanced cases the
true fungous growths occur.  Encephaloid usually begins deeply in the substance
of the breast,"as a soft  globular tumor, which rapidly increases in bulk;  the in-
teguments covering it are not at first  adherent, but are usually pushed before it,
and speedily  become  permeated  by  a largely ramified network of veins.  The
mass feels as if composed of several soft and rounded tumors,  which communicate
an obscurely fluctuating sensation, causing  perhaps the surgeon to mistake the
growth for a cystic formation, or an abscess.   The breast  now rapidly assumes a
very prominent and conical  form; the  skin  covering it at  its  most projecting
part becomes thinned and reddened, and at last gives way, leaving a large circu-
lar ulcer, from which a fungous mass  of  grayish or reddish-brown  color speedily
sprouts up, with a good deal  of discharge of a foul, bloody, and offensive charac-
ter.   From this, disintegrated masses are occasionally detached  by a kind of
slou"-hino- action, and cases may even occur in  which the whole of the fungous
protrusion  sloughs away, and cicatrization taking place, a tolerably perfect cure
may result.  These cases, however, are so rare,  as scarcely to influence our prog-
nosis of the necessarily fatal  character  of the affection.   Implication  of  the 
696
DISEASES  OF  THE  BREAST.
glandular structures in  the  vicinity of the tumor,  followed  by constitutional
cachexy, occurs  in  this as in true scirrhus of the  breast.  The progress of the
disease  is always extremely rapid,  more  particularly  in  young  and otherwise
healthy subjects.
   Colloid cancer and  melanosis of the breast occur  so rarely, and only in con-
nexion  with the other varieties of the disease,  that  they can  merely be looked
upon as presenting  points of pathological interest.
  The causes of cancer of the breast are usually of  an' extremely obscure cha-
racter.  The most marked circumstance that influences its occurrence is certainly
sex, it being, as is well known, almost entirely confined to women; yet instances
in which this affection is met with  in the male breast occasionally occur.  Its
peculiar frequency in the female may possibly be owing to the great and sudden
alternations of the  functional activity of  the breast in women.   The  changes
that are impressed upon this organ at puberty and during pregnancy, the various
alternations it undergoes, and inflammatory  affections to  which it  is subject
during  lactation, the frequent irritation to which it is exposed by sympathizing
with uterine derangement, and  the diminution  in its  vital activity  that takes
place at the change of life, are sufficient  to explain the  great liability of this
organ to disease generally; and  may not improbably give a clue to  the reason
why it is so peculiarly the seat of cancer in women.   The age at which cancer
of the breast most frequently occurs  is between the thirtieth and fiftieth year.
According to Birkett,  it is most commonly met with between  the ages of forty-
five  and fifty;  a period of, life that is popularly looked upon as specially obnox-
ious to this malady.   At these ages, cancer of the breast usually affects the form
of scirrhus.  When occurring, as it very  rarely does, in early life, under the
age of twenty, it more frequently assumes the encephaloid character.   In elderly
women, scirrhus also  is the prevalent form,  though I have seen two or three
instances of encephaloid at an advanced period of  life; one  case, in a woman
upwards of seventy years of age.  Indeed,  cancer, in  either form,  may affect this
organ up to the latest periods to which life is prolonged.   Married  women  are
said to be more  liable than single ones to cancer of the breast.   It may, however,
fairly be doubted whether they are porportionately so.  And it is a common belief,
founded, I believe,  in  some degree on truth, that the disease is most common in
those women who have not borne children.
   Injuries inflicted upon  the breast, such  as blows, squeezes, &c, are commonly
referred  to, and are greatly dreaded  by women,  as the causes of cancer.  That
they might be so in constitutions otherwise predisposed to the affection, does not
appear improbable,  and that they are so in reality, I have not the  least doubt.
The number of instances that have fallen  under my observation, in which a blow
or squeeze of the breast  has speedily been followed by the appearance of a can-
cerous tumor in it, leave  no doubt whatever on my mind of the  truth of the
popular belief that associates the injury with the disease, in the relation of cause
and effect.  Lacteal inflammations are likewise frequently supposed to tend to
the production of cancer of the breast.   Of this doctrine  I think  that we do not
possess at present sufficient proof, though it appears  to me highly probable that
disturbances of the functions of the organ during lactation may predispose to
the occurrence of this disease.
   The diagnosis of cancer of the breast, from other diseases affecting this organ,
is of the first importance, and is attended by  corresponding difficulties.  The
great point is to determine whether  the tumor of the  breast  is of a cancerous
character or not; beyond this it  matters little that the surgeon should go; and,
indeed, except in some of the forms of cystic disease of this organ, few practi-
tioners would feel disposed to endeavor to carry their diagnosis beyond this point.
The great  and essential difficulty in determining the nature of a tumor of the
breast consists in the fact of the same signs being  more or less common to many 
             DIAGNOSIS  OF  CANCER  OF THE BREAST.          697

growths in this region;  a hard, circumscribed, indolent mass, chronic in its pro-
gress, with a certain amount of  pain, being the usual characteristics presented
by all solid mammary tumors; and though in nine cases out  of ten, a tumor
presenting these characters, which has existed for a year or more, and has resisted
ordinary absorbent and alterative treatment  is of  a  scirrhous  character, yet
instances  of the reverse occasionally occur.   Nothing can better exemplify the
difficulty of diagnosis in tumors of the  breast, than the circumstance, which is
not unfrequently witnessed, that after the removal of the diseased mass, its sec-
tion, and  careful examination, surgeons of equal experience will differ as to
whether it is malignant or  not, and to what class of affections to refer it.  And,
indeed, in  many of these cases it is impossible to ascertain its precise nature with-
out having recourse to microscopical observation.
   It is  extremely difficult  to lay down  any definite rules of  diagnosis, by which
the question as to the malignancy of a tumor of  the breast can be solved.   In
the majority of cases of cystic growth in this region, there is little difficulty; the
existence of cysts of sufficient size to be readily felt or seen through the  skin,
being generally characteristic of the malignant cystic growths.  It must be borne
in mind,  however, that  cases, such as one  to which allusion has already  been
made,  may occur in  which cysts are conjoined with cancerous development.
   The diagnosis between cystic sarcoma and some forms of cancer of the breast
with large cysts, is not  always easy,  indeed may  be impracticable, and can only
be determined after  removal by microscopical examination.  I have lately had a
patient in  the hospital  fifty-nine years  of age, in  whose breast a  hard tumor, as
large as half an orange, had existed for five  years, it was  perfectly and freely
movable,  unconnected  in  any way with the skin, there was no retraction of the
nipple, and no lancinating pains.   On  its upper side, several large cysts could be
felt, and almost seen through the skin.   On examination after removal, it was
found  to be encysted scirrhus, with large cysts, the  size of cherries, containing
bloody  and yellow  fluid.   The  only very suspicious  circumstances here  were
 the age of the patient,  and the  existence of one  small  indurated gland in the
axilla.
Non-malignant Tumors.	Scirrhous Tumors.
Feel—Moderately bard, nodulated, irregular in shape, occasionally more or less lobed, not very distinctly circumscribed, some-times elastic in parts. Mobility is considerable, though occasionally there is a deep pedunculated attachment. Skin of the natural color throughout, though thinned and expanded, with the tumor lying close beneath it. Only implicated in the advanced stage of cystic sarcoma. Nipple usually not retracted. Veins of the skin not much dilated. Pain often moderate, if severe, continuous or of a neuralgic character, not much in-creased by handling. Axillary glands of usual size, or but slightly enlarged and movable. Lymphatics not affected; supra-clavicular glands not af-fected. No constitutional infection.	Feel of a stony hardness, knobby, and dis-tinctly circumscribed, or else somewhat square, occupying the whole of the sub-stance of the gland. Mobility at first considerable, but soon be-comes fixed to the deeper structures by a broad attachment. Skin becomes early implicated—at first dim-pled, then red or purple, and in other cases brawny and leather-like, so that it does not admit of being pinched up into folds. Nipple usually retracted. Veins of the skin very greatly dilated. Pain very severe and lancinating at times, especially at night after handling, and when the skin is implicated. Axillary glands much enlarged, indurated, and fixed. Indurated mass of lymphatics under and parallel to edge of the pectoral stretching into the axilla; supra-clavicular glands enlarged. Constitutional cachexy as disease advances.
  In these cases of doubt, the safer plan, perhaps, would be, to make an explo-
ratory puncture, and to examine under the microscope the contents withdrawn 
cos
DISEASES OF THE BREAST.
by the groove in the needle.  Between cancer, and the ordinary solid tumors of
the breast, the diagnosis is often extremely difficult, but wo may arrange the chief
signs of the two forms of disease in distinct  groups, when, by  comparing them
together, the differences may be more clearly seen.
   Treatment of cancer of the breast.—In cases of cancer of the breast, the first
question  that  presents itself to the surgeon, is whether any plan of treatment
short of the removal of the  tumor, holds out a prospect of cure, or  even of re-
lief; and if not, whether the extirpation of the cancerous breast can be under-
taken with  a prospect of  ridding the patient of an otherwise fatal disease; or at
least of prolonging her existence.   To these questions the remarks made at page
392, et seq., on the general treatment of cancer may be considered applicable.
The management of  cancer  of the breast, however,  involves  so many special
considerations  of importance that it becomes necessary to  consider its special
bearings somewhat in detail.
   No constitutional means appear to be of the slightest service  in arresting, and
still less in removing, cancerous tumors of the breast.   The advantages stated to
have been derived from the use of arsenic, conium, iron, and various preparations
of mercury, have not been borne out by experience; and indeed it may be stated
generally that  these and all other known remedies are perfectly valueless in the
curative treatment of this disease.
   Compression by various means, whether by plasters, as employed  by Young;
by agaric, as used by Becamier; by the spring-pads of Tanchou, or the slack
air-cushion of  Dr. Arnott, has been much  praised, not only as a palliative,  but
as a curative means of treatment in this disease; and cases are  recorded, which,
however, even  the  warmest  advocates of this plan of treatment are forced to
admit  to be altogether exceptional, in which the employment of  this means has
been stated to have effected a complete removal of the tumor.   But although I
am not prepared to deny that hard and chronic tumors of the  breast may have
become absorbed during the employment of this treatment; and indeed I have
had occasion to observe this in my own practice, in cases of chronic ina»imary
growth;  I  think that evidence is altogether wanting to show that an undoubted
case of cancer of the breast has ever been cured by this means.   And  notwith-
standing the high  authority with which some of  these alleged cases of cancer
have been brought before the profession, no positive proof has been  adduced to
show that the tumor that was observed was really and truly of a cancerous cha-
racter, and that it may not have  been either a chronic mammary tumor,  or an
encysted abscess of the breast.   Every practical surgeon well  knows that it is
utterly impossible in the  present state of science to diagnose in many cases with
complete certainty the true nature of a tumor of the breast, and must frequently
have witnessed cases  in which, after extirpation,  the morbid  growth has been
found  to be of a different character to what had originally been  supposed.  I am
acquainted with at  least  half a dozen cases in which some of  the most experi-
enced  surgeons, both in this country and in Paris, have amputated the breast,
for supposed scirrhus, when, after removal, it was found simply to have been the
seat of a chronic  abscess,  with  very dense walls.  And with regard  to hard,
chronic, and indolent tumors of the breast, few surgeons will  hazard a positive
diagnosis, as to whether  it  is of a scirrhous character  or not, until they have
actually seen a section of it.   And even then how often does it not happen that
men of equal  experience will differ in the  judgment they pronounce as  to its
nature.  For these reasons it is impossible not to receive with the utmost hesita-
tion the  cases of supposed cancer of the breast reported as cured by the advo-
cates of compression, and not to suspect that the cases recorded by these gentle-
men as instances of the  successful employment of this  plan of treatment, may
have  been other chronic tumors of the breast, than those of  a cancerous cha-
racter. 
OPERATION  IN  CANCER OF THE BREAST.          699
  But though I think that there is no evidence  before  the profession to prove
the utility of compression as a curative  agent in cancer of the  breast, I think
that when practised with Dr. Arnott's slack air-cushion, or Tanchou's spring-pad,
it  is of considerable value as a palliative  in  some of the earlier stages of this
disease;  when  it may undoubtedly occasionally  arrest its  progress for a time,
diminish the size of  the  swelling, and  lessen the violence of those attacks of
lancinating pain which are so distressing  to the patient.   In conjunction with
the pressure, much relief to suffering may be afforded by the use of belladonna
plasters,  or of atropine or aconite  inunctions,  together with  the  internal exhibi-
tion of conium.   In the advanced stages of the disease,  however, when the skin
is involved, the pressure is often unbearable,  increasing the pain, and acting as
a source  of irritation to the patient.  In some cases of this kind, in which the
slack  air-cushion could not  be borne, I have seen relief afforded  by moderate
pressure with thick layers of amadou, supported by an elastic  bandage, bella-
donna or conium in powder being  dusted on the  innermost  layer of amadou.  A
very thin gutta-percha shield, moulded  to the part, may sometimes be advanta-
geously applied over this, and kept on by turns of an elastic roller.   When the
disease has run into an ulcerated stage, the internal administration of conium, so
as to blunt  the sensibility, and the local application of chlorinated  lotions to lessen
the foetor,  together with the  application of the  watery  extract  of  opium, or of
belladonna are  of much use.    In  such cases as these, the application of caustics
or the preparations  of arsenic have been greatly va*mted, and occasionally por-
tions of the diseased  surface  may be cleansed or removed by these means; but
it  is seldom that the whole mass can be  thus got to slough away.
   The constitutional and ordinary local treatment of cancer of the  breast being
thus,  at  the most,  of a  palliative character, the  question of operation always
presents  itself  at last.   The  objects proposed by an operation are in the first
place, by the extirpation  of  the diseased  breast, to prevent constitutional infec-
tion, and thus permanently to free  the patient  from her necessarily fatal affection;
or, failing in this, to retard the progress of the constitutional infection, and  thus
at least to prolong existence.   How far these objects are attained by amputation
of the cancerous breast is a subject of important inquiry to the surgeon.   The
operation has of late  been discountenanced by many excellent pathologists; not
so much from any intrinsic danger it may  possess, for although occasionally fatal
from erysipelas or some similar accidental complication, there is nothing specially
hazardous about it; nor from  its being now, as formerly, open to  the objection of
subjecting  the patient to unnecessary pain, all suffering during  its  performance
being prevented by anaesthetics, and little inconvenience being  experienced at
subsequent dressings, which are usually of a nearly painless character; but the
great  objection  lies in the  fact  of  the disease, in  many  cases, returning with
equal, and  in others perhaps with greater rapidity after the  operation, than if
none had been  performed.
   The principal points in connexion with the operation appear to resolve  them-
selves into  two questions :—1st. Whether, in any cases of  cancer of the breast,
constitutional  infection may be prevented by amputation of that organ;  and if
so,  under  what  circumstances this  will  most  probably happen ?   And, 2dly.
Although the disease may eventually return in the part or  elsewhere, whether
excision  may not arrest the rapidity of the fatal termination ?
  In answer to the first  question, it  is  not  easy to  give a very definite  reply.
Nothing  shows more clearly the worthlessness of so-called surgical statistics than
the discrepancy that exists between those that have been published as exhibiting
the liability to a relapse of cancer after operation.  Thus, Hill states, that out
of 88  cancers on which he had operated at least  two years before the return was
made  there were only 10  relapses, and 2 deaths; whilst Alexander Munro states,
that out  of 60 cancers which  he had seen  removed, in only 4 patients was there 
700
DISEASES  OF  THE  BREAST.
no relapse at the end of the  second year.  Boyer only saved 1 in 25, and Mac-
farlane gives a still more unfavorable account of his practice; for  he says, that
out of 32 cases of cancer operated upon by himself, there was not  one  instance
of radical  cure;  and of 80 other cases that he was acquainted with, the result
was  in  every  instance  unfavorable.   Warren, on the other hand, saved 1  in
3 ;  and Cooper 1 in 4.   Amidst such conflicting statements  as these, it is clearly
impossible  to eliminate more than the general fact, which is well-known  to every
surgeon, that in a large number of the cases of cancer that are operated upon,
there is a tolerably speedy  return of the disease.   In these cases there are, how-
ever, many points to be taken  into  account, that  gross statistics  can  take  no
cognizance of;  much being necessarily dependent upon the skill with which the
operation is performed, as well as upon the care employed by the surgeon to cut
widely of the disease, and  to extirpate completely not only the whole of the
morbid mass, but those tissues in its neighborhood that might be supposed to  be
implicated.
  In many of the cases also,  it is by no means improbable that the practice,  at
one time pretty generally followed, may have been adopted, of merely extirpating
the tumor without removing  the whole of  the breast.   I am therefore disposed
to look upon  any deductions  based  upon  the statistics of such  men  as Hill,
Macfarlane, and Benedict as  of very little value when applied to the surgery  of
the present day.
  It would, however, appear from the result of those inquiries,  that in a certain
proportion  of cases, whatever the precise ratio be,  and this is still undetermined,
the disease may be effectually removed by extirpation of the breast.
  As to the second question,—whether as a general  rule life  may not  be pro-
longed by the performance of the operation,—it would appear, if the statistics
collected by Leroy D'Etiolles are accurate, that hitherto it  has not.  And Dr.
Walshe,  who has completely exhausted this question, comes to the conclusion
that the operation cannot as a general rule be regarded as a means of prolonging
life, but that in  the majority of  cases death is hastened  by such interference.
Sir A. Cooper and Sir B.  Brodie, both agree, that in the  majority of cases, the
disease returns in  two or three years after  the  operation,  and then kills the
patient.  Benedict amputated the breast for cancer in 98 cases, and  in 85  of
these, death was said to be hastened by the  operation.   Of Dr. Macfarkne's 32
cases, 2  terminated fatally from the immediate  effects of the operation, and
reproduction of the cancer  occurred in all the others, either  in  the integuments
of the chest, or in the axilla, within the following periods:  in 9 cases,  between
the sixth and twelfth week;  in 13, between the third and the ninth months;  in
4 between  the ninth and the twelfth months; in 3, about the second year; and
in 1, about the third year.   The very early occurrence of relapse, however, in  so
many of these cases, would almost lead to  the conclusion that sufficient care was
not taken in the operation to extirpate the whole of the diseased tissue.
  But though the general result of a statistical inquiry into this subject, based
upon the imperfect materials and probably very incorrect figures at present before
the profession, leads to the conclusion that operations  for cancer of the breast,
when indiscriminately  performed,  have  hitherto not only failed to cure the
disease, but actually in a great number of cases  hastened  its fatal  termination,
yet it must be borne in mind that instances do occur  in which life is certainly
prolonged  by this means considerably beyond its  average duration in cancer of
the breast.  Thus, i Callaway operated on a case in which  no return took place
for twenty-two years.  Yelpeau states that he has removed  encephaloid tumors
of the breast, and that the patient has remained free from the disease for eight
or ten years; and Sir B. Brodie and  other surgeons relate  similar instances  in
which the  patient's life has thus  been prolonged  after the  performance of the 
OPERATION IN CANCER  OF  THE  BREAST.           701
operation.  And  the experience of  the most eminent practical  surgeons is
decidedly in favor of having recourse to it under certain  circumstances.
  There is, however, another point  of view from which these operations may be
considered ; for even if they do not prolong  life, they may greatly improve the
patient's condition, and place her  in a state of comparative comfort during the
remainder of her existence.  Thus  she may be suffering so much  pain from the
local affection, or if it be ulcerated,  be so much affected by the fcetor of  the dis-
charges, that she may be placed in a position of far greater  comfort by having
the local source of disease and irritation removed; and though she  die eventually
of cancer, it may be with much less suffering to herself and others for her to be
carried  off by secondary deposits in the lungs or  liver,  than to be worn out by
the external affection.
  In considering the propriety of operating in cancer of the breast, it is of the
utmost  importance to determine those cases in which the operation may  possibly
be the means  of preserving or prolonging life, from those in which  there  is no
prospect of its being of any service, or in which indeed it must inevitably hasten
the patient's death.   Whatever the  value of statistics may be in determining the
question as to  whether in cases of cancer of  the breast generally, the operation
will effect a cure or prolong life, they are not equally valuable in their  applica-
tion to individual cases.   When a  surgeon is called for his  opinion respecting
the propriety of amputating the breast in the patient before him,  it is not suffi-
cient for him  to be  able  to state what  the general result of the  operation may
be, but he must be able to satisfy himself whether the particular instance under
consideration may not be one of those cases, exceptional perhaps, in which there
is a fair probability of the operation extirpating  the disease entirely from  the
system, or at  all events prolonging  the  patient's existence.   In order to do this
it is necessary to endeavor to lay down some rules that may guide us in selecting
those cases in  which the operation  may be advantageously done, and in setting
aside others in which we  know that it will almost to a  certainty  hasten the pa-
tient's death.   And indeed it is the absence of all  such considerations in general
statistical investigations into the results of  operation for cancer, that deprives
them of much of their value  as guides in actual practice.
   Though nothing can be more unsurgical or improper  than the  indiscriminate
extirpation of all cancerous  tumors of  the  breast from every patient who may
present herself in whatever  stage of the disease;  and though  such a  practice
would doubtless be followed by fully as disastrous  results as those  that occurred
to Macfarlane, Benedict, and others ; yet there can be little doubt  that a  surgeon
who would employ a certain principle of selection,  would obtain a very different
and a far more successful  result in  his practice.  Sir B. Brodie has very clearly
and succinctly pointed out the most important circumstances by which the ques-
tion as to the propriety of operating in these cases should be determined.  Before
doing so, he very justly dwells on the fact that in  many  cases the  operation may
fail, and the disease speedily recur through  the negligence  of the  surgeon in
leaving behind portions of the gland, slices of the tumor, or contaminated tissues,
and that thus the operation may receive  discredit,  for what is in reality the fault
of the surgeon who performed it.
  The cases in which no operative  interference should be undertaken, are those
of infiltrated  cancer of the mammary gland  in which the disease will probably
be found to be of a constitutional character;—those in which the skin is impli-
cated, being either tubercukted, brawny, tucked in or dimpled  by the adhesion
of a pedicle passing from the  tumor to it.  When the skin is brawny, the cancer-
germs are widely diffused  through it,  and, as  I have very distinctly seen in one
instance, will exist in contiguous portions of the integument that appeared per-
fectly healthy  to the naked eye.  So also when the integument is tubercukted,
or in any way attached to the tumor, it is impossible to say how far the cancerous 
702
DISEASES  OF  THE  BREAST.
 affection may extend  in  it, and an  operation would probably  be followed by
 speedy return.   In a case that I examined some  time since, in which a surgeon
 had removed a cancerous  tumor of the breast, involving a very small portion of
 the skin, and in which the neighboring parts had been widely cut away, cancer-
 cells were found at the very edge of the cut integument, which was to all appear-
 ance healthy; and the disease in this, as in the former case, rapidly returned in
 the cicatrix.  Then again if the axillary glands be enlarged, and still more so if
 those  above the clavicle are implicated, no operation should be performed, as it
 is  not only impossible  to  remove all  the diseased glands, but the general lym-
 phatic system will  probably be poisoned.   So also if the tumor be firmly fixed to
 subcutaneous structures, as to the pectoral  muscles and fat, it will be better not
 to  interfere, on  account of the extensive infiltration of these  parts with cancerous
 matter.   To these  cases in which the operation  should not be practised, others
 may be added.   Thus, if the tumor is recent—and more particularly if growing
 with much rapidity—it should not be  removed, as it will certainly speedily recur.
 Tanchou and Hervez de Chagoin have especially  pointed out  that as the disease
 becomes chronic, and has  a greater  tendency to localize itself, the operation pre-
 sents a better chance of success than in the earlier stage of increase.  Dr. Walshe,
 who has paid much attention to this subject, makes the following statements with
 regard  to cancers  generally, which appear to be so  specially applicable to this
 affection when seated in the breast, that I quote  the whole paragraph : " Of a
 given  number of cancerous individuals a considerably larger proportion will be
 saved from  untimely death under the influence of well devised and judiciously
 sustained treatment, aided, if this become necessary, by extirpation performed at
 a comparatively late  period, than will recover under  the influence of the opera-
 tion (unpreceded by methodized treatment) effected at the very earliest possible
 stage of local development."  Then again, if the  disease though of old standing
 have suddenly taken  on a  rapid increase, it would not be prudent to  extirpate
 the breast, for the  same reasons that would deter our doing so in a rapidly-grow-
 ing recent cancer.  If also it be largely ulcerated, it does not admit of extirpa-
 tion, as the surrounding skin would be implicated to a considerable extent. If
 it be of large size,  and  the  patient aged, weak, and  anemic, the  shock of the
 operation—as I have  more than once seen—may be fatal;  or death may speedily
 result from  erysipelas or some such cause.   Lastly, if both breasts be affected,
 all  operation is necessarily  contra-indicated, as should  also be the case if there be
 a very strong hereditary tendency to cancer.
  The exclusion of all the cases that fall under  the preceding categories will
 necessarily limit very materially those in which an operation  may be undertaken;
 it can, however, be performed with every prospect of its being advantageous to
 the patient, if the  tumor  be of moderate size, slow or nearly stationary in its
 growth, unconnected with  the  skin, pretty distinctly circumscribed,  and not
 complicated by enlarged glands  in the axilla or elsewhere.   The  patient has an
 especial good chance, according to Brodie, if the disease be seated in the nipple.
 In  all cases when  an operation  is undertaken, the whole of the breast should
 be removed, and the contiguous tissues pretty widely excised.  The integuments
 being loose  in this situation, readily come together even after considerable loss
 of substance.  When the tumor is pedicukted, only being attached to the gland
 at one point, some  surgeons  have recommended that it  alone should be extir-
 pated, the breast being left.   This practice, however, is not,  I  think, a very safe
 one; in two instances I have seen it followed by speedy relapse, and should cer-
tainly in future  always be  disposed to  extirpate the whole of the organ  in  this,
as in every case of cancer of the breast.
  Belapse of cancer after  operation may take place in two ways;  either in
the vicinity of  the part operated  upon, or  in some internal organ.   When
recurring in the neighborhood  of the previously affected part, it is  probably 
AMPUTATION  OF  THE  BREAST.
703
owing  to the  cancer-cells having diffused  themselves  so  widely into the  skin,
the subcutaneous cellular tissue and muscles, or neighboring lymphatic glands,
that after the removal of the tumor these cells become the germs of new growths.
Under these circumstances it may recur in the cicatrix and then implicate the
glands ; or, in  the glands without the cicatrix  having been previously affected.
In local relapse of this  kind, it  often  happens  that the disease so reproduced,
runs its course more rapidly than if no operation had been  done ; the increased
action set up in the part during the healing process appearing to give augmented
force to the reproductive energy of the cancerous growths.  In some cases it even
returns in  the  cicatrix before  cicatrization is completed, the ulcerated surface
then assuming the ordinary character  of the cancerous ulcer.  In  other  cases
some weeks or months after the cicatrix  is fully formed, it assumes a dusky
red  or purplish tinge, becoming hard, stony, and nodulated at points.  These
nodules being round or oval, often  very numerous, and varying in size from a
pin's head  to a pigeon's egg, studding the whole length and breadth  of the cica-
trix, and at last running into  true cancerous ulceration.   Under such circum-
stances as these the only hope of prolonging the patient's life lies in the speedy
excision of the whole of the diseased structures.

                      AMPUTATION OF THE  BREAST.
   The operation for the removal of a breast, whether affected with cancer or
other disease, may be  performed in the  following way:—The patient should lie
upon a table, with the arm hanging over the side, and held by an assistant.  If
the tumor be large,  and the loss of blood a matter of much consequence, another
assistant should compress  the  subclavian artery on the first rib.  If the  veins
about the part be much dilated, measures  should be taken to arrest the flow of
blood from them, as it  may sometimes be  dangerously profuse; indeed, South
relates the  case of  a  patient who died from this cause, during the operation.
A transverse elliptical incision, of sufficient length, should then be made, first
below, and next above, the nipple, so as to include a sufficient quantity of integu-
ment.   The dissection should then be rapidly carried down, by a few strokes of the
scalpel, to the pectoral muscle, and the breast removed from the  cellular bed in
which it lies.   The line of incision is best made  in a transverse  direction, so
that the outer angle, being the most dependent, will readily allow the  escape of
any fluids collecting in it.  After the  removal  of the diseased breast, it and the
tumor, as well as the whole interior of the wound, must be carefully examined,
in order to  ascertain that no slices of morbid  tissue have been left behind.  If
so, they must  be freely cut out; and if, as  sometimes happens, the growth  is
rather firmly adherent to the pectoral muscle, or subjacent structures, these  must
also be removed.   Should it be found that there  are any enlarged  glands in
the  axilla,  they may be  extirpated, either by extending the wound upwards in
this region, or by making a separate incision into the  axilla, and carefully dis-
secting them out.   In doing this, the  edge of the  scalpel should  be carefully
used, and the glands rather teased out with the  handle of  the knife and  a for-
ceps, so as  to avoid the hemorrhage, which is apt to be troublesome in this  situa-
tion.   After any bleeding vessels have been ligatured, the incision through which
the  breast  was taken out  may  be brought together by a  few points of suture,
and supported by a bandage, so as  to  prevent  bagging of matter.  In  many
cases it will unite by the first intention, for, owing to the yielding nature of the
parts in this situation, the lips of the cut  come into very good apposition, even
though a considerable mass have been  removed.  By some it has been supposed
that relapse or cancer is less liable to take place if  the wound unite by granula-
tion, than if it come together by more speedy union; of this, however, there is
at present no proof with which I am acquainted.
   The male breast, though very rarely the seat  of disease may  occasionally 
704
DISEASES OF THE ABDOMEN.
become affected in a somewhat  similar manner to the mammary gland  in  the
female; being, in some instances, hypertrophied, in others, the seat of an abnor-
mal secretion of milk, and, in other cases, affected by the  formation  of cysts,
encysted, and scirrhous tumors.  These growths  require removal  by the same
kind of operative procedure that is adopted when  they affect the female  breast,
though of a less extensive character.
               DISEASES  OF  THE  ABDOMEN.


                           CHAPTER  LII.

                                 HERNIA.

   By hernia, in its widest sense is meant the displacement of any organ from the
cavity in which it is naturally contained, by being protruded through an abnor-
mal or accidental opening in its  walls; when, however it escapes  through one
of the natural outlets of the part, it is not considered hernial.   Thus, the pro-
trusion of the brain through an aperture in the cranium, or of the lung, through
one in the  thoracic walls, or  of a portion  of intestine through the  abdominal
parietes, is termed a hernia of these organs; but the descent of the bowel through
the anus does not come under this  designation.   Here, however, we  have only
to consider the hernial protrusions  that occur  in the abdomen—the common
situation of this disease.
   A hernia may occur at  almost  any part  of the  abdominal wall, though it  is
far more liable to do so in some situations than  in others,  being commonly met
with  at these points where the muscular and tendinous structures are'weakened
to allow the passage of the spermatic cord in  the male, and of the round ligament in
the female; or for the transmission of the  large vessels to the lower extremity;
hence the inguinal and crural canals are the common situations of this disease.
It may, however, oCcur in various other situations, as at the umbilicus, the thy-
roid'foramen, the sciatic notch, in  the vagina, the  perineum,  through the muscular
portions of the abdominal wall, the diaphragm, &c.
  In whatever situation it occurs  a hernia is composed  of a sac and its contents.
The sac is  the prolongation of  that portion of the peritoneum which overlies and
corresponds to the aperture through which  the hernia  protrudes, and  is in all
cases composed of a neck and body.   The  neck  is usually narrowed, thou_h in
some old hernue it becomes wide and expanded;  it is commonly short, consisting
indeed of a sudden constriction of the sac in this situation, as  happens in many
forms of  femoral hernia; but in other cases it is  elongated,  narrowed, and thick-
ened, and even vascular in  its structure.   The  neck of the hernial sac usually
becomes greatly thickened, and of an opaque color, in  consequence of the depo-
sition of  plastic matter in or upon it, from the  irritation  to which it has been
subjected by the pressure of the hernial tumor or the truss, from  the  incorpora-
tion of the subserous cellular tissue that lies external to it, or  by the puckering
together of its^ folds which  have been compressed  by the  aperture in  which  it
lies.  Ihe  body of the sac varies greatly in shape and size, being usually globular
or pyriform, sometimes elongated  and cylindrical; it may vary from the size of a
cherry to a tumor as  large as the head.  When recent it is  usually thin  and
transparent  though in some cases it becomes greatly thickened, having arborescent
vessels ramifying on it, and being almost laminated in structure; this is especially 
STRUCTURE  OF  A  HERNIAL SAC.
705
the case in old femoral herniae.   In other instances, however, it becomes thinned
and atrophied as the tumor expands, so that the contents become visible through
it.   This is especially the case in old umbilical herniae, in  which I have seen it
as thin as the finest gold-beater's skin.   In some cases  the hernial sac undergoes
degeneration, becoming converted into a fibrous or even calcareous layer.
   The sac, though usually forming a perfect inclosure  to  the  hernial  contents,
occasionally constitutes but a  partial investment to them, more  particularly in
such organs as the coecum or bladder, which are naturally partially uncovered by
peritoneum.   In other instances again it may be ruptured, or altogether absent;
more rarely a double hernial sac is  met with, one being protruded into or placed
behind the other.  There are even instances of three sacs occurring together,  and
Sir A. Cooper relates a case in which six were met with in the same person.
   The abdominal  parietes outside  the  sac undergo important changes.   The
aperture through which the hernia protrudes usually becomes circular; after a
time,  indurated and rounded at the edge, and considerably enlarged;  when
situated in  the movable  portions  of  the  abdominal wall, as  in the inguinal
regions, it becomes displaced in old herniae, being dragged down  by  the weight
of the protrusion,  usually towards the mesial line.   The subserous cellular  tissue
always becomes greatly thickened, often  indurated and  fatty, so as to constitute
one of the densest investments of the sac, and in some old cases of hernia, closely
to resemble omentum.  The more superficial structures, such as the integument
and fascia, become much  elongated and stretched; often  tense, but  not unfre-
quently hanging in folds; they are usually thinned, but if a truss has been long
worn, become thickened and condensed by the pressure of the  pad.
   The  contents of the  sac vary  greatly, every viscus except tlm pancreas  and
stomach having been  found,  in  hernial tumors.   Most frequently a portion of the
small  intestine, more particularly  of the ileum,  is  protruded, constituting  the
form of hernia called enterocele.  The quantity of intestine within the sac may
vary from a small section of the calibre of the gut, the whole" diameter not  being
included, to a coil several feet in length, with its attached mesentery.  After a
portion of the intestine has  once  descended, the protruded part tends to increase
in quantity, until,  as in some large  and old hernia, the greater  portion has been
known to lie in the sac.  The large intestine is rarely found in a hernia, though
the coecum is occasionally met with.   When intestine has been long protruded, it
usually becomes thickened in  its coats, and  narrowed,  grayish  on the surface,
and  more  or less  deranged  in  its  functions.   The corresponding mesentery
becomes thickened, hypertrophied and vascular.
   Omentum is often found  in  hernial sacs, together with intestine,  but is  not
unfrequently met with alone;  constituting the disease called epiplocele.   After
having been protruded for some  time it becomes thickened, brawny and  lami-
nated,  losing its ordinary cellulo-adipose texture,  and becoming indurated.   Its
veins usually assume a somewhat  varicose condition, and the mass of omentum
acquires a triangular shape,  the apex  being upwards at  the abdominal aperture,
and the base below broad and expanded.  In some cases it can be unfolded, in
others it is matted together into a cylindrical mass.  Occasionally apertures form
in it, through which a coil of intestine may protrude, thus  becoming secondarily
strangulated within the sac.   In other instances  cysts are met with  in it con-
taining fluid;  or into which the intestine may even slip.  When intestine and
omentum together are found in a hernia, the disease is termed an entero-epiplocele,
and under these circumstances  the  omentum  usually descends before, and  occa-
sionally envelopes the intestine.   Besides these the ordinary contents of herniae,
the stomach, liver, spleen, sigmoid flexure of the colon,  bladder, uterus, and
ovaries, have all been found in them.
  Adhesions  commonly form within the sac in old standing cases.  These may
take place between the contained viscera merely, as between two coils of intestine,
                                     45 
706
HERNIA.
 or between these and the omentum ; or they may form between the wall of the sac
 and its contents, either by broad bands, or else  by bridging across from  one side
 to the other, and inclosing a portion of the viscera.   In recent cases these adhe-
 sions are soft, and may readily be broken down;  but when  of longer duration,
 they are  often very dense, and are especially firm about the neck of the sac.
    Besides the viscera, the hernial sac always contains a certain quantity of fluid
 secreted  by and lubricating its  interior.  In  most  cases this is in but small
 quantity, but in some instances, when the sac is inflamed, or the hernia strangu-
 lated, a very considerable bulk of liquid has  been  met with :  I have seen as
 much as  a pint escape from a large hernia in an old  man.  When  abundant, it
 is generally of a brownish color, though clear and transparent, and  is met with
 in largest quantities in inguinal herniae.  In some instances  this fluid becomes
 collected in a kind of cyst within the sac, formed by the omentum contracting
 adhesions to its upper part, and leaving space  below for the  fluid  to collect, in
 which this accumulates between  the omentum  above  and the wall of the  sac
 below; this condition, represented in the annexed figure (225), has been called
 hydrocele of the hernial sac, and   constitutes a  somewhat rare form of  disease.
 The fluid is often in considerable quantity; in a case in which I tapped  some
 years ago, nearly three pints of dark brown liquid had thus accumulated, and
 were drawn off.
   If we limit the term hydrocele of the hernial sac to those cases in which there
 is a slow  and gradual accumulation of fluid at the bottom of an old  hernial sac,
                       which  has been cut off from all communication with the
                       peritoneum  either by the radical cure of  the hernia, or
                       by the adhesion of  intestine  or omentum to the upper
                       part and neck of the sac, it naust be considered a disease
                       of unfrequent occurrence, and but few cases  are recorded
                       by surgical writers.  Mr. Curling, in  his work on the
                       Testis, states that during his connexion with  the London
                       Hospital, he has seen only one case, and the only others
                       with which I am acquainted are two related  by Pott, two
                 /y* by Pelletan, one by Boyer, and one by Lawrence.  This
                 '[    disease must not be  confounded with the accumulation
                       of fluid, in whatever quantity, in strangulated hernia or
                       in hernial sacs  that communicate  with the peritoneal
                       cavity.   Its distinguishing feature is the accumulation
                       of fluid in a sac that has been cut off  from  all commu-
                      nication with the cavity of the peritoneum.
   The symptoms of hernia, though varying considerably according to  the contents
of the sac and the condition in which it is placed, present  in all  cases many
points in common.  Thus there is an elongated or rounded tumor at one of the
usual abdominal apertures, broader below than above,  where it is often narrowed
into a kind  of neck;  usually increasing in size  if the patient  stands, holds his
breath coughs, or makes much muscular exertion.  It can be pushed back into
the abdomen on pressure,  or goes back readily if the patient lies down, but  reap-
pears when  he stands up.  On coughing, a strong and distinct impulse  maybe
felt in it.                                                       r        J
   When the hernia is altogether  intestinal, it is usually smooth, gurglin^ when
pressed upon, and sometimes tympanitic and rumbling.  It may be returned into
the cavity of the abdomen with a  distinct slip and gurgle, it has a well-marked
impulse on coughing and is usually accompanied by various dyspeptic symptoms,
and often  with a good deal of dragging uneasiness.
•  Th„ 0ine,ntal hernia is usually soft and doughy, returning slowly  on pressure
into the abdomen, feeling irregular on the surface, and having an ill-defined out-
line.  It occurs most frequently on the left side, and is rare in infants, in whom
 
CAUSES  OF HERNIA.
707
the omentum  is short.  In entero-epiplocele  there  is a combination of the two
conditions and their signs; but these are usually so uncertain, that few surgeons
care to predict before opening the sac what the probable nature of the contents
may be.
   Ccecal hernia necessarily only occurs on the right side.  It is a  large, knobby,
and irregular tumor, irreducible, owing to the adhesions contracted by that portion
of coecum which is uncovered by peritoneum-   The peculiarity of these herniae
consists in the sac being  absent, or only partial in  the majority of cases, owing
to the peritoneum stripping off as the gut descends.   When  these  herniae are
large, and thus partially invested by serous membrane, a sac usually exists at their
upper aspect, into which a portion of small intestine  may fall, and which  may
in some cases constitute  a second  hernia  lying above  or before the ccecal  one,
which will be found situated at the  posterior wall when this  hernial pouch is
opened.   Occasionally the vermiform  appendix and the caput-coli are found in
the sac, but can  rarely be  returned. The rule of ccecal hernia only having a partial
 peritoneal investment, does not hold good  in all cases; and  instances have  occa-
 sionally been met with in which this portion of intestine lay in a distinct sac.
   Hernia of  the bladder or cystocele is of very rare occurrence;  and like  that
 of the coecum, is usually enclosed  in a partial peritoneal investment, though it is
 not necessarily so.  South states that there is  a preparation at St.  Thomas's Hos-
 pital, in which the fundus of the bladder, with its peritoneal covering, has passed
 into a distinct sac.  In some instances the  cystocele is accompanied by an entero-
 cele.  These herniae are  always irreducible, are attended by a  good deal of diffi-
 culty in urinating, with varying tensions, according to the quantity of fluid they
 contain; by squeezing them, urine may be forced out  through the urethra, and
 fluctuation has  been felt in them.  Urinary calculi have been formed in  these
 tumors, and have been removed by incision through the scrotum, or  have  ulce-
 rated out.
    The causes of hernia are usually sufficiently well marked.  In some instances
 the  disease is  congenital, arising from preternatural patency of the abdominal
 apertures ; in other  cases again, it occurs at a later period of life,  in consequence
 of some forcible effort, as in lifting a heavy weight, jumping, coughing, straining
 at stool, or in passing water through a tight stricture.  It is especially apt to
 occur from such causes as these  in tall and delicate people, more particularly in
 those who have got a natural disposition  to weakness, or bulging of the groins.
 The displacement of the  abdominal viscera by a gravid uterus, will also occasion-
 ally give rise to the  disease.   Hernia is  especially apt to occur from a combina-
 tion of causes; thus if an aged person, one with a feeble organization, or whose
 abdominal apertures have been patented in consequence of rather sudden ema-
 ciation, makes  a violent effort, a hernial protrusion is very apt to  occur.
    Amongst the most  frequent predisposing  causes of hernia are certainly sex
 age, and  occupation.  Men are far more liable to this disease than women.  Thus,
 according to  Malgaigne,  in France one man in thirteen and one woman  in fifty-
 two, are the subjects of  hernia,   But, though men are more generally liable  to ,
 hernia than women, they are less so to certain forms of the disease, especially  to
 the femoral and umbilical.  It is to the inguinal that they are particularly subject,
 although old women very commonly suffer  from this form.  According to Mr.
 Lawrence,  out of  83,584 patients  who  applied to the City of London  Truss
 Society,  67,798 were  males, and  15,786 females; for the interesting statistical
 account  of the relative  frequency of  the different kinds of rupture, deduced
 from the foregoing figures, I would refer to Mr. Lawrence's most excellent Trea-
 tise on Hernia, 5th ed. p. 11.                                               .
    A«_ exercises a very  material  influence upon the frequency of hernia.   Mal-
 gaigne, who  has carefully  investigated this subject, finds that  in  infancy the
 disease is  sufficiently common, owing to the prevalence of congenital hernia at 
70S
HERNIA.
 this period of life; and that in the first year after birth hernia occurs in the pro-
 portion of 1 in  every 21 children.   It then goes  on decreasing in frequency,
 there being 1 in 29 at the second year;  1 in 37 at the third year;  until, at the
 thirteenth year, it has fallen to 1 in 77.  Shortly after this, its frequency begins
 to rise again, and  then goes on progressively increasing until the  close of life;
 thus, at the 21st year, there is one case in 32 ;  at the 28th year,  1 in 21; at the
 35th, 1 in 17 ;  at the 40th, 1 in 9;  at 50, 1 in 6; from 60 to 70,  1 in 4;  and
 from  70 to 75, 1 in 3.   In  women, hernia most frequently occurs from  the 20th
 to the 50th years.   Those occupations in which the individual is exposed to vio-
 lent muscular efforts, more  particularly of an intermitting character, predispose
 strongly to the occurrence of hernia, and in these employments the  tendency to
 the disease is often greatly increased by the injurious habit of wearing tight girths
 or belts round the waist, which, by constricting the abdomen, throw the whole
 pressure of the abdominal contents upon the inguinal regions.
    The conditions in which  a hernia may be found, are  very various, and entail
 corresponding differences in the result and treatment of the  affection.  When
 first formed, most herniae may be said to be incomplete, being for a time retained
 within the orifice of the canal through which they eventually protrude; when
 they have got altogether beyond  the abdominal walls, they are said to be com-
 plete,  and  this is the condition in  which they are usually presented to  the sur-
 geon.
    A  hernia  is  commonly at first reducible, that is  to  say, it may readily be
 pushed back into the cavity of the abdomen, protruding  again when the patient
 stands up, holds his breath, or makes any exertion, and having a distinct and
 forcible impulse on coughing.  Though the hernial contents, in these cases, are
 reduced into the abdomen, the sac is not; it almost immediately  contracts adhe-
 sions to the cellular tissue, by which it is firmly fixed in its new situation, though
 in some particular cases,  as we shall hereafter see, it may be pushed back.
    In the treatment of a  reducible hernia,  our object is  by the application of a
 proper truss, to retain the protrusion within the  cavity of the  abdomen.  In
 order to do this, the  patient must be provided with a proper kind of truss, adapted
 to the particular  nature of the hernia.  Amongst the best are, I  think, Salmon
 and Odys', or Tod's, for inguinal hernia, and the Mocmain for the femoral.  In
 umbilical and ventral ruptures, an elastic pad and belt may most conveniently be
 used.   In selecting these trusses, care should  be  taken that  the  spring is of
 proper strength,  adapted to the size and power of the individual, and that it be
 properly shaped, so  that  it  does not  touch any  part of the abdominal wall, but
 merely bears upon the points of pressure and counter-pressure.  The pad should
 be convex, and firmly stuffed, and  of sufficient  size to press not  only upon the
 external aperture, but upon the whole length of the canal.  Before applying the
 truss,  the hernia  must be reduced, by placing the patient in the recumbent posi-
 tion, relaxing the muscles by bending the thigh upon the abdomen, and pressing
 the tumor back in the proper direction; the truss should then  be  put on, and be
 worn during the  whole of the day; indeed, the patient should never be allowed
 to stand without  wearing it.   At night, it may either be  left off altogether, or a
 lighter one applied.   In  some cases the skin becomes irritated by  the pressure
 of the pad;  under these circumstances, an elastic  air-cushion  may be used, or
 the parts subjected to pressure may be well washed  with  spirit lotion. The truss
 may be known to fit by testing it in the following way.   The patient should be
 made to sit down on  the  edge of a chair, and then  extending  his legs,  opening
 them widely, and bending the body forwards, cough several times.   If  the her-
 nia do not slip down behind  the pad on this trial, we may be sure that the truss
 is an efficient one, and will keep the rupture up under all ordinary circumstances.
   Various means have been  contrived in order to effect a radical  cure of a redu-
cible hernia, an endeavor being made to accomplish the object sought by obli- 
IRREDUCIBLE HERNIA.
709
terating the sac, or closing the aperture that allows  the  escape of the hernial
protrusion.  If the accomplishment of these conditions would always prevent the
recurrence of the rupture, the radical cure might under certain circumstances be
undertaken.  But it is impossible  to look upon the closure of the abdominal
aperture, or the agglutination of the walls of the sac, as the sole conditions
required.   To accomplish this, it would be necessary to  effect changes in the
shape and connexions of the abdominal contents, to alter the size  of the  abdo-
minal cavity, and indeed to modify in various ways many conditions independently
of those immediately connected with the hernial protrusion.  Many of the means
of radical  cure,  such as those in which obliteration  of the  interior of the sac or
its neck is sought to be effected by the application of sutures, or of ligatures, the
introduction of caustics, its  excision, scarification,  puncture,  or injection  with
tincture of iodine, are attended with so much danger from peritonitis, and so
seldom by any good results, that their consideration  need not detain  us here.
The same remark applies to the attempt to obliterate the canal through which
the hernia protrudes, by invaginating and stitching into it a portion of the neigh-
boring integument,  which operation, though much cried up, especially by some
of the continental surgeons, who have practised it, has been found very seldom
to be attended by any permanently  beneficial results;  the invaginated portion of
tissue, commonly undergoing a kind of cellular transformation,  and  speedily
yielding  to  the  outward pressure  of the viscera, allowing reproduction of the
hernia to take  place.  The only means of radically curing a  hernia, that is at
the same time safe and permanently successful, is by the  compression of a well-
made truss-pad.   In this way it not unfrequently  happens that  the herniae of
infants become  radically cured; the same result however seldom occurs at a more
advanced period of life.  In order that compression should succeed in  this way,
it is necessary that  it should not only be  applied  to the  external aperture
through  which the rupture  escapes, but  to  the whole of the canal.   It must
also be continued for a very considerable time, for at least a  year or two, and
care should be  taken that during the treatment the  rupture  is not allowed to
descend.  Every time it comes down, any good  that  may have been derived is
necessarily done away with, and the  treatment  has  to begin, as  it were, anew.
After the cure is supposed to have been effected in this way,  the application of
the truss must be continued for a very considerable length of time, lest by any
unfortunate movement the rupture descend again.
   Irreducible herniae are usually of old date, and  large size.  They generally
contain a considerable quantity of thickened omentum, as  well as  intestine and
mesentery.  In many instances, a  rupture of this kind is partly reducible, the
greater portion remaining behind.   It is usually the gut which slips up, and the
omentum that cannot be returned.   The irreducibility of a rupture, may either
be owing to its  shape, to the existence of adhesions, or be dependent on its very
nature.   If the  sac become  the seat of an  hour-glass contraction, or its neck
become elongated and narrowed, the hernial contents may continue permanently
protruding.   So also the expanded  condition of  the lower part of the omentum,
and the narrowing of its neck may prevent a return of the rupture.  The  exis-
tence of adhesions, either betwen the sac and its contents, or between protruded
intestine and omentum, will commonly render  a hernia irreducible; and  most
frequently these are associated with changes in the shape of the sac or the omen-
tum.   Hernia of the coecum and bladder can  never be returned, on account of
the anatomical conditions to which  reference has already been made.
   An  irreducible hernia is  usually a source of great inconvenience;  it has a
tendency to increase if left to itself, until at last it may contain, as in some ex-
treme cases it has been found to do, the greater portion of the abdominal viscera,
forming an enormous tumor, inconvenient by its size and  weight, in which the
penis and scrotum are buried.  Even when the irreducible hernia is of small 
710
HERNIA.
size, it gives rise to a sensation of weakness in the part, with dragging pains, and
is very frequently accompanied by colicky sensations and dyspeptic derangements.
The patient also, under these  circumstances, is in a state of considerable^ danger,
lest the rupture becomes strangulated by violent efforts, or injured and inflamed
by blows.   For these reasons,'it is necessary not only to protect a rupture of this
kind from external  violence,  but to endeavor  to prevent  its increase in size.
This  may best be done by letting the patient wear a truss with a large concave
pad, which supports and protects it provided the rupture  be not of too great a
size for the application  of  such  an  instrument.   If its magnitude be very con-
siderable, it must be supported by means of a suspensory bandage.  Mr. Bransby
Cooper has recommended that an  attempt should  be made to convert the irre-
ducible into a reducible hernia, by keeping the patient in bed for several weeks,
on low diet, with the continued application of ice to  the tumor; and if it contain
much omentum, giving small  doses of blue pill and tartar emetic, so as to promote
the absorption of the fat.   This plan, which appears to have  answered well in
some cases, certainly deserves a further trial.
   The occurrence of inflammation  in an  irreducible hernia is a serious com-
plication, and one that simulates strangulation very closely.  When this complica-
tion occurs the  part becomes swollen,  hot, tender, and painful.  There is not
much tension  in the tumor,  which is seldom increased beyond its usual magni-
tude ; there is a good deal  of pyrexia, and symptoms of peritonitis  spreading
from  the vicinity of the inflamed rupture set in.  In  some cases there is vomiting,
but it is not constant, and never feculent, occurring generally early in the disease,
and consisting principally of the contents  of the  stomach, being apparently an
effort of nature  to get rid of an indigestible meal.   If there is constipation, as
usually happens in all cases of peritonitis,  it is not complete, flatus occasionally
passing per  anum,  together  with  a small  quantity  of fluid fteces.   It  is of
importance in these  cases to observe that the inflammation commences in the
body  of the sac, and extends into those parts of the abdomen that are contiguous
to its neck; the stomach and  intestinal derangements being secondary to this con-
dition.  The treatment of an irreducible hernia must be directed to the peritonitis
which attends it; the application of leeches  to the  sac  and  its neck, the free
administration  of calomel and opium, the  employment  of  enemata, with  strict
antiphlogistic regimen  and rest, will  usually speedily subdue all  inflammatory
action.
   An irreducible hernia occasionally becomes obstructed, then constituting the
condition termed incarcerated hernia.   This condition principally occurs in old
people, by the accumulation of flatus, or of undigested matters, such  as cherry
stones or mustard seeds, in an angle  of the gut,  In these cases there is con-
stipation, with eructation, and perhaps occasional vomiting.   There may be some
degree of pain, weight, or uneasiness about the tumor, but there is  no tension in
it or  its  neck, and the symptoms  altogether  are  of a  chronic and  subacute
character.  The treatment of such a case  as this should consist in the administra-
tion of a good purgative injection ;  the  compound colocynth  enema is the best,
thrown up as  high as possible  by  means of a long tube.   Ice  may then be
applied to the tumor for about half an hour, and then the taxis, as will im-
mediately be described, may be used under chloroform.  The ice maybe omitted
in those cases in which, on  handling the tumor,  gurgling  can readily be felt;
but the  taxis  should always  be used, as by it the  incarcerated gut may be
partially emptied of its contents; or if any additional protrusion  should have
happened to have slipped down, this may be returned.  After these means have
been employed, an active purgative,  either  of calomel or croton oil and colocynth
should be administered, and if any inflammation ensue, this must be treated as
already described. 
              STRANGULATION — SEAT OF  STRICTURE.           711


                         STRANGULATED HERNIA.

  A hernia is said to be strangulated when a portion of gut or omentum that is
protruded, is  so tightly constricted that it cannot be returned into the abdomen;
having its functions arrested, and if not relieved speedily, running into gangrene.
This condition may occur at all periods of life, being met with in infants a few
days old, and in centenarians.  It  commonly arises from a sudden violent effort
by which a  fresh  portion  of intestine  is  forcibly protruded into  a previously
existing hernia, which  it distends to  such a degree as to produce this strangula-
tion.  But though old  herniae are more subject to  this condition  than  recent
ones, it may  occur at  the  very first formation  of a hernial swelling, the gut
becoming strangled as it is protruded.   There are therefore  two distinct kinds
of strangulation.   One which may be said  to be of a passive kind, chiefly occur-
ring in elderly people,  the subjects of old and perhaps irreducible herniae, which
in consequence of some accidental circumstance become distended by the descent
of a larger portion of intestine than usual, and this, undergoing constriction and
compression at the neck of the sac, gradually becomes strangulated.   The other
kind of strangulation chiefly occurs in younger individuals ; in it the symptoms
are of a more active character, the bowel becoming protruded in consequence  of
violent exertion, and undergoing rapid strangulation, the  tension  of the parts
not  having   been  lessened by the  previous long  existence of an  irreducible
hernia,
   The mechanism of strangulation may  be attributed either to  a spasmodic
action of the walls of the aperture through which the  hernia protrudes, or else
considered as dependent  on changes taking place  in the protruded parts, sub-
sequent to and occasioned by their constriction by the tissues external to them.
The strangulation cannot, I think, ever be regarded as of a spasmodic character,
the  aperture in the  abdominal  wall, through which the hernia escapes, being
tendinous, or fibrous, and certainly not in  any way contractile, though the action
of the abdominal muscles may undoubtedly increase the tension  of its sides; the
continued and permanent character  of this strangulation, when once it has taken
place, would  also discountenance this opinion;  those forms of hernia, indeed,  as
the  ventral, which occur in purely muscular structures being very rarely strangu-
lated, and when they are so, the constriction being generally occasioned  by the
formation of dense  adventitious bands upon or within the sac, and not by any
muscular agency.
   Strangulation certainly appears in all cases to  be the result of congestion  of
the  protruded parts, induced  by the constriction  to which they are  subjected;
the  mechanism being as follows :—A knuckle of intestine, or bit of omentum is
suddenly protruded during an effort of some kind.  This  immediately becomes
compressed by the sides of the narrow aperture through which  it has  escaped;
the  return of its venous blood is consequently interfered with, and swelling and
oedema rapidly ensue, together with stagnation of the  blood in  it.   If the con-
 striction be  excessively'tight, the walls of the ring being very hard and sharp,
the  part that is so strangulated may be deprived of its vitality in the course of a
 few hours.   If the  strangulation be less severe, the  congestion will  run into
 inflammation, the changes characteristic of this condition  speedily supervening.
 In proportion as the congestion augments, and the  inflammation comes on, the
 return of the protruded parts is necessarily rendered more difficult by the increase
 of their swelling.
   The stricture is most commonly situated outside the neck of the sac in the ten-
 dinous or ligamentous structures surrounding it; not unfrequently in the altered
 and thickened  subserous cellular tissue.   In other cases again, and indeed with
 great frequency, it is met with in the neck of  the sac itself, which is narrowed,
elongated, and tubular; or constricted by bands that  are incorporated with it. 
712
STRANGULATED  HERNIA.
 More rarely it exists in the body of the sac, which may have assumed an hour-
 glass shape.  In some cases it would appear as if this particular shape were owing
 to an old hernia having  been pushed down by a recent one  above it.  The
 stricture is sometimes, though by no means frequently, met  with inside the sac,
 consisting of bands of adhesions  stretching across this, or  in the indurated  edge
 of an aperture of the omentum, through which  a portion of  the gut has slipped.
   The changes induced in the strangulated parts result from the pressure of the
 stricture  and the consequent interference  with the  circulation  through them.
 If the strangulation is acute, that  portion  of intestine which lies immediately
 under the stricture will be seen to be nipped or marked by a deep sulcus, which
 is occasioned partly by the pressure to which  it has  been  subjected, and partly
 by the swelling  up of the congested tissues beyond it.   The changes that  take
 place in  the protruded intestine rapidly increase in proportion to the length of
 the continuance of the strangulation.   The tightness  of  the stricture and the
 acuteness of the  strangulation have, however, more to do with these changes than
 even the time that it has  lasted.   I have seen the bowel so  tightly nipped that,
 though the strangulation  had only existed eight hours when the operation  was
 performed, the vitality was lost in the  part  constricted (Fig.  229).  And in other
 cases I have known the strangulation to have  lasted for five days before the  ope-
 ration was performed and yet the part recover itself.
   The first change that takes place in the protruded  parts in a case of strangu-
 lated hernia is  their  congestion;  this rapidly runs on  to inflammation,  and
 speedily  terminates in gangrene.   The protruded bowel becomes, at first, of a
 claret, maroon, or purplish-brown color,  sometimes ecchymosed on the surface,
 with thickening and stiffening of its coats, owing to effusion into their substance;
 some liquid is also usually poured  out into its  interior.  In this stage, that of
 congestion, the omentum will also be found  with its veins a good  deal congested.
 When inflammation has set in, the bowel preserves the same color as  in the con-
 gested condition, but usually becomes coated here and there with flakes of lymph,
 which give it a rough and villous look; the omentum has a somewhat rosy tinge,
 and there is usually a good deal of reddish fluid poured out into the sac.   When
 gangrene occurs, the bowel loses its lustre and polish, becoming of an ashy gray,
 or dull black color, soft and somewhat  lacerable, so that its coats readily separate
 from one another; the serous membrane especially peeling  off.  The omentum is
 dark purplish or of a kind of dull yellowish gray, and there is usually a consi-
 derable quantity of dark,  turbid serum in the sac, the whole contents of which
 are extremely offensive.   Most usually when  gangrene occurs  in  a strangulated
 rupture,  inflammation of the sac and its coverings takes place, accompanied after
 a time, by a reddish-blue  or congested appearance and some tenderness on pres-
 sure, and if  the part is  left unreduced, eventually  emphysematous . crackling.
 If the case  is left without  being relieved, gangrene of the skin will at  last
 take place, the sac giving way and the fecal matters being  discharged through
 the softened and  disintegrated tissues.   Under such circumstances as these,
 which, however, are  very  rarely  met  with  at the  present  day,  the  patient
 usually eventually  dies of  low peritonitis by extension of the  inflammation to the
 serous membrane.   No effusion, however, of feculent matter will take place  into
 the peritoneal cavity even  under  such unfavorable conditions.   The  portion of
bowel immediately within the stricture becoming adherent by plastic matter to
this on its external surface;  and  thus  the escape of any extravasation into the
 cavity of  the abdomen being prevented.   It does not always follow that there is
any external  evidence of  the occurrence of gangrene  within  the sac; and  the
bowel is  frequently nipped to such an extent as  to prevent its regaining its vita-
lity without any  unusual condition being presented  until the sac  is actually laid
open and  the intestine examined.
   In  the more advanced  cases of  strangulated hernia,  the  peritoneum  always 
   SYMPTOMS AND DIAGNOSIS  OF  STRANGULATED HERNIA. 713

becomes inflamed, usually to a considerable extent, the disease affecting a diffuse
form, accompanied by the effusion of turbid serum, often  of  a very acrid and
irritating  character,  and mixed with  flakes of lymph, sometimes to such  an
extent as to give it a truly puriform appearance.   This  glutinous lymph  mats
together contiguous coils of intestine, often appearing to be smeared over them
like so much melted  butter.
  The symptoms of  strangulation are of two kinds; as they affect the  tumor,
and as they influence the constitution  generally.   The tumor, if the hernia  be
an old one, will be found increased in size, or may appear for the first time when
actually strangulated.  It will generally be found to be hard, tense, and rounded,
more particularly if it be an enterocele.   When the hernia  is in a great measure
omental, it is, however, not unfrequently soft and doughy,  though strangulated.
It seldom increases in size  after strangulation has occurred,  as no fresh protrusion
can take place below the stricture, but I have known it to be greatly augmented in
bulk after the strangulation had existed for some hours, by  the effusion of serum
into the sac.  If the hernia have previously been reducible, it can no longer be
put back and there is no impulse in it, or increase  in its size  on coughing, the
stricture preventing the transmission of the shock to the contents  of the tumor;
and in this way, as pointed out by Mr. Luke, the situation of the constriction may
sometimes be ascertained by observing  at what point the impulse ceases.
  So soon as the strangulation has occurred,  the patient  becomes uneasy and
restless.   If the constriction be of an  active character,  he will be seized  with
acute pain in the part, which speedily extends to the contiguous  portion of the
abdomen,  assuming the characters of peritoneal  inflammation.  The first thing
that  happens when intestine is strangulated, whether a large coil  be constricted,
or a small portion only of  the diameter of the gut be nipped, is an arrest of the
peristaltic movement of the part implicated, the occurrence of obstruction to the
onward course of the intestinal contents, followed by constipation, vomiting, and
colicky pains.  The  constipation  is always  complete, neither faeces  nor flatus
passing through ; the bowels may sometimes act once after  the strangulation has
occurred from that portion which lies below the seat of constriction,  but  they
cannot, of course, empty themselves thoroughly, or from above the strangled part.
Vomiting usually sets in early, and is often of a very severe and continuous cha-
racter, with much retching and straining; at first consisting  of the  contents of the
stomach, with some bilious matters, but afterwards becoming feculent,  or sterco-
raceous, owing to inversed peristaltic action  extending as  far down as the con-
stricted part of the gut.  These symptoms are attended by  colicky and dragging
pains about the navel.  They are more severe in their character when the strangu-
lation is acute and  the hernia is intestinal, than when it is  passive, and the rup-
ture omental.   They occur equally in the incomplete as in the  complete forms of
the disease ;  indeed, it not unfrequently happens that the hernial tumor may be
so small as to have escaped observation;  the occurrence of the above symptoms
being  the first indication  of the probable nature of the mischief.  Hence, it is
well  always to examine for hernia when called to a patient suddenly seized with
constipation, vomiting, and colicky pains, even if told that no tumor exists.
  After the strangulation has existed  for some time, the  inflammation that  oc-
curs in the sac extends to the  contiguous peritoneum, accompanied by the ordi-
nary signs of peritonitis, such as tension of the abdominal muscles, tenderness,
with lancinating pains about the abdomen, and tympanitis.   The  patient lies on
his back with the knees drawn up, has a small, hard, quick, and  perhaps inter-
mittent pulse, a dry  tongue, which speedily becomes brown, and a pale, anxious,
and dragged countenance, with a good  deal of heat of skin, and inflammatory
fever.  In some cases, this is of a sthenic type, but, in the  majority of instances,
especially in feeble subjects, it assumes the irritative form.   AVhen gangrene of
the rupture takes place, hiccup usually comes on, with sudden cessation of pain 
714
STRANGULATED  HERNIA.
  in the tumor, an intermittent pulse, cold sweats, pallor, anxiety, rapid sinking of
  the vital powers, usually with slight delirium, and speedy death.
     Strangulated hernia requires to be diagnosed—
     1st. From an obstructed irreducible hernia.   In this there are no acute symp-
  toms, and the rupture will generally be found to be a large one of old standing.
  It may become somewhat tense and swollen,  but is not  tender to the touch, and
  always presents a certain degree of impulse  on coughing.  There is no sign of
  peritonitis.  There may be constipation, but  there is no vomiting, or if there be
  any, it is simply of a mucous and bilious character, consisting of the contents of
  the stomach.  The speedy restoration of the intestinal  action, by the treatment
  already indicated as proper in these cases, will remove any doubt as to the nature
  of the affection.
     2dly. From an inflamed irreducible hernia.   Here there is great tenderness
  and pain in the tumor, with pyrexia, and some general peritonitis, but there is
  no vomiting;  or if the patient  have vomited once  or twice, he does not continue
  to do so with that degree of violence, or in the same quantity, as he would if the
  peritonitis were the result of strangulation.   Then again, the constipation is not
  absolute and entire, but flatus and liquid faeces will usually pass.
     3dly. From general peritonitis conjoined with hernia, the diagnosis is often
  extremely difficult, more especially if the hernia be an irreducible one.   In these
  cases, however, it will be observed that the peritonitis may be most intense at a
  distance  from  the  sac;  that there will be little or no vomiting, or if there be,
  that it is simply of mucus, and the contents of the stomach;  and that the con-
  stipation is by no means obstinate or insurmountable by ordinary means.
     4thly. In the case of  double hernia, one tumor may be strangulated and the
  other not,  though  irreducible.   Under these circumstances it may at  first be a
  little difficult to determine which one is the seat of constriction.   This, however,
  may be ascertained, as in a case that was lately under my care at the Hospital,
  by observing greater tension and tenderness about the neck of  the strangulated
  than of the unconstricted one.  Besides these various conditions of hernia, which
  may be confounded with  strangulation, there are other tumors which may likewise
  be mistaken for this disease, but these we shall  have to consider when  speaking
  of the special forms of hernia.
     The treatment of strangulated hernia, is  one of the most important subjects
  in surgery.  The object  sought to be accomplished is the reduction of the stran-
  gulated gut, or the  removal of the stricture;  and afterwards the treatment of the
  peritonitis. The  reduction of the  hernia is effected by the  employment of the
  taxis, by which is meant the various  manual procedures employed in putting
  the rupture back.   The  taxis,  when  properly performed, is seldom attended  by
  any serious consequences to the patient.  I have never known it followed  by
  death, and out of  293 cases of hernia reported  by Mr. Luke, as having been
  reduced by the taxis in the London Hospital, none died.  It is not unfrequently
  followed,  however, by rather a sharp attack of peritonitis, which might probably,
  in some instances, prove  fatal; in one instance I  have seen  it followed by very
  abundant hemorrhage from the bowel, probably owing to the rupture of some of
  the congested vessels of the strangled portion of the gut.  In using  the taxis,
  great care should in all  cases be employed, and no undue force  should  ever be
  had recourse to.   No good can ever be effected by violence, the resistance of the
^ ring cannot be overcome by forcible pressure, and a vast deal of harm may be
  done by squeezing the tender and inflamed gut up against its edge, causing it to
  overlap, and thus to be bruised or even perhaps torn.  AVhen the parts are much
  inflamed, the taxis should be employed with great caution;  and  if it have been
  fairly and fully used by another surgeon it is better not to be repeated.  AVhen
  gangrene has occurred, it should never be employed, as the putting back of  the 
THE  TAXIS IN STRANGULATED  HERNIA.           715
mortified gut into the abdomen would be followed by extravasation of faeces and
fatal peritonitis.
  In using the taxis, it should be borne in mind that there are two obstacles to
overcome:  the resistance  of the  parts around the ring,  and the bulk of  the
tumor.  The first may be somewhat lessened by relaxing the abdominal muscles,
and consequently diminishing the tension exercised upon the tendinous apertures
and fascia;  of the groin.   In order to effect this, the patient should be placed in
a proper position, the body being  bent  forwards, the thigh adducted, and semi-
flexed upon the abdomen; the surgeon may then, by employing  steady pressure
on the tumor,  endeavor to squeeze out some of the flatus from the strangled por-
tion of intestine, and thus  to effect its reduction.  In doing this, the  neck of the
sac should  be  steadied by the fingers of the left hand;  whilst, with the right
spread over the tumor, the surgeon endeavors to push it backwards, using a kind
of kneading motion, and sometimes in the first instance drawing it slightly down-
wards, so as to disentangle it from  the  neck of the sac.   The  direction of  the
pressure is important; it should always be  in the line of the descent of  the
tumor.  These means may be employed as soon as the patient is seen by the sur-
geon, when, by steadily carrying on the taxis for a few minutes,  he will perhaps
hear and feel a gurgling in the tumor,  which will be followed by its immediate
reduction;  should, however, this result not ensue after employing the  taxis for
about a quarter of an hour or twenty minutes, it will be  desirable to  have re-
course at once  to further means, the object of which is by relaxing the  muscles
and lessening the bulk  of  the tumor to enable the hernia to be reduced.
   The means to  be employed must be modified according to the condition of the
strangulation, whether it be of the  active or passive kind.  If it be  very acute,
occurring in a young, robust, and otherwise healthy subject, the patient may
have  about twelve or sixteen ounces of blood taken  away from  the  arm; he
should then be put into a hot bath,  where he may remain for  twenty minutes or
half an hour, or  until he feels faint, and whilst in the bath in this condition the
taxis should be employed.   If it do  not succeed, he should be taken out, wrapped
up in blankets, and have chloroform administered.  AVhen fully under the in-
fluence  of  this agent, which  is certainly the most efficient that we possess for
relaxing muscular contraction, the  taxis may be tried once  again.  Should it
still fail, the operation should be immediately proceeded with.
  No good can  possibly come of delay in these cases, and repeated  attempts at
the taxis should  be carefully avoided.   If the hernia does not admit of reduction
in the early stage of the strangulation, it will necessarily be much less likely to
do so when the  parts, by  being  squeezed and bruised  by much manipulation,
will  have their  congestive condition greatly increased.  The frequent  employ-
ment  of the operation without opening the sac,  of late years, very properly
renders surgeons much less averse to early  division of the stricture than was
formerly the case.
  When the strangulation is less acute, or occurs in a more aged or less robust
subject, it  is well  to omit the bleeding, and  to trust to the warm bath  and  the
chloroform.
  When the strangulation is of a passive  character, and occurs in feeble or
elderly people, other measures may be adopted with the view of lessening  the
bulk of the tumor, which, rather than the tension of the parts, offers the chief
obstacle to  reduction in these cases.   Under such circumstances, especially when
the tumor is large  and not very tense, I think it is well to dispense with the  hot
bath, which has sometimes a tendency to  increase  any congestion that may
already exist in  the hernia; I have in more  than one case seen a strangulated
rupture enlarge considerably after the employment of the bath.   In such cases
as these, more time may safely be spent in attempts at reduction than in very
acutely strangulated herniae.  It  is, I think,  a useful practice to commence  the 
716
STRANGULATED  HERNIA.
treatment by the administration of a large enema, which, by emptying the lower
bowel, will alter the relations of the abdominal contents, and may materially fad
litate the reduction of the tumor.   The best enema is one of gruel and castor-oil,
with some spirits of turpentine added to it;  it should be injected through a full-
sized tube, and passed high up into the gut, and with a moderate degree of force.
In administering it, care must be taken that no injury be done to the bowel.   It
would scarcely be necessary to give such a caution as this, were it not that I was
summoned about a year and a half ago by two very excellent practitioners to see
a woman  with strangulated femoral hernia, to whom an  enema of  about two
quarts of tepid water had been administered ;  and as this had not returned, and
did  not appear to have gone  up the bowel, they suspected that it must have
passed out of the rectum into the surrounding cellular tissue.   As  the patient,
however, did not seem to be suffering from  this cause, and as the symptoms  of
strangulation were urgent, I operated on the hernia.   Death suddenly occurred,
apparently from exhaustion, in about eight hours, and on examining the body it
was found that the rectum had been  perforated, the fluid injected into the nieso-
rectum,  separating the gut from the sacrum, and had thence  extended into the
general  sub-peritoneal cellular tissue which contained  a quantity of the  liquid.
Some of the water also appeared to have  got into the peritoneal cavity.
  In the large herniae of old people in which there is a good deal of flatus, after
the  enema has been administered, a bladder of ice may be applied for three or
four hours with excellent effect.   Chloroform may then be given, and the taxis
employed under its influence.
  After the reduction of a strangulated  hernia, constipation and retching, with
nausea,  may occasionally continue ; and the  tumor, if the hernia have been small
and  deep-seated (more particularly if femoral), may continue  to be felt, though
less tense  than before; consisting simply  of the sac thickened and inflamed, with
serous fluid in it.   Under these circumstances we must be careful not to operate.
I have,  on two or three occasions, seen an empty sac operated on, to the  annoy-
ance of  the surgeon and danger of the patient.   The mistake may be avoided by
observing that the symptoms  gradually lessen in severity by waiting, and  that
the tympanitis subsides, the abdomen becoming more supple, &c.
  The length of  time that the congestive condition  of the bowel  will continue
after a strangulated portion of intestine  has been reduced is  very considerable.
In a case of strangulated femoral  hernia which was  some time ago  under my
care reduction was effected; but strangulation  recurring  at the end  of twelve
days an operation became necessary;  this was performed,  and the  patient died
on the eighth day after it, or the twenty-first from  the first strangulation.   On
examination, the  small intestine was found congested  in  two distinct portions,
each of which were about eight inches in length, and had several feet of healthy
gut  intervening.   One of these congested portions lay opposite the wound, and
was  evidently the intestine that was last strangulated.   The other was altogether
away from the seat of operation, but was equally darkly congested,  being almost
of a black color, and was clearly that portion which had been constricted some
time previously;  and thus, although  twenty days  had elapsed, there was little
appearance of the gut having as yet  recovered itself.
  After the taxis has been fairly employed for a  sufficient time,  and has  not
succeeded in reducing the hernia, the operation must be proceeded with.  It is
impossible to lay down any definite rule as to the time that it is prudent to con-
tinue efforts at reduction, but  it may be stated generally that after  the different
adjuvants of the  taxis, the  surgeon may think it desirable to apply, have been
fairly tried and failed, the operation should be undertaken without further delay.
There are few surgeons who will not at once acknowledge the truth of the remark
of the late  Mr. Hey of Leeds,—that he  had  often regretted performing this
operation too late, but never having done it too  early.   It  is true that cases are 
             OPERATION FOR STRANGULATED  HERNIA.         717

occasionally recorded, in which after four or five days of treatment the hernia
has gone up; but how rare it is to meet with such cases in practice ;  and in all
probability in delaying the operation in the  hope of finding one such  case, the
lives of dozens  of patients would be  sacrificed.  Mr.  Luke  has shown as the
result of the experience at the London Hospital, that the ratio of mortality in-
creases greatly in proportion  to the length of  time that the strangulation is
allowed to continue.   Of 69 cases of strangulated hernia operated upon within
the first  48 hours of strangulation, 12 died, or 1  in  5-7 ;  whilst of 38 cases
operated  on after  more than 48 hours had elapsed,  15 died, or 1 in 2-5.  In-
deed, one great reason  of the  greater mortality from  operations for  hernia in
hospital than in private practice, probably arises from the fact that much valu-
able time  is frequently consumed before assistance is sought, or in fruitless
efforts  to reduce the swelling before the  patient's admission.   Not only is time
lost in this way, but the bowel  is often bruised and injuriously squeezed, so that
inflammation already existing in it is considerably increased.

                OPERATION  FOR STRANGULATED HERNIA.

   The operation for  strangulated hernia may be  performed  in two ways: either
by opening the sac, exposing  its contents, and dividing the  stricture wherever
it is situated, from within; or,  it may be done by dividing the stricture outside
the sac without opening this.   In either case the great object of the  operation,
the division of the stricture by the knife, is the same; but the mode in which
it is effected  is different.   AAre  shall first describe the operation in which the
sac is opened—afterwards that  in which it is not; and then briefly compare the
two procedures.
   The patient having been brought to the edge of the bed, or placed on a table
of convenient height, the bladder should be  emptied and the parts that are the
seat of operation shaved.  An incision of sufficient  length  is  then made  over
the neck of the sac;  this  may be best done by a fold of skin being pinched
up, transfixed by pushing the scalpel across its base with the back of the instru-
ment turned towards the hernia, and then cutting upwards; a linear incision is
thus made which may be extended at either  end if necessary;  the dissection is
then carried through the superficial fascia and fat with  the scalpel and.forceps.
If any small  artery spout freely, it had better be tied at once, lest the  bleeding
obstruct the view of the part in the subsequent steps of the  operation.  As the
surgeon approaches the sac, more caution is required,  more  particularly if the
subserous cellular  tissue is dense, opaque and  laminated.   The  surgeon must
pinch this up with the forceps, make a small incision into it, introduce a direc-
tor, and lay it open  upon  this.  If it is thin and  not opaque, so as  to admit
a  view of the subjacent parts,  he may dissect it  through with the unsupported.
hand.  In this way he proceeds until the sac is reached which is usually known
by its  rounded  and tense appearance, its  filamentous character, and by the
arborescent arrangement of vessels upon its surface.   In some cases the surgeon
thinks that he has reached the  sac, when  in reality he has only got upon a deeper
layer of condensed cellular tissue in close contact with  it; here the absence of
all appearance of vessels, the dull  and  opaque character  of the tissue and
its more solid feel, together with the absence of the peculiar tension that is cha-
racteristic of the sac, will  enable him to  recognise the real state of things.  In
other cases again  it may  happen that the sac  is so thin, and the superficial
structures so little condensed,  that  the  surgeon  lays it open in the  earlier
incisions before he thinks he has reached  it.   Under these circumstances a por-
tion  of the  intestine protruding might  be  mistaken  for the  sac.   This dan-
gerous error may be avoided by observing the peculiar smooth and highly po-
lished appearance  presented by the  dark and congested  gut; the absence of 
718
STRANGULATED  HERNIA.
arborescent vessels and the  non-existence of any adhesions  between  its deeper
portion.- and the tissues upon which it lies.  If the  sac is  prematurely opened
and omentum protrudes, the granular appearance and peculiar feel of  this tis-
sue will at once cause its recognition.
  The sac having been exposed, must be carefully opened; this should  be done
towards its  anterior aspect; and if it be  a small  one, at its lower part.  It
may best be done, if the sac be not very tense, by seizing a portion of  it  between
the finger and  thumb, and thus feeling that  no intestine is  included;  a small
portion of it is  then pinched up by the forceps, and an opening  is made into it
by cutting upon their points with the edge of the scalpel  laid horizontally.  If
the sac be very tense, it cannot be pinched up in this way, and then it may best
be opened by introducing the point of a fine hook very cautiously into  its sub-
stance, raising  up a portion  of it in this way, and then making an aperture into it.
There  is little risk of wounding the gut in doing this, for, as the tension of the sac
arises from the effusion of fluid into it, a layer of this will be interposed  between
it and  the gut.   In these cases, the fluid sometimes squirts out in a full  jet, and
occasionally exists in very considerable quantity.   I have seen at least a pint of
slightly bloody serum escape on opening the sac of an old strangulated  inguinal
hernia.  3Iost  frequently, however,  there is not more than from  half an ounce
to an ounce, and sometimes the quantity is considerably less than this.    In some
instances, scarcely  any exists, and  then it becomes  necessary to proceed with
extreme caution in opening the sac, as the  gut, or omentum, is  applied closely
to its inner wall.   In such cases as these, the sac is not unfrequently sufficiently
translucent to  enable the surgeon to see its contents through it, and he should
then open it  opposite  to the omentum or to any small mass of fat  that he may
observe shining through it.   The opening once having been made into the  sac, may
be extended by the introduction of a broad  director (Fig.  227), upon which it is
to be slit  up to a sufficient extent to admit of the examination of its contents.
   The next point in the operation is the division of the stricture; and this  requires
considerable care, lest  injury be done to neighboring parts of importance, or the
gut be wounded.  Vessels  and structures  in  the vicinity of the stricture are
avoided by dividing it  in a proper direction in accordance with  ordinary anato-
mical considerations, which will be described when we  come to speak of  the special
forms of  rupture.   All injury to the intestine is prevented  by introducing the
index  finger of the left hand up to  the seat of stricture, insinuating the finger-
nail underneath it, and dividing  the  constriction by means  of a hernia-knife,

                                     Fig. 226.
having a very limited cutting edge (Fig. 226).  If a director be used to guide
the knife, the intestine will be in considerable danger, as  the instrument may

                                   Fig. 227.
be slid under that portion of it which lies beneath the stricture, or the tense gut
curling over the side of the groove may come in contact with the edge of the knife.
These  accidents are prevented by using the finger as a director (Fig. 228), and
slipping the hernia-knife (which should have not quite so long a probe-point  as
those usually made) along the palmar surface of the finger, upon its flat side; the 
            OPERATION  FOR  STRANGULATED  HERNIA.          719


finger serving to keep the bowel out of the way, and detecting any part that may
be interposed between the edge of the knife and the stricture.

                                    Fig. 228.
  During the division of the stricture, the protruded portions of intestine must
be protected from injury by the knife, either by the operator spreading his left
hand over them, in such a way that they may not be touched by the edge of the
instrument, or they may be protected by an attentive and careful  assistant.
  In some  cases the stricture is so tight  that it is at first almost  impossible to
get the edge of the nail underneath  it.  The surgeon will, however, generally
succeed in doing so, by directing his assistant to draw down the coil of intestine,
so as to loosen it, as it were, from underneath the stricture;  he will then usually
succeed in passing his finger up in the middle of the coil, where  the mesentery
lies.   So soon as the blunt end of the  hernia-knife  has been got  under the
stricture, its sharp edge must be  turned up, and the constriction divided in a
proper direction, to a very limited  extent, from the one-eighth to the  quarter of
an inch.  The  intestine and omentum must then be examined, and  dealt with
according to the condition in which  they are found.  If these  structures are
sufficiently  healthy to admit of reduction,  the intestine should  first of all be
replaced.  This  must be done by pushing it back with as much gentleness as
possible, and chiefly by using the  index fingers.   When it has slipped up into
the abdomen, the omentum must be returned in the same way.  In reducing the
hernial protrusion after the sac has been laid open, care  should be taken that the
margins of this  are firmly  held down by means  of a  pair of forceps, lest it,
together with its contents, be  returned en masse, the  stricture being undivided.
After reduction, the surgeon should pass his finger up into the  canal through
which the hernia has descended, and see that all is clear.  Three or four sutures
should next be applied through the lips of the wound, with a few cross strips of
plaster between  them, a long pad of lint laid  over it, and  a spica bandage to
retain all in proper position.  About the third or fourth day the sutures may be
removed, and water-dressing applied.   If inflammation or suppuration should set
in, the part must be well poulticed, and care should be taken to leave the most
dependent aperture free, as otherwise the pus formed in the external incisions may
flow back through the internal aperture into the peritoneal cavity, and  occasion
fatal inflammation there.
  The patient should be kept quiet in bed and, if there be no signs of peritonitis,
have an opiate given  him.   The  bowels  will probably act in the  course of the
first twenty-four hours;  should they not do so, a castor-oil and gruel enema may
be thrown up.  It is, I think, of  very great importance not to administer any
purgative in these cases, and to take little heed of the  bowels not acting, even
for three or four days after the operation. If the mechanical obstacle have been re-
moved they will be sure to recover their proper action, though in consequence of the
gut having been severely constricted and almost wounded by the pressure of the
strangulation, it may require to be left quiet for a few days before it can recover
its peristaltic action.  The administration of purgatives, by still further irritating
it, will increase the risk of inflammation in it, and will probably do much harm. 
720
STRANGULATED  HERNIA.
 The patient, of course, must be kept upon the simplest and most unimtating diet,
 indeed should only be allowed barley-water and ice for the first day or two, after-
 wards, some beef-tea, but no solid food till  all risk of peritonitis have passed.
   The great danger to be apprehended after operations  for hernia is the super-
 vention of peritonitis.  This may have existed  before the operation, may be
 impending at the time, and may be occasioned, or at all events greatly increased,
 by the necessary wound of the  peritoneum.   Two distinct  kinds of peritonitis
 commonly follow  operation for  hernia; one the active or  acute,  the  other, the
 passive or latent.
   The acute peritonitis is the variety commonly met with  in strong and  robust
 people, otherwise healthy, who are the subjects of this  operation.  It presents
 the ordinary symptoms of  acute  idiopathic  inflammation  of the abdomen; there
 is tenderness of a diffused  character, with lancinating pains.  The  patient lies on
 his back, with his knees drawn  up, has an anxious  countenance, a quick, hard
 pulse, a dry tongue, and much inflammatory fever; the respiration is principally
 thoracic, and tympanitis  soon comes  on.   The  bowels are  usually constipated,
 though sometimes irritated.   The treatment of this  form of  herniary peritonitis
 is best conducted upon ordinary  antiphlogistic principles; the disease is a purely
 inflammatory one, and proper  means must be taken to subdue it.   This may be
 best done by free venesection and the application, perhaps  repeated,  of two or
 three  dozen leeches to the abdomen; calomel  and opium in pill must be admi-
 nistered every fourth or six hour, and the patient confined  to barley-water and ice.
 As the inflammatory action is subdued, the constipation  which is  occasioned by
 it will be relieved without the necessity of administering any purgatives.   The
 tympanitis may best be removed  by turpentine enemata, and any lurking tender-
 ness by the application of blisters.
   Latent or passive peritonitis is a form of disease that appears to be of the
 diffused or erysipelatous character, chiefly occurring in old people, or in weakly
 subjects, and is especially apt to follow upon inflammation of the omentum and
 its consequent suppuration.  In  hospital-patients especially, in whom all disease
 is apt  to assume a low character, this  inflammation  is peculiarly liable  to occur.
 In some instances it sets in without the appearance of any marked local symptoms
 of inflammation,  no pain or uneasiness in the abdomen;  but, two  or three  days
 after the operation, the patient becomes depressed, with a quick and weak pulse,
 an anxious  countenance, a tumid and tympanitic  abdomen,  and   rapid sinking
 of strength.^  In  the majority  of  cases, however, some of the ordinary local signs
 of peritonitis are present.   After death, the abdominal cavity will be  found'to
 contain a quantity of turbid serous fluid, mixed with flakes of lymph, in  many
 instances  in such quantity as to give  it a puriform appearance, and not unfre-
 quently matting together the  coils of  intestine.   In the treatment of this affec-
 tion it is necessary to support  the patient, and in some instances even  to admi-
 nister stimulants, such as ammonia, the brandy-and-egg mixture, &c.   Depleting
measures of all kinds are quite inadmissible ;  and indeed, the remedy that offers
most prospect of benefit to the patient is opium, in  full  doses, one grain being
given every third or fourth hour  until  some effect is produced upon the constitu-
tion.   Opium not only acts as a  useful stimulant in  these cases, but has a ten-
dency  to allay the increased vascular action.  At the same time a blister to the
abdomen, to be dressed with mercurial ointment, may be advantageously employed,
 and turpentine enemeta administered with the view of removing the tympanitis,
which  is a source of much distress to the patient.
   The condition in which the  contents of the sac are found in a case of hernia
determines greatly the course  that the  surgeon should pursue  after the division
of the  stricture.  Most frequently the  intestine  is deeply congested,  being  of a
reddish-purple, a  claret, or  chocolate color.  This congested  state  must not be
confounded  with gangrene  of the part, which might happen if the  surgeon were 
GANGRENE  OF THE GUT.
721
Tig. 229.
>s^2H&r!v
to content himself simply with judging of its condition by the color.   However
dark this may be, the gut cannot be said to be gangrenous so long as it is polished
and firm, free  from putrescent odor, and without a greenish tinge.   In  cases in
which  there  is much doubt as  to whether its  vitality continues or not, it has
been proposed to scarify its surface lightly with the point of a lancet.   If blood
flows from the punctures, this may be taken as a proof of the continuance of the
vitality of the  part.  Such a procedure as this, however, is certainly attended by
some degree of danger, and can seldom be required.
  When the intestine is merely congested, however deeply this may be, the rule
is that it should be returned into the cavity of the abdomen in the hope of its
ultimately recovering itself;  this it will generally do if it have not been too much
handled after  the sac has  been opened; but in some cases it will  slough a few
days after it  has  been reduced, and the faeces being  discharged through the
wound, a feculent  fistula will be formed, which may happen as late as the eighth
or tenth day after  the operation.   In those cases, however, in which the intestine
has been very tightly nipped by a sharp-edged stricture, so that a deep sulcus or
depression is  left upon it, it seldom, I think, recovers itself, whether the whole
of the coil of  gut has been thus affected, or the constriction has been limited to
a small portion of the diameter of the  intestine.  It  is remarkable  how very
quickly changes which are incompatible with life may ensue in a portion of gut
that has been  very tightly strangulated.   I have known a coil of intestine that
had been but eight hours  strangulated be-
fore  the  operation   was  performed, so
tightly constricted as  not to  regain  its
vitality after its reduction (Fig. 229).  In
such cases as these the patient usually dies
of peritonitis in the course of a few days,
without the bowels having acted, all peri-
staltic motion  having necessarily been an-
nihilated  at   the  injured   point.   On
examination after  death, the constricted
intestine will be found to be of a black or
ashy-gray color, without  having  any floc-
culi or lymph  deposited upon  its surface,
though these may  be in abundance in the
neighboring parts.  From the  very un-
favorable result of those cases in which
there has been very tight nipping of the
protruded bowel, a very cautious prognosis
should be given, and in reducing the gut after the division of the stricture, care
should be taken not to push it  far back into  the  abdomen, but to  leave it near
the inner ring, so that in the  event of  its ultimately giving way, there will be
less risk of feculent extravasation.  In those cases in which the nipping has been
very severe, the sulcus being distinctly marked,  and the intestine excessively
dark and  congested though not gangrenous, it would  I think, be better after
dividing the stricture to leave the gut outside the ring rather than to return it;
the reduction of intestine in this state being almost invariably followed by fatal
peritonitis.
  AVhen  the intestine is  gangrenous, the fetor on opening the sac, perhaps even
the condition  of  the integuments and  of the more superficial structures, the
softened,  lacerable, or  pulpy look of the  protruded  part, its loss  of lustre, and
peculiar greenish-black or dark-gray color, will cause the nature of the mischief
to be readily recognised.   Some difference of opinion exists as to the proper line
of practice to be adopted in such cases.   Travers  and  Lawrence seem  to think
that the  division  of the  stricture is  unnecessary,  or may even  be  injurious.
                                     46
 
722
S T R A Mil' L A TED  HERNIA.
 Whilst Dupuytren, A. Cooper, and Key, advise that it should be done, and that
 the  stricture  should be divided  in  the usual way,  so as to allow the escape of
 fteces; and that a free incision should then be made into the  protruded  portion
 of bowel which must be  left unreduced.  In  this way an artificial anus will
 necessarily be formed, through which the feculent matter finds  exit. ^ The gut
 in the vicinity of the stricture is  retained in situ by masses  of plastic  matter,
 which  prevent  the  peritoneal cavity being opened.  If the  intestine should
 already have given way before the operation is performed, the stricture  must be
 divided and the part then left unreduced, care being taken not to interfere with
 any  adhesions  or connexions lying  inside  the  neck of the sac, though I fully
 agree with Aston Key, in thinking that  the danger of disturbing them has been
 exaggerated.
   AVhen  a  small  portion  of the bowel only is gangrenous, the better  plan, I
 think, would be to return it  into  the cavity of  the abdomen, without laying  it
 open, but it should not be pushed any distance into this cavity;  the  pressure of
 the  surrounding parts will prevent extravasation ; when the slough  separates it
 will  probably be discharged into  the cavity of  the intestine,  and the aperture
 resulting will be closed by the adhesions  that extend  between its margin and the
 abdominal wall.
   The management of adhesions varies  according to the condition of the bowel
 and  the nature and situation of the  bands.   As has just been remarked,  if
 gangrene  is present, especial care must be taken not to disturb any connexions
 that have been formed about the  neck of the sac,  and which constitute the most
 effectual barrier against feculent extravasation.  AVhen the adhesions are recent,
 consisting merely of plastic  matter, in  whatever situation they exist, they may
readily be broken  down with the handle  of the scalpel, and  the  parts  then
 returned.   AVhen of old standing, and dense, they must be dealt with according
to their connexions.  Most  frequently  these adhesions occur  in the shape of
thickened bands situated within and stretching across the neck of the sac. In
other cases, again, they may be found either as filamentous bands,  or as broad
attachments  connecting  the  sac  with its  contents,  and  tying  these, perhaps,
 together.   When of a narrow and constricted form, and more  particularly when
 seated in the neck of the sac, or stretching like bridles across its interior, they
 may readily be divided with a probe-pointed bistoury,  or  the hernia-knife.  If
 consisting of broad attachments,  they may be dissected away by a little careful
manipulation from the parts in the neighborhood in which they lie.   Thus, they
may be dissected from the inside of the  sac; though if the  connexions be very
 extensive and of old standing here, it may sometimes be more prudent to dissect
away the portions of the sac in connexion with them, or to leave them  untouched,
than to endeavor to  separate  them.   They may, however, attach themselves in
such  situations  that it becomes  necessary to divide them.   Thus I have, in a
recent case of congenital hernia,  found  it necessary to dissect away some very
extensive  and wide-spread adhesions that  had formed between the omentum
and  the testicle, and which indeed had almost  completely  enveloped  that
organ.
  Internal Adhesions between the  omentum and intestine  or mesentery occa-
sionally exist, consisting  usually of pretty firm bands stretching across from one
part  to  the other, sometimes  connected  with the inner wall of the sac, but in
other cases confined  to its contents; as these bands may constitute the real stric-
ture, continuing to strangulate the gut after the division of the structures out-
side  and in the  neck of  the sac, they must necessarily be divided.   This ope-
ration  requires great care, lest  the neighboring  intestine be wounded,  and is
best  done  by passing a  director underneath, and cutting them through with a
probe-bointed bistoury; or,  if this cannot be done on account of their connex-
ions, they must be seized with the forceps and carefully dissected off the gut. 
         MANAGEMENT OF ADHESIONS  AND  OF OMENTUM.     723

 In a case of large inguinal hernia, containing both gut and omentum, on which
 J operated some years ago, I found after dividing the stricture, and taking hold
 of the omentum in order to push back  the intestine, that this could  not be  re-
 duced.  On searching for the cause of difficulty, and drawing the mass well down,
 I found high up in the  part, corresponding to the neck of the sac, a narrow band,
 like a piece of whipcord, stretching across from the omentum to  the  mesentery
 and firmly tying down the gut.   On dissecting this  carefully through, the con-
 stricted portion  of intestine  subjacent to it sprung up to  its full diameter, all
 constriction being removed, and was then very readily reduced.
    Treatment  of Omentum.—If the omentum is  small  in  quantity,  healthy in
 character, though congested  and apparently recently protruded, not having un-
 dergone those changes that occur in it when it has been a long time in a hernial
 sac, it should  be reduced after the  intestine has been  put  back.   If, however,
 its mass be very large, or if it be hypertrophied, or otherwise altered in struc-
 ture, at the same time that it is congested, I think the best surgeons  are agreed
 that it should not be returned into the  abdominal  cavity, as inflammation of it,
 epiploitis, will probably set in and terminate fatally with effusion into the peri-
 toneal sac.  So also, if  the omentum is in large quantity, and has become  in-
 flamed in the  sac, it should not be returned, as the inflammation in it is very apt
 to run on to a kind of  sloughy condition of the whole mass.  If gangrenous, it
 can necessarily not be reduced.  In all these cases of hypertrophied, inflamed,
 or gangrenous omentum, the best practice consists  in cutting off the mass, as  re-
 commended by Sir A. Cooper and Lawrence.   If it  be left in  the sac, inflam-
 mation or sloughing of it may occur, and the patient can derive no corresponding
 advantage to the danger he will  consequently run.  The excision of the  mass
 may readily be performed  by seizing  and cutting it  off  at a  level  with the
 external ring.   As the arteries of the stump, which are sometimes pretty nume-
 rous, are apt to bleed freely, they must be tied singly by fine ligatures, which
 should be left  hanging out of the wound.   There is often a tendency to the  re-
 traction of the stump of the omentum into the  abdominal cavity, in which case
 the ligatures, dropping into the peritoneum, may become  sources of great irri-
 tation  ; in order to prevent  this, the  better plan is, I  think, to knot them
 together, and to fix their ends by a piece of plaster upon  the  forepart  of the
 abdomen.   Surgeons formerly were in the habit  of including the constricted
 neck of the omentum  in a tight  ligature, cutting  off the mass below this, and
 leaving the stump in the inguinal  canal or ring.   This practice has been gene-
 rally abandoned, from dread of peritonitis being induced by the  constriction  of
 the ligature.   It may, however, be safely followed in some instances, in those
 particularly  in which the protruded mass is very  much indurated, having a
 narrow neck.  In two cases of this kind, occurring  at  the Hospital during the
 past winter,  I have employed this practice with  excellent effect.  The quantity
 of  omentum that is cut  off  varies considerably ; the mass removed usually
 weighs from four to six  ounces, but in some instances it may amount to a pound
 or more.
   Sacs or  apertures are occasionally formed in the omentum, in which a knuckle
 of intestine may have become enveloped or by the  margins  of which it may be
 strangulated.   These envelopes of omentum around  the  gut, which have been
 especially described by P.  Hewett, may  occur in all  kinds of hernia, at least in
 the inguinal, the femoral, and the umbilical, and sometimes acquire a large size,
 completely shutting in the gut.  It is  of importance to bear their existence in
 mind, and in all cases to unravel the omentum before removing it, lest  it con-
 tain a knuckle  of intestine, which might be wounded in the operation.
   Wounds of the Intestine may accidentally occur at two periods of the operation,
either by the sfrgeon  cutting too  freely down upon the sac, and opening this
before he is aware of what he is about;  or else, at the time of the division of 
724
STRANGULATED  HERNIA.
the stricture, a portion of the gut which lies beneath it getting in the way of the
edge of the knife, and being nicked by it.   The first kind of accident can  onby
happen from a certain degree of carelessness ; but  it is not  always  so  easy to
avoid wounding the gut when the stricture  is so  tight that the finger-nail cannot
be slipped under it as a  guide  to  the  hernia-knife.  In such cases as these, a
very narrow director must be used  ; and this is a most dangerous instrument, as
in passing it deeply out of sight under the tight  stricture, a small portion of the
gut may curl up over its side into the groove, and thus become  notched by the
knife as this is slid along it.  This accident has happened to the best and most
careful surgeons.   Lawrence relates two cases  that  occurred to him, and Sir A.
Cooper, Cloquet, Jobert, and Liston have all met with it.   It may be known to
have occurred by the bubbling up of a small quantity of flatus and liquid faeces
from the bottom of the incision.  The treatment of a wound  of the gut must
depend upon its size.  AVhen very small, rather resembling a puncture  than a
cut, the practice recommended by Sir A. Cooper should be adopted, viz., to seize
the margins of the incision with a pair of forceps, and to tie a fine  silk  thread
tightly round them, the ends of which should then be  cut  off, and the gut re-
turned into the abdominal cavity.  Such a  proceeding as this  does not appear to
give rise to much, if to any, increase of danger.   In a case that  occurred to me
at the  Hospital last year, in which, owing to the  excessive tightness of the stric-
ture, a very narrow  director could only be  got under it,  the  gut  immediately
above it was notched and opened by a kind of punctured wound; this was  tied
up in the way mentioned, and after the death  of the patient, which took place
on the fourth day  after the operation, from  gangrene of the strangulated portion
of bowel, the silk  ligature was  found to be completely enveloped in a plug of
plastic matter.   If the wound be of larger size, it must  be closed by the glover's
stitch.
   Wound of one of the Arteries in the neighborhood  of the sac may occur during
the division of the stricture, either  in consequence  of some anomaly in the  dis-
tribution of the vessel, or from the  surgeon  dividing the parts in  a wrong direc-
tion.   This accident usually happens to the  epigastric or obturator arteries,  and
Lawrence has collected fourteen recorded cases  in which  it has occurred ;  the
result in these has been very various.  In some the patients have  died; in others,
after much loss of blood, and  consequent faintness, the bleeding  ceased  spon-
taneously.   The proper treatment would certainly consist  in cutting down upon
and  securing the  bleeding vessel.  In the event of the surgeon operating on a
case of hernia, without having been able previously to satisfy himself as to its
precise character ;  or if from any cause  in  dividing the stricture he has reason
to dread the  proximity of an artery, he may safely and readily divide the con-
striction with a knife that would not easily cut an artery, and he  will find that if
he blunt the edge of his  hernia-knife, by drawing it over the back of the scalpel,
that it will still be keen enough to relieve the strangulation, whilst it would push
before it any artery that might happen to be in the way.
   Sloughing of the sac is of rare occurrence, and when  it happens is commonly
attended by fatal results; it is not, however, necessarily so.   In an old woman
on whom I recently operated for  femoral hernia  of very large size, the sac
sloughed away,  exposing nearly the whole of Scarpa's triangle  with almost as
much distinctness  as if it had been dissected;  but although in much danger for
a time from an acute attack of peritonitis, she ultimately recovered.
   Artificial Anus and Pascal Fistula.—When an aperture exists in the bowel
by which the .whole of the  intestinal  contents escape externally, the disease is
said to be an artificial anus.  AVhen but a  small portion so escapes, the greater
part finding its way out through the anus,  a faecal fistula is said to exist.    The
quantity of feculent  discharge  necessarily depends  upon  the  'extent of the
destruction of the  intestinal coats, and  its character, on  the part of the  gut 
TREATMENT OF ARTIFICIAL  ANUS.              725
that is  injured.  The escape takes place involuntarily, and  usually  continu-
ously.   This condition  may occur in several ways.   Thus,  the  gut may be
accidentally wounded during the operation, and the faeces afterwards continue
to be discharged through the aperture so made, or it may have been gangrenous,
and have given way into the sac  before the operation; or, the surgeon may have
intentionally kid open a gangrenous portion of intestine, so  as to facilitate the
escape  of the faeces.   In some  cases in  which  the bowel  has been  severely
nipped,  and is dark and congested, though it have not fallen  into a state of gan-
grene, it may not be  able to recover itself after  its return into the abdominal
cavity, but will give way in  the course of three, four, six, or even ten days after
the operation.  In  these  cases,  a  small  quantity of feculent matter is first ob-
served in the dressings, and gradually a  greater discharge appears, until at last
the fistulous opening is completely established.  In such cases, it is of import-
ance to  observe, that although the bowel  gives way within the peritoneal cavity,
the faeces do not become' extravasated into this, but escape externally.   This im-
portant  circumstance is owing to the fact of the portion of the bowel that is nipped
losing its peristaltic action, and consequently remaining where it is put back;
the parts in the neighborhood inflaming, throwing out lymph, and becoming con-
solidated to each other and to the  parietal peritoneum, so as to include  the gan-
grenous portion of the gut, and completely to circumscribe it.  It is consequently
of great importance, in such cases  as these, not in any way to disturb the adhe-
sions that have formed between the sides of the aperture in the gut and the neck
of the sac.
   The pathology of artificial anus is sufficiently simple.   The edges of the  aper-
ture in the gut are glued by plastic matter to the abdominal wall, and  whether
the whole or a portion only of the calibre of the intestine is destroyed, the aper-
tures of the upper  and lower end, though at first lying almost in a continuous
line, soon come to unite at a more or less acute angle.   These are at first similar
in size,  and present no material differences in shape or appearance; as the disease
becomes more chronic, they  gradually alter in their characters, the lower aperture
being no longer used for the transmission of faeces, gradually becoming narrower
(Fig. 231 b), until  at last it may be almost completely obliterated, whilst the
upper portion of intestine becomes dilated, in consequence of there being usually
some slight obstruction to the outward passage of the faeces (Fig. 231 a).  The
mesenteric  portion, opposite the  aperture, becomes drawn out into a kind of pro-
longation or spur, the full importance of  which was first pointed out by Dupuy-
tren.  This spur-like process projects between the two  apertures, and being de-
flected by the passage of the faeces, has at last a tendency to act as a kind of valve,
and thus to occlude the orifice into the lower portion of the  gut.   The integu-
ments in the neighborhood of such an aperture as this usually  become irritated,
inflamed, and excoriated, from the constant passage over them of the faeces.  In
some cases, the mucous  membrane lining  the edges becomes everted, and  pout-
ing; and, in others, a true prolapse takes place, large portions of the membrane
protruding.  An  artificial anus  fully formed in this way never undergoes  spon-
taneous  cure.
  AVhen a faecal fistula has formed, the condition of parts is somewhat different.
In these cases, the aperture  in the intestine consists of merely a small perfora-
tion in its coats, unattended by any considerable loss of substance, through which
a quantity of thin fluid and feculent matter exudes, giving rise  to a good deal of
irritation of neighboring  structures.   In  some cases, there are  several  apertures
communicating with the gut, and extending through the skin.   Fistulous open-
ings of this kind not unfrequently undergo spontaneous cure  after existing  for a
few weeks or months.
   Treatment of Artificial Anus.—As the existence of an artificial anus, by in-
terfering with nutrition, commonly gives rise to  considerable emaciation, it be- 
726
STRANGULATED  HERNIA.
comes necessary to support the patient's strength by a sufficient quantity of good
and nourishing food; this is of  greater consequence the higher the fistula is, as
the interference with the earlier stages of the digestive process, and  the  loss of
nutritive material by the discharge of the  chyme, is proportionately great.  If
the aperture be merely of a fistulous kind, the pressure of a pad, to prevent the
escape of feculent matter, may enable  a  spontaneous closure of it to take place.
If the aperture be a true artificial  anus, surgical means must be adopted in order
to effect  a  cure.   In accomplishing this, two important  indications have to be
fulfilled: the first is to diminish or destroy the projecting valvular or spur-like
process, and thus to re-establish  the continuity of the canal;  and,  after this has
been done, the  external wound may be closed, by paring its  edges  and bringing
them together with hare-lip pins.
   The first object is best accomplished by Dupuytren's enterotome (Fig. 230); this
consists of an instrument something like  a  pair of scissors, with  blunt but ser-
rated blades,  which may be brought together by acting upon a screw that tra-
verses its handle.   One blade of the instrument is  (a) passed into the upper,
the other (b) into  the lower portion of intestine,  they are  then  approximated
slowly and fixed by means of the screw in such a way as  to compress  on  either
side the spur-like process (Fig. 231).  A'ery gradually, day by day, this screw is
tightened so as to induce  sloughing of this  projection and cohesion of  its serous
surfaces.   As this  action goes on  the irritation caused by the instrument will
occasion  plastic matter to be thrown out in the angle formed by the intestine, so
that the  peritoneum and  mesentery become consolidated, and  all opening into
the peritoneal cavity avoided.   Should the  spur-like process be accidentally cut
through before  the  lymph is thrown out  in sufficient quantity, the peritoneum
would  be open, and  death probably ensue.   Hence the  necessity for caution
in this  procedure.   So  soon as the blades of the instrument have come into
Fig. 230.                                Fig. 231.
contact, and the spurlike process has  consequently sloughed away, the great ob-
stacle to the closure of the artificial anus will be removed, and the continuity of
the canal being thus re-established, its  lips may be pared and brought together
by hare-lip pins and sutures. 
             OPERATION WITHOUT  OPENING  THE  SAC.          727

  [The late Dr. Physick devised and executed an operation by which he effected
the destruction of the eperon or spur, and the je-establishment of the continuity
of the intestinal canal, more easily than by the employment  of the cumbersome
and inconvenient enterotome of Dupuytren.  He passed a curved needle armed
with a  ligature completely through  the spur-like  ridge, the needle  entering
through the orifice of one gut and emerging by the other.   The extremities of
the ligature being then loosely tied, in order to approximate the peritoneal surfaces,
were fastened  at the external  opening;  and the thread was allowed to remain
thus for several days, until by its action  as a seton,  sufficient effusion of plasma
had taken place to effect the consolidation desired.  The ridge of gut was then
divided by a bistoury.*—Ed.]

                OPERATION WITHOUT  OPENING  THE  SAC.
   The possibility of removing the stricture in strangulated hernia without laying
the sac open, naturally suggested itself when  it was known that in many cases
the stricture was seated in the tendinous and  cellular tissues outside the neck
of the sac, and that when these were divided the protrusion was readily reduced.
This operation was  performed by Petit  as long  ago  as 1718, but was seldom
practised until it was revived of late years by Aston Key and Luke.  The great
advantage sought to be gained by this operation  is, that as the peritoneum is
not interfered  with or its cavity opened, the risk from  peritonitis will be propor-
tionately lessened.   The wound made  by the operation  being altogether super-
ficial, and the  sac not opened, its risk has been compared  to that  of the taxis,
with the addition of what would result from a superficial wound.  This  argu-
ment would be conclusive in favor of the operation without opening the  sac if
it could be shown  that in all cases  of strangulated  hernia the peritonitis  is
occasioned by  interfering  with the  peritoneal cavity;  it  must,  however,  be
admitted even by the advocates of Petit's operation that this is  not  the case.
In many instances the  inflammation  exists before  any operation  is performed,
being evidently produced by the  stricture  of and  consequent injury to the gut.
But it  cannot with  fairness be  argued, that though  the peritonitis  may exist
before the operation, the incision of  the  peritoneal cavity does not increase it.
Even in  healthy  persons,  laying open  the  abdomen,  handling the gut and
omentum,  and  pushing the  fingers  into  the  peritoneal sac, would always  be
followed by intense,  perhaps  even fatal, peritonitis.   It is only reasonable to
believe that the same  procedures in an  already inflamed peritoneum would  be
followed by equally disastrous results.
   That the  opening made into the cavity of the abdomen in reality adds to the
frequency of the peritonitis, cannot I think be doubted by any practitioner.   It
not  unfrequently  happens  in strangulated  hernia, that no sign of peritoneal
inflammation  sets in until  two or three days after  the operation is performed,
and then occurs evidently as the  result of this procedure.   That  the fatality of
the peritonitis, even  if existing before  any operation be  practised, must  be
greatly increased by interference with the serous  sac, is evident  from the fact
that has been  already mentioned that death very rarely occurs (not more than
once in many hundred  cases), after the  reduction of  a strangulated hernia  by
the taxis.   Fully admitting, therefore, that in many cases  the peritonitis exists
before the  operation,  and  is occasioned by causes independent of it;  it is I
think impossible to deny that the inflammation is frequently directly occasioned
by opening  the peritoneal cavity, and handling the viscera, and that when already
existing, its fatality is greatly increased by this procedure.
   There are,  however, two objections that may be urged against Petit's opera-
tion, with more justice than that it does not tend to  prevent the occurrence of
peritonitis.  The first is, that if the intestine be not seen, it may sometimes be
                » Vide North American Medical and Surgical Journal, Vol. II. 
728
STRANGULATED  HERNIA.
  returned in a gangrenous condition; and second,  that  the gut may possibly be
  returned still strangled by bands of adhesion, or by occlusion in an omental aper-
  ture.   With  regard  to  the  first objection, it may be stated, that if the intes-
  tine  is in a gangrenous state there will usually be some evidence  of this con-
  dition, either in the change  that has taken  place in  the general  symptoms of
  the patient, or in the condition of the sac and  its coverings, which will enable
  the surgeon to guess at  the condition of the enclosed parts, and would of course
  induce him to. expose them  fully and  examine them  thoroughly.   This objec-
  tion, however, cannot apply to those cases in which the  strangulation  has only
  existed for a time that would be insufficient to allow of the occurrence of gan-
  grene, and does not  therefore apply to the performance of Petit's operation in.
  recent cases of strangulation.   AVith regard to  the occurrence  of internal stran-
  gulation, it is excessively rare, and  when it does occur it still  more rarely hap-
  pens^ whether the strangulation is effected by bands of adhesion, or by an aper-
  ture in the omentum, that the parts can be returned without  opening the sac
  adhesions usually existing also between this structure and its contents.0 But the
  best answer to the  objections against the operation without  opening the sac, are
  the results that have  followed this practice.   Mr. Luke, who has had great expe-
  rience on this subject states,1 that he has operated in 84  cases of hernia.   In
  25 of these the sac was opened; in 59 the sac remained unopened.   Of the
  25  in which it was opened, 8 died, whilst of the 59  in which Petit's operation
  was performed, only seven died.   That the ordinary operation indeed of opening
  the sac is an  exceedingly fatal one, is well known to  all hospital surgeons, and
  is fully proved by surgical  statistics.   Of 77 operations for hernia, reported  by
  Sir A.  Cooper, 36  proved fatal;  and of 545 cases  recorded  in the journals, and
 collected by Dr. Turner,  260  are reported to have  died.   The  result, therefore,
 of Mr. Luke's operation is most favorable,  when contrasted with such as these.
   Ihe operation, without opening the sac, may be practised in all forms of hernia,
 but is much more readily done in some varieties of the disease than in  others.
 it is especially applicable in cases of femoral  hernia, in which  the stricture  is
 commonly outside the sac, as will be mentioned when speaking of that form  of
 the  disease.   Of 31 cases of femoral hernia operated  on  by Mr. Luke, the sac
 only required to be  opened in 7.  In inguinal hernia it is not so easy to perform
 Petit s operation ; indeed, in the majority of cases, the surgeon will fail to remove
 the stricture in this way.  This is owing to the constriction being usually seated
 in .the neck of the sac, and is  especially observable in congenital hernia.   Of 20
 inguinal herniae operated on by Mr. Luke, the sac required to  be opened  in 13
 instances.                                                        r
   For the various reasons that have been  mentioned, I am decidedly of opinion
 that this operation should always be attempted in preference to the ordinary one
 or opening the sac,  m those cases in which the hernia has not long been strangu-
 lated,  presents no sign of the  occurrence of gangrene in it, and more especially
 when it is femoral.   Even if the surgeon fail in completing Petit's operation, in
 consequence of the incorporation of the stricture in  the neck of the sac, or the
 constriction of this  part,  no  harm  can  have resulted; for the  sac, after being
 exposed, may at any time be opened in the ordinary way, and the operation com-
 pleted by dividing the stricture from within.
  AVhen the hernia is of  large size and  irreducible, it  is of especial importance
to avoid opening the sac.   If this be done, the contents will inflame, and fatal
peritonitis commonly ensues.   In these  cases,  as  Mr. Luke has pointed  out,  it
rarely  happens that the adherent parts are seriously strangulated, but the whole
mischief seems to be occasioned and to be received by the new protrusion that
has taken place, and gives rise  to the tension ;  and if this can be  liberated and
reduced, the surgeon has done  all that need be accomplished.  The evidence of
                       » Medico Chirurgical Transactions, Vol. 31.    » 
             OPERATION WITHOUT  OPENING  THE  SAC.           729

the reduction of the recent protrusion, although the old adherent and irreducible
hernia be left, is usually sufficiently obvious, the portion of gut returning with a
slip and a gurgle, with considerable  diminution in  the general  tension of the
tumor.
   With regard to the mode of performing Petit's operation  little need be said
here,  as  it is precisely identical with the steps of the old operation up to the
period of the exposure of the sac, except that, when  it is not intended to open
this, the incisions should be carried more directly over its neck.   The  stricture,
if situated outside the sac, will  then  be found either  in  some of the tendinous
structures surrounding it, or else in the subserous cellular tissue lying  upon it.
After  the  division of the constricting bands  in  this  situation, by means of a
probe-pointed knife carried underneath them,  or by dissecting down upon  them,
an attempt at  the taxis may be made by compressing the  tumor  in  the  usual
way, at the same time that its neck is steadied  by the fingers of the left hand.
If the  contents can  be reduced,  the  incision in the superficial  structures  is
brought together by a few strips of plaster, over which a pad and bandage may
be applied.   Should peritonitis come on, as  the result of the strangulation,  it
must  be treated in the usual way.   If, after the surgeon has  fairly divided all
the strictures outside the sac, and  finds still that the return of the hernia is pre-
vented by some constriction in its  neck, it will be necessary to lay this  open and
 divide the constriction in the usual way.
   [M. Guerin has proposed the subcutaneous  division of the stricture, in  those
cases  of recent  strangulated herniae in which there is no reason for believing that
the stricture is seated at the neck of the sac, or that the  part strangulated  is
gangrenous.
   This process has been several times practised, and in every instance  with per-
fect success, by Dr. Pancoast of this city; who, however, restricts the performance
of the operation to those cases of strangulated  inguinal hernia, in which the
stricture is situated at the external abdominal ring; in which it is believed that
the gut is not gangrenous, and in which the surgeon would  be willing to return
the intestine by the taxis if he could.
   Concerning the performance of the operation under such circumstances, Dr. Pan-
coast  says,' " I accordingly raised a transverse fold of skin about an inch  and  a half
high immediately below the external ring, and punctured it at its base with a sharp-
pointed bistoury, but taking especial care to carry the point of the instrument in
front  of the upper column of the ring, which could be distinctly felt with the finger ;
I then without relaxing the fold, withdrew the bistoury and inserted  in its place a
grooved director, the end of which I insinuated for near an  inch under  the upper
column of the ring, and of course between it and the cremaster fascia covering
the sac.   I then relaxed  the fold, and smoothed it  out on the director; then
placing my left  forefinger under the director, and the thumb on the outer end,
I strained  as it were, the column  of the ring upwards till I could see the out-
line of the director through  the  skin.  I  then dropped vertically  through the
skin,  immediately below  the  ring, the end of a sharp-pointed  curved bistoury
into the groove of the director, and inclining  the heel of the instrument  back-
wards, slid the point forward in the groove  and divided the stricturing edge of
the column for about half an inch.   The division of the tendon was accompanied
with the usual  creaking sound.  The bistoury and director were now  removed,
and but a few drops of blood escaped  by either puncture.)  The  patient was
placed in the usual  position for the  taxis,  and the  contents of the hernial sac
were returned,  without the slightest  difficulty, into  the abdominal cavity, with
immediate relief to the patient.   On the second day,  the punctures, which were
scarcely distinguishable among the  wrinkles of the skin, were healed, the patient got
up perfectly well, re-applied his truss, and resumed his ordinary business."—Ed.]
a Operative Surgery, p. 3S9. 
730
S T R A N G I'LATED  HER N I A.
                  REDUCTION OF THE HERNIA IN MASS.

  The reduction of the hernia  in mass consists in the return of the sac, and its
contents into the abdomen, still in  a state of strangulation.   AA'hen  it is said
that the parts are  returned  into the abdomen, it  must  not be understood that
they are pushed back into its cavity, but that the external protrusion is caused to
disappear  by being pushed into the subserous cellular tissue, behind and under-
neath  the parietal peritoneum  between it and  the abdominal  muscles.  This
remarkable  accident, which was first  described by the  French surgeons of the
last  century, received little notice from practitioners  in  this country,  until
attention was drawn  to it by Mr. Luke.
  Reduction in mass has only  been observed in cases  of inguinal hernia, and
has chiefly occurred  from the patient's own  efforts  in  reducing a strangulated
rupture.   It is a remarkable fact, that in most of  the instances in which it has
occurred,  only a very slight  degree of force appears to  have been  employed in
the reduction of the tumor,  and the accident would seem to have resulted  from
the adhesions between  the sac and the neighboring parts being much weaker than
natural, so that a moderate degree of force caused the whole to slip through the
canal.  It  may, however, occur  from the surgeon's efforts, if  these are too forcible
or long continued.
  The symptoms indicative  of  this accident are constitutional  and local.  The
constitutional symptoms consist in a continuance of those that are indicative of
the existence of strangulation,  notwithstanding the disappearance of the tumor.
The vomiting and constipation persisting,  the  patient  speedily becomes  much
depressed  in strength, being  seized  with hiccup and  prostration of all  vital
power; signs of gangrene then take place within the sac.
  An examination of  the parts of hernia will  usually enable  the surgeon to
recognise  the nature of the accident; he will ascertain that a  tumor had  previously
existed, and will  learn  from a description  of  its general  characters, and the
symptoms occasioned by it, that it was in all probability a strangulated rupture.
He will then find,  on examining the part, that there is a total absence  of all that
fulness which is occasioned  by the  presence  of the  sac, even after its contents
only have been reduced;  the sac, in  such  cases, always giving  rise to a feeling
of fulness and roundness in the part.  He will, on the contrary, find that the
abdominal ring is  peculiarly and very distinctly  opened;  it is  much larger than
usual, and somewhat rounded. On pushing the finger into the canal, this  will be felt
quite empty, but in some cases on deep pressure with the finger, especially when the
patient stands up or coughs, a rounded tumor may be indistinctly felt behind the
ordinary seat of the hernia.   In many cases, however, the  most careful manual
examination will fail to detect any prominence of  this kind.
  If after careful  examination  of such a case as this, in which the symptoms of
strangulation continue, the surgeon learns  by the previous  history that  a tumor
has existed, that it has suddenly gone up,  and further, if he finds that the seat
of  the supposed  hernia presents  the negative  evidence  that has  just  been
described, it will then  be necessary for him to push his inquiries a step further
by an  exploratory incision.   Such  an incision  as this  may first  be  used as  a
simple means of diagnosis, and as  it does  not penetrate the peritoneal cavity,
there is no  danger attending it; and  if the hernia be found, it will serve the
purpose of the ordinary incision required in  the operation,  and may be used for
the relief of the strangulation.   The first incision should be made so as to expose
the abdominal ring ; if this  be  found peculiarly round and open, it would increase
the  probability of the existence of the  condition  sought for.   The  inguinal
canal must next be laid open, and the parts contained within it carefully examined.
If no  appearance  of hernial sac is found, but the cord distinctly and clearly
seen, still further  presumptive  evidence will  be afforded of  the reduction having 
VARIETIES OF  INGUINAL  HERNIA.
731
been effected in mass; for if the hernia have been put back in the usual way,
the sac will necessarily be left in  the canal, and will preserve  its usual relations
to the cord.   This supposition will be strengthened almost to a certainty if it be
found that the " condensed cellular capsule immediately investing the sac," as it
is termed by Air. Luke, in other words the condensed and  laminated subserous
cellular tissue, has been left in  the canal.   An opening made  into this, will, as
that surgeon observes, allow the finger to be brought into contact with the hernial
tumor itself.   Should, however, this condensed cellular tissue  not  be found,  it
must not be concluded that  no hernia is  present, inasmuch as this investment
may have been accidentally absent.  The finger should  then be passed into the
internal ring, which will probably be found open, and being carried from side to
side the tumor, if present, will  be detected  lying external to the peritoneum
behind the abdominal wall.   AVhen found it must be  brought down into the
canal by  enlarging the ring.   It must then be opened, its contents examined,
and the stricture in  its  neck divided.  The intestine that has  been so strangled
must be dealt with in accordance with the rules already laid down.   If  the tumor
cannot be readily brought down so as to admit of an examination of it  and its
contents, the patient should be desired to  make some propulsive efforts,  so as to
cause it to protrude.  If it still do not come down,  it must be opened, and the
stricture  cautiously divided within the abdomen with a sheathed bistoury.
   Hydrocele of the hernial sac is a rare  condition, the pathology of which has
already been adverted to.  In  the treatment, two lines of practice are open, the
palliative and the curative.   The first consists in  merely tapping, and thus with-
drawing  the fluid, and the other in freely laying open the lower portion of the
sac, and  endeavoring to secure  its closure  by granulation.  This operation which,
however, is not devoid of danger, has been performed with success by Pott and
others.
                            INGUINAL  HERNIA.

   By inguinal hernia is meant that protrusion  which occupies the whole  or a
portion of the inguinal canal, and when fully formed passes out of the external
abdominal  ring.   Many varieties  of this hernia are recognised  by surgeons.
Thus it is said to be complete when it passes out of the external ring; incomplete
or interstitial,  so long  as it is  contained  within the  canal;  oblique, when  it
occupies  the whole course of the  canal; direct, when it passes through a limited
extent of it;  congenital, when  it lies  in the sac of the tunica vaginalis ; and en-
cysted or infantile, when  it lies behind this.   Inguinal herniae constitute the
commonest species of rupture;  and would be much more frequent than they are
were it not for the obliquity of the canal,  and the manner in which its sides are
applied to one another, and closely overlap the spermatic  cord.   They occur with
most readiness in those cases in which the canal is short  and the apertures wide.
Although these herniae are commonly incomplete in  their early stages, it is sel-
dom that they come under the observation  of the surgeon, until the protrusion
has passed beyond the external abdominal ring.
   The oblique inguinal hernia, often called external, on  account of  its relation
to the epigastric artery,  passes through  the whole length of the canal, from one
ring to the other; and usually protrudes through the external one, constituting
one of the forms of  scrotal hernia.  As it passes along  the canal,  it necessarily
receives  the  same  investments that the spermatic cord does, although these are
often greatly modified in character by being elongated, hypertrophied, and other-
wise altered in appearance.  If  we regard the  inguinal canal as described by
Maclise,  to consist of a series of invaginations of  the different layers of the abdo-
minal parietes, the outermost being the skin, and the innermost the fascia trans-
versalis, with the peritoneum  drawn  over this, it is easy to understand how the
hernia in its descent has these prolongations drawn over it, thus becoming sue- 
732
INGUINAL HERNIA.
 cessively invested with the same coverings as the spermatic cord.  Thus it first
 pushes before it that portion of the peritoneum which lies  in a fossa, just exter-
 nal  to  the epigastric vessels; it next receives an investment  from the fascia
 transversalis, which often becomes thickened  and laminated,  constituting the
fascia propria of the sac;  as  it passes  under the internal oblique, it receives
 some of the fibres of  this muscle, in the  shape of the cremasteric fascia; and
 lastly, when it reaches the external abdominal ring, which it greatly distends and
 renders round and open, it becomes covered by the intercolumnar fascia, receiv-
 ing  also a  partial investment around its neck from some  of the expanded and
 thickened fibrous bands that lie near the ring, and which are always most marked
 upon its outer  side.
   The relations of the spermatic cord and testes, and of the epigastric artery to
 an inguinal hernia are necessarily of great importance.   The spermatic cord will
 almost  invariably be  found to  be  situated  behind or  rather  underneath  the
 oblique inguinal hernia,  and the testis will be found to lie at its lower and back
 part, where it may always be distinctly felt.   In some cases the  elements of the
 spermatic  cord become  separated, the vas deferens lying  on one side, and  the
 spermatic vessels on the  other.   In other rare cases again,  an instance of which
 there is in a preparation in the University College Museum, the hernia lies behind
 the cord, and has the  testis  in  front.   In other cases  again, it  may happen, as
 was  observed  during an  operation, in which  I assisted  my friend  the late Mr.
 Morton, that the elements of the cord are all separately spread  out oh the fore-
 part of the hernial tumor.
   The epigastric artery has  the  same relations to the oblique  inguinal  hernia
 that it has to the spermatic cord, lying to the inner side of, and behind its neck.
 The pressure of large and old inguinal herniae has, however,  a tendency to modify
 somewhat the  relations  of this vessel.   By distending the rings, and dragging
 the posterior wall of the  canal downwards and inwards, they shorten the canal,
 and  cause a great  deflection  of the artery from  its natural  course; which is
 changed from an oblique  direction to being curved downwards and inwards under
 the outer edge of the rectus muscle.
   The direct  inguinal hernia  does not pass out  like the oblique through the
internal abdominal ring,  but  pushes forward through a triangular space, which is
bounded by the epigastric artery on the outer side, the edge of the rectus on the
inner, and the  crural arch at its base; through this the hernial tumor protrudes,
pushing before it, or rupturing the posterior wall  of the inguinal  canal.   The
coverings that  this form  of hernia receives vary according to the length of the
canal that  it traverses and  the portion  of the posterior wall  through which it
protrudes.   In fact, there are at least two distinct forms of direct inguinal hernia,
which differ according  as they are situated above or below the obliterated remains
of the umbilical artery.  One, the most common variety,  is situated below the
cord-like remains  of this vessel, between it and the outer edge of the rectus.
The  other,  which is of less frequent occurrence, is situated  above this vessel, be-
tween it and the epigastric artery.  In that form of direct inguinal hernia, which
lies beW the  umbilical  artery, the protrusion takes place  through  that part  of
the posterior wall of the inguinal canal which is situated almost behind and oppo-
site to the external ring.   In this situation, the investments successively received
by the hernia are first the peritoneum and the fascia transversalis; it then comes
in contact with the conjoined tendons of the internal  oblique and  transversalis
muscles, which it may either  rupture or push before it, thinned out and expanded.
Most frequently these are ruptured, constituting a  partial investment to the pro-
trusion, which is  most evident  on the innermost part of the sac, that which is
nearest the mesial line.   As the hernia passes  through  the external abdominal
ring, it receives from it the intercolumnar fascia and fibres, and lastly is invested
by the common fascia and integuments.  In that form of direct  inguinal hernia 
SYMPTOMS  OF  INGUINAL HERNIA.
733
which lies above the umbilical  artery, but which is of rare occurrence, the pro-
trusion may pass under the lower edge of the transversalis muscle, and then re-
ceives a partial investment of cremasteric fascia, especially on its iliac side, as it
comes  into relation  with the internal oblique.  This  form of direct  inguinal
hernia, therefore, receives very nearly the same covering that the oblique does,
though its investment by the cremaster is not so perfect.   It does not come into
relation with  the conjoined tendons.
Fig. 232.                                   Fig. 233.
   In the direct inguinal hernia, the spermatic cord lies to the outer side of the
 sac (Fig. 232), and its  elements are never separated from one another, as occa-
 sionally happens in the  oblique.   The epigastric artery also is on the outer side,
 but  usually arches very distinctly over  the neck of the  sac, sometimes indeed
 completely encircling the upper as well as the outer margin (Fig. 233).
   The incomplete  or interstitial hernia is usually of  the oblique kind, but  Law-
 rence has observed that it may be of the direct variety.   It often escapes notice,
 but may not  unfrequently be observed on the opposite side to an ordinary ingui-
 nal hernia.  Double inguinal hernia on opposite sides are of very common occur-
 rence, and they may be of  the same, or assume different forms.  In some in-
 stances, as in the annexed drawing, from  a preparation in  the University College
 Museum, the two forms may be observed on the  same side (Fig. 232).
   In females, inguinal  herniae are not common, except at advanced periods of
 life; they will then be seen  to have the same relations as in the male, except that
 the round ligament is substituted  for the  spermatic cord.
   The symptoms  of inguinal hernia vary somewhat according to its character,
 whether interstitial, complete, or scrotal,  oblique  or  direct.  In  the interstitial
 hernia, a degree  of fulness will be  perceived in the canal when the patient stands
 or coughs, and on  pressing the finger on  the internal ring, or passing it up into
 the external ring, and directing the patient to cough, a distinct impulse, together
 with tumor may  be felt.   In the ordinary oblique inguinal hernia, a tumor of an
 oblong or oval shape, oblique in its direction, taking the course of the canal down-
 wards and forwards, will be  felt protruding through the external abdominal ring,
 and presenting all  the usual signs of a hernia.   So  long as it is confined to the
 neighborhood of the  pubes, it is of moderate  size;  but when  once it gets into
 the scrotum, where it meets with  less  resistance, it may gradually enlarge  until
 it attains an enormous bulk.   The testicle, however, may always be felt pretty

 Fig. 232.—Double inguinal hernia on the same  side—oblique  above, direct below—separated by epi-
gastric vessels.
 Fig. 233.—Double direct inguinal hernia—neck of sac crossed by epigastric artery. 
734
INGUINAL nERNIA.
 distinctly at its posterior inferior part.  In women, this form of hernia descends
 into the labium, but never attains the same magnitude as in men.   When of
 large size, these ruptures usually contain both intestine and omentum, most fre-
 quently a portion of the ileum,  though the  various other viscera, such as the
 ccecum, bladder, &c, have been found in them.   In the direct inguinal hernia,
 the symptoms pretty closely resemble  those of the oblique, except that the tumor
 is more rounded, and usually not so large; the neck wider, and situated near the
 root of the penis, with the cord on its outer side.
   The different forms of inguinal hernia are not unfrequently complicated  with
 various other affections;  either with  different kinds of rupture, or with diseases
 of the cord or testis, such  as hydrocele of the cord, of the tunica vaginalis, or
 varicocele; these various complications necessarily make the diagnosis somewhat
 more obscure, but with care and practice it may generally easily be made out.
   The diagnosis of inguinal hernia is usually  readily effected, the  characters
 and position of the tumor enabling the surgeon to determine its true nature. In
 most cases it is useless to endeavor to ascertain whether the hernia is  oblique or
 direct, all old oblique herniae having a tendency to drag the inner ring downwards
 and  inwards, approximating it and bringing it nearly opposite to the outer  one,
 shortening and destroying the obliquity of the canal.  Hence the direction of the
 neck and of the axis of the tumor  in these cases so nearly resembles what is
 met with in the  direct  form of  hernia, that the  surgeon should not attempt to
 undertake the operation, more particularly the division of the stricture, on any
 imaginary diagnosis.  Some forms of femoral hernia may occasionally be  con-
 founded with the inguinal; the distinguishing point between these  two forms of
 the  disease will be considered in the section on femoral hernia.
   The diagnosis of inguinal hernia from other diseases in this vicinity has to be
 considered under the two conditions in which  the rupture is found, in the canal,
 and  in the scrotum.  Whilst in the canal the  inguinal hernia requires to be
 diagnosed,—1st,  From abscess,  descending from the interior of the  abdomen
 or pelvis through the canal, and  passing out through the  abdominal ring.  The
 diagnosis may here  be effected by recognising the soft  fluctuating  feel of  the
 abscess, which though reducible on pressure, and descending on coughing with
 a  distinct  impulse, does  not present the more  solid characters and the gurgling
 sensation of a hernia.  2dly, From encysted or  diffused  hydrocele of  the cord.
 In the encysted  hydrocele there  is a smooth oval  swelling situated on the cord,
 which can be apparently reduced, being pushed up into the canal, and  descends
 again on  coughing or straining;  but  it maybe  distinguished from hernia by
 being always of the same  size, by not  being reducible  into the cavity of  the
 abdomen, by the absence of all gurgle, and by its very defined outline.   In  the
 diffused hydrocele of the cord, the absence of distinct impulse  on coughing,  the
 impossibility of returning the swelling completely within  the abdominal cavity,
 and, of feeling the cord in a free and natural state, will prevent  the disease being
 confounded with hernia,   3dly,  Fatty or other tumors occasionally form on  the
 cord, but the circumscribed character and limited size of these swellings,  the
 absence of impulse  on coughing,  and  of reducibility into  the cavity  of  the
 abdomen, will point  out that they are  not herniae.   Ithly,  The  lodgment of the
 testis in the inguinal canal will give rise to a tumor, which  closely resembles  in-
 complete inguinal hernia, and if it should happen to become  inflamed in this
 situation, the difficulty of the diagnosis  from strangulated hernia may be very con-
 siderable.  In the ordinary  undescended testis the absence of that organ in  the
 scrotum on the affected side, the  peculiar sickening pain occasioned by the pres-
 sure of the tumor, the absence  of gurgling, and of all possibility of reduction,
will  enable the  diagnosis to be effected.   A very remarkable  case of  inflamed
testis in the inguinal canal  simulating a strangulated inguinal  hernia,  occurred
some time  ago at  the Hospital.   A man about forty, said to be laboring under 
DIAGNOSIS  OF INGUINAL  HERNIA.
735
strangulated hernia,  was sent up  from the country  for operation.   On being
called to him,  I found the house-surgeon attempting the reduction of the tumor
in the  hot bath;  but as  soon as I felt the  swelling,  I was  convinced from its
hard, solid, and irregular feel that it was not an  ordinary hernia.   On inquiring
into the history of the case it appears that the patient had, for the last two days
suffered from  occasional  vomiting, and had been constipated; that  the tumor
in the  groin had  not appeared suddenly, though  it had enlarged with great
rapidity, and that it was excessively painful; and  that he had  always  worn a
truss for a supposed rupture on that side, until the last few weeks, when, in  con-
sequence of the  instrument breaking,  he  had discontinued it.   On examining
the groin carefully, a tumor about  as large as the fist  was  found in the right in-
guinal  canal;  it was  tender to  the  touch, hard,  and irregular  at  the upper  and
outer part, but somewhat soft and fluctuating below; when the finger was passed
into the external ring, the  outline of the  tumor could be very distinctly felt in
the canal.  There was no impulse in it on  coughing, but some abdominal  tender-
ness on that side.  The right testis was not  in the scrotum.   I ordered the  man
to be bled, the tumor to be leeched, and salines administered; under this treat-
ment the case did well.
   AVhen the hernia had descended into the scrotum, it maybe confounded,  Firstly,
with hydrocele of the tunica vaginalis.  In  this disease, there  is an oval  or pyri-
form tumor, usually translucent, unchangeable  in size or shape by pressure, and
having the cord clear and distinct above it, with an  absence of impulse on cough-
ing, or of gurgling in attempts at reduction.   In cases of congenital hydrocele
in children, in which there is still an opening communicating with the peritoneal
cavity, the  tumor may be diminished  in  size, by steady pressure, but gradually
returns again, fluctuates, and is translucent.   In these cases its translucency, the
gradual manner in which  the sac is emptied, and is refilled, so different from
the sudden  slip up and protrusion of  a hernia,  enable  the  surgeon  to establish
the  diagnosis.   It not unfrequently happens that hernia is  complicated  with
hydrocele of the  tunica vaginalis.   In these cases, the two separate tumors can
usually be  distinguished, there being  some degree of constriction, or of conso-
lidation, between  them.   The hydrocele  will  present its  ordinary characters of
translucency, irreducibility, and circumscribed outline, and is commonly placed
anterior to the hernia, which lies towards  the back  of the scrotum, and  may be
 distinguished  by its reducibility and impulse on coughing.   It sometimes  hap-
pens, as in a case which recently fell under my observation, that a hydrocele of
 the cord is associated with one of the tunica vaginalis, and a hernia; under  such
 circumstances, the diagnosis requires  a  little care, but may be effected  readily
enough by  separately determining the  characters  of the different swellings.
 2dly.  From varicocele, the diagnosis may be effected  in the way pointed out by
 Sir A. Cooper.  The patient should be placed  in  the recumbent position, and
 the swelling reduced; the surgeon then presses upon the external ring with his
fingers, taking care to cover the whole of it, and desires the patient to stand up.
 If it be a hernia, the tumor cannot descend, but if a  varicocele, it will speedily re-
appear, whilst the pressure  is being kept up, the blood being conveyed into it
 through the spermatic arteries.  3dly.  Tumors of the testis may be distinguished
 from hernia by their solid feel, rounded shape, by the absence of all impulse on
 coughing, and, especially, by the cord being felt free and  clear above them, and
 the inguinal  canal unoccupied.   4thly.  In hasmatocele, the cause of the swell-
 ing, its pyriform  shape, opacity, solid  feel, the absence of impulse on coughing,
 and the defined  characters of the cord,  will enable the surgeon to make the
 diagnosis.
   Treatment of Inguinal Hernia.—AVhen  reducible, the rupture must  be  kept
 up by  a well-made truss, the pad  of which, of  an oval shape, should press not
only upon the external  ring, but  upon the whole  length of the  canal.   When 
                        f
736                       INGUINAL  HERNIA.
irreducible, and of large  size, nothing can be  done beyond supporting it  in a
bag-truss.
  AVhen strangulated, if the taxis  properly  employed  in  the direction  of the
canal have failed, the operation must be proceeded with  in the following way :—
The bladder having been emptied, and the pubes  shaved, the patient should be
brought to the edge of the bed, and the surgeon, standing between his legs, and
having the skin covering the external ring well pinched up, divides the fold in the
usual way,  by an incision three inches in length, commencing about an inch above
the external abdominal ring (Fig. 234).  Should any spouting vessels, as the super-

                                 Fig. 234.
ficial external pudic, be divided in this incision, they had better be ligatured. The
surgeon then proceeds with the section through the subcutaneous structures;  he
will find in many cases the superficial fascia considerably thickened, more parti-
cularly if the patient has  long worn a truss.   He divides this structure in the
line of the external incision, and then exposes the intercolumnar fascia, which
will also generally be found thickened and incorporated with the superficial fascia.
In many cases, the intercolumnar fibres will be found condensed into a thick and
broad fillet, which limits the further extension of the ring, and produces an evident
constriction upon the neck of large inguinal herniae.  An opening should be care-
fully made into this fascia, a grooved director passed under the edge of the ring,
and this slit  up-   In some cases, though but very rarely, it will  now be found
that the hernia may be reduced, its strangulation depending on the constriction of
the margins of this aperture ;  most  commonly, however,  the stricture is situated
deeper than this.  The cremasteric fascia, which is generally considerably thick-
ened, is now  exposed, when its fibres will be found to form a kind of reticulated
mesh over the hernial tumor.  This structure  must be carefully divided upon a
director, when the subserous cellular  tissue, or fascia propria, will be laid bare.
This structure is usually thickened and vascular, and not unfrequently the stric-
ture appears  to be situated in  it, or in a kind of condensed ring formed by the
incorporation of it with  the meshes  of the cremaster.  If it be found, after the
division of these fasciae,  that the stricture  has been removed, and the hernia can
be reduced, it would of course  be unnecessary to lay open the sac, and the safety
of the patient will be considerably enhanced, more particularly if the operation
is performed  for an old scrotal hernia of large size, by not doing so.   If, however,
as will happen in the majority  of instances, in inguinal hernia, it be found that
the stricture  is in  the  neck of the  sac itself,  occasioned  by a condensation, con-
striction, and puckering of it,  the sac must be carefully opened at  its  anterior
part, the  finger  introduced, and the  stricture divided from within, by pressing 
                OPERATION  FOR INGUINAL  HERNIA.             737

the finger-nail under it, and cautiously sliding the  hernia-knife along this.   It
is an established rule in surgery, that this division should be effected in a direc-
tion immediately upwards, so that it may lie parallel with the epigastric vessels,
whether it be situated upon the  inner or outer sides of these.  It is true that if
the surgeon could be sure that he had to do with an oblique  inguinal hernia, he
might safely divide the  stricture outwards, or, if he was  certain that the protru-
sion was of the direct kind, he might make  the section inwards; but, as it com-
monly happens that he cannot determine with absolute  certainty which hernia
he  is operating upon, he adopts the safer plan recommended by Sir A. Cooper
and Lawrence, of  cutting upwards from the middle of the ring, parallel to the
epigastric vessels.
  The seat of stricture in inguinal hernia will thus  be seen to differ in different
cases, and  in some instances it exists  in two situations.   I think it  most com-
monly occurs in the neck of  the sac, owing to contraction and  elongation of it
with condensation  of the  subserous  cellular tissue  lying immediately upon it.
In other cases, though much more rarely, it seems to be formed by a thickening of
the transversalis fascia at the inner ring, but altogether outside the sac; occa-
sionally it is met with in some part of the canal, at the lower  edge of the internal
oblique, but much more  frequently at the  external  abdominal ring.   In many
cases there is very tight constriction in  this  situation, as  well as in  the deeper
portions  of the canal,  or  at  the  inner ring; hence after the division of any
stricture at the external  abdominal  ring,  the  deeper  portions  of the canal
should always be  carefully examined before  any attempt is made  to put the
hernia back.
  The operation for an  incomplete inguinal hernia requires to  be conducted  in
the same way as that which has just been  described, except that the incision
need not  be quite  so  long,  and  should not extend beyond the external ring.
After this has been laid open a flat  director  must be passed under the lower edge
of  the internal  oblique and transversalis  muscles,  which  must be carefully
divided; should the stricture  not be relieved in this way, and the sac require to
be kid open, the deep section must be made in the  same way and in  the  same
direction as has already been described.
  Inguinal Herniae, which contain either the ccecum, the sigmoid flexure of colon,
or the urinary bladder.—In these cases the protruded viscera are only partially
covered by peritoneum, hence in  operating upon such herniae, when strangulated,
care must be taken that the intestine be not wounded, which is apt to occur,  in
consequence of the surgeon dividing the parts without due caution, not suspect-
ing himself  to be  in the  neighborhood of the  gut, in consequence of his not
having reached a sac, which does not exist.  As the protruded parts are generally
adherent in these  cases, the surgeon must  content  himself  with leaving them
unreduced after the division  of the stricture;  under such circumstances, it has
happened  that the protrusion is ultimately drawn back into the abdomen by some
natural action of the parts.
  Operations for strangulated inguinal hernia are  required during a  greater
range of  ages  than those for any other kind of protrusion.   I have operated
successfully for an ordinary oblique inguinal hernia in a  child four months  old,
and it has been done on centenarians.   AVhen small and recent, the protrusion
usually consists of  intestine only; when large it commonly contains omentum  as
well.  The treatment of these contents, and the  after-management of the case
must be conducted in accordance with the rules laid down at pages 719 etseq.
  Hernia of the tunica  vaginalis or Congenital Hernia.—In this case the hernia
descends inside  the tunica vaginalis, which  constitutes its sac.  It is always
oblique, passing through the whole  length of the  canal, and taking the course  of
the spermatic cord.  This hernia differs from an ordinary oblique hernia in the
absence  of a true  peritoneal  sac, and in the protruded parts lying in the tunica 
738
INGUINAL HERNIA.
vaginalis  and in contact with the testicle (Fig.  235).   The great peculiarity,
indeed, of this hernia consists in its descending along the canal, left open by the
descent of the testis.   It is well known that in the foetus the testis originally lies
below the kidney, and as it descends in the later months of foetal life into the
inguinal canal and scrotum, it pushes before it a prolongation of the peritoneum,
exactly resembling a hernial  sac.
  That prolongation of the peritoneum which is carried down around the testis
in its descent, may be divided into two portions, the funicular and the testicular.
The funicular being  that which  corresponds to the cord, extending from the
internal ring to the scrotum; the testicular being  that which becomes the tunica
vaginalis.  A congenital hernia occurs in consequence of the funicular prolonga-
tion not  becoming,  as in  the  normal  condition,  converted  into a filamentous
fibro-cellular  tissue, but remaining pervious, and thus serving as a medium  of
communication between the  general cavity of the peritoneum and the tunica
vaginalis, and along the open channel thus left the congenital hernia descends.
The reason why in many cases  the hernia is not truly congenital, but occurs  in
after-life, is that the funicular portion is only partially closed or contracted, and
that under a  sudden effort  this septum is broken through, and thus the gut falls
into the  tunica vaginalis.
  Hernia of the tunica vaginalis, though usually called congenital, is not so in
reality; the tendency is congenital, but the disease is not.   It not unfrequently
happens, it is true, that these herniae show themselves early in life;  in infants a
few weeks or months old;  though at these ages even the funicular  prolongation
of the peritoneum may be so completely  occluded, that  the hernia which occurs
is of an ordinary oblique character.   Not unfrequently, however, the hernia does
not occur  until  a considerably later period of life than this, and may suddenly
happen in the adult.   Thus,  Velpeau relates instances in which it occurred for
the first time between the  ages of eighteen  and  twenty-five.  I lately operated
in a case on a man thirty-five years of age, in whom this  kind of hernia occurred
for  the first time when he was  twelve years old; and about two  years ago, in a
case at the Hospital, on a man  about fifty, in whom, on the most careful inquiry,
it would  appear  that the  protrusion had not occurred until he was about thirty
years of age.
  The symptoms of hernia in the tunica vaginalis  closely resemble those of the
ordinary oblique; most commonly, however, the scrotal tumor is much rounded,

                 Fig. 235.                               Fi:r. 236.
              Congenital hernia.                       Infantile hernia.

and the neck feels narrow and constricted.   The testis also cannot be felt dis-
tinct and separate from the tumor, but  is surrounded by and as it were, buried
in the substance  of the  hernia, through which it may sometimes be felt at  the
lower and back part of the scrotum.
 
INFANTILE AND  FEMORAL  HERNIA.
739
  The treatment of congenital hernia consists in  the reduction of the tumor,
and the application of a proper truss, the pad of which should compress the whole
length of the inguinal canal.   In some cases in children, a radical cure may be
effected in this way, but in order to accomplish this  desirable result  the truss
must be worn for at least  a  couple of years.   The application  of  a truss with
an air-pad  will in many instances be found especially useful, more particularly in
children, in whom  it applies itself with greater  exactness  than  an ordinary
incompressible one.
  When strangulated, the  congenital hernia does not commonly admit of reduc-
tion, and thus necessarily renders an operation imperative.  This procedure  is
more  commonly required  for this  kind  of  hernia in adults  than in infants.
During the last three years I have  operated  in 7 cases of congenital hernia;
of these 5 were on adults, whose  ages varied from twenty-two to fifty;  and  2
on infants under six weeks  of age.   The operation  is the same  as that for
oblique inguinal hernia, but the parts concerned are usually thinner, the  tunica
vaginalis serving for a sac ; hence more caution than usual is required in these
cases.   The sac  commonly  contains  a  large quantity  of  dark-colored fluid,
there being in  fact a hydrocele conjoined with the hernia.  The stricture will,
I believe,  always be found in  the neck of the sac, which appears to be condensed,
elongated, and narrowed.  Hence  it  is useless in these  cases to  endeavor to
relieve the strangulation,  without laying open the sac and dividing its neck from
within. As the congenital hernia is always  external to  the epigastric vessels,
the section of the stricture may be done with perfect safety in a direction upwards
and outwards;  though if the  surgeon should have  any doubt as to the exact
nature of  the case,  it will  be better  to divide the  stricture directly upwards.
The reduction of the contents of the hernia will often be prevented by adhesions
in the neck of the sac,  or between them and the testes.  I have  found both
the gut and omentum  closely incorporated with this organ, and requiring some
nice dissection to separate them.   In  operating upon infants of a very tender
age, much caution will necessarily be required, on  account of the density  of the
coverings,  their tension, and the small size of their apertures.   The testis as well
as the spermatic cord,  the veins of which are excessively turgid, will usually be
found much congested, and of a black or bluish-black color.
  A species of congenital hernia has  been met with in  the female, especially in
children, in which the protrusion takes place into the canal of Xuck, which invests
the round  ligament.  It is  of  extremely rare occurrence, and requires the same
treatment as the corresponding disease in  the male.
  The encysted hernia of the tunica vaginalis, or infantile hernia, as it has been
somewhat absurdly termed, occurs in those cases in which the funicular portion
of the tunica vaginalis  is  partly obstimeted by a septum, or by being converted
into filamentous tissue, but in such  a way as  to leave  a pouch  above, which  is
protruded  down behind or  into the  tunica vaginalis, so that it  lies  behind this
cavity  (Fig. 236).   There  are no characters by which the encysted can be dis-
tinguished from the ordinary congenital hernia.   If it should become strangu-
lated, it must be borne in mind that during  the operation, the  tunica vaginalis
will first be opened; no hernia will be seen here, but the tumor lies behind this
sac, and requires to be dissected into through the double serous layer of which it
is composed.   The stricture would probably be in the neck, and requires to be
divided in the usual way.

                            FEMORAL HERNIA.
  By femoral  hernia is usually meant a protrusion that escapes under Poupart's
ligament,  and enters  the sheath of  the  vessels internal  to the femoral vein.
This hernia  passes down into the innermost compartment  of the sheath,  which 
740
FEMORAL HERNIA.
Fig. 237.
is occupied by fat and lymphatics, and usually contains  a gland or  two.  It
                                passes first of all through the crural ring, where
                                it has Grimbernat's ligament to its inner side;
                                the septum, which separates the femoral vein
                                from the inner compartment of the sheath of
                                the vessels  to its outer aspect; Poupart's liga-
                                ment  in  front,  and the  bone behind  (Fig.
                                237).  After  passing through the crural ring,
                                it  enters the  crural canal, which extends for
                                about an inch and  a half down the thigh  on
                                the pectineus muscle, and is  covered by the
                                iliac  prolongation of the fascia lata.   As it
                                approaches the lower corner of the saphenous
                                opening,  where the  canal terminates,  it passes
                                under the falciform  process of the fascia lata,
                                and out upon the thigh through the saphenous
                                aperture; here it expands, becomes rounded,
                                and has often a tendency to turn upwards over
                                Poupart's ligament  (Fig. 239), lying in this
way upon the iliac region, and sometimes even  ascending to a  considerable dis-
tance upon the anterior abdominal wall.   In the descent of the hernia through
this course it first of all pushes  before it the peritoneal  sac, and then receives
an investment through the subserous cellular tissue.   It next comes into relation
with the septum crurale, a mass  of  dense cellular  tissue, containing fat and
lymphatics, occupying  the crural ring.   This septum often becomes incorporated
and matted with the  contiguous  portion  of the sheath, thus constituting the
fascia propria of this  hernia, whiclris  commonly thickened, laminated, and of
an opaque fatty structure, like omentum.  As the  hernia continues  to  descend,
it comes into  relation with the cribriform fascia, which occupies  the  saphenous
opening, and  lastly, pushes before it the integumental structures.
   As the tumor descends through this course, it necessarily comes into relation
with very important  parts (Fig. 238).   Thus it is separated from the femoral
                                                vein solely by the septum of the
                                                sheath of  the  vessels.   It has
                                                the epigastric artery above and
                                                to its outer side, and  the sper-
                                                matic cord in the male, or round
                                                ligament in the female,  almost
                                                immediately above it.  The ob-
                                                turator artery,  when arising in
                                                the normal manner from the in-
                                                ternal iliac, does not come into
                                                relation with  the  neck  of the
                                                sac;  but when it takes  its ori-
                                                gin, as it not unfrequently does,
                                                from the external iliac, the com-
                                                mon femoral, or the  epigastric,
                                                it may have important relations
                                                to this part of the hernia. Most
                                                commonly, under these circum-
                                                stances, it passes to the iliac or
                                                outer side of the neck, but  oc-
                                                casionally  it winds  round  its
  Fig. 237.—1, Femoral artery; 2, femoral vein; 3, innermost compartment of the sheaths of the vessels,
into which a small hernia is protruding; 4, saphena vein.
  Fig. 238.—1, Femoral hernia ; 2, femoral vein; 3, femoral artery, giving off,4, common trunk of epigas-
tric and obturator arteries; 5, epigastric  artery; 6, spermatic cord.
 
       RELATIONS  AND SYMPTOMS  OF  FEMORAL  HERNIA.     741

inner or pubic side, coming into pretty close relation with it, and then, as will
immediately be mentioned,  may be in considerable danger during the operation.
The combination, however,  of this particular variety of the obturator artery and
femoral hernia, is not a very common occurrence, because, in the first place, this
internal distribution of the artery is rare; and when it does  occur, as it passes
directly over that portion of the crural ring through which  the sac would pro-
trude, it necessarily strengthens this, and  so diminishes the chance of rupture.
  The contents of a femoral hernia  are  usually intestinal, and most commonly
consist of a portion of the ileum.  Occasionally omentum is contained within the
sac, but seldom in large quantity.   I have, however, twice  had occasion to ope-
rate in cases of old femoral  hernia, in which it became necessary to remove large
portions of adherent omentum; in one, ten and a half ounces, and in the other,
about seven.   In each case there was a small knuckle of intestine strangulated
behind the omentum.   The ovaries, Fallopian tubes, &c, have been known to be
strangulated in this variety of hernia.
  The symptoms of femoral hernia are usually well marked; they consist  of a
tolerably firm, tense, and unyielding tumor,  of a rounded shape, situated in the
groin, to  the inner side of the femoral vessels, having its neck under Poupart's
ligament, though as it increases in size its base may be turned above this struc-
ture ;  sometimes, though rarely, it passes downwards  upon the  thigh.   Its size
varies  considerably, most commonly it is not larger than a walnut or a pigeon's
egg, and  then  is deeply seated in  the angle between the body of the pubes and
the femoral vessels, but occasionally it may^
attain a considerable bulk, as large as the fist
or a French roll; when large, this hernia usu-
ally rises up above Poupart's ligament,  and
extends outwards in a direction parallel to it,
so that it assumes an elongated shape;  it is
then usually somewhat doughy and soft, even
when  strangulated; very different  from the
excessively tense feel that it has when small.
  In some  rare cases the femoral hernia has
been found lying external to the  vessels, the
mouth of the sac being between them and the
iliac spine.   Under these circumstances stran-
gulation cannot well occur, inasmuch as the
mouth will  be  the widest part of the sac,  but,
as Hesselbach has observed,  if the  fascia  iliaca be torn by the  pressure of the
tumor, the  rupture may be strangled in  the aperture thus  formed.   Should  an
operation ever be required  under such circumstances, it must be borne  in mind
that the circumflex ilii artery may be in some danger.
  The diagnosis of femoral hernia is not  always  easy.  When the hernia is
large, and  more  particularly when  it rises up above Poupart's ligament, which
some herniae, even of very  moderate size, are apt to do, it might at first be mis-
taken for an inguinal  rupture.   The diagnosis,  however, may always be effected
by ascertaining the relation that the neck of the sac  has to  Poupart's ligament,
the inguinal hernia being situated above, the femoral below  this cord.  When a
small  femoral  hernia in a fat subject rises upwards, so as to overlay Poupart's
ligament, it resembles very closely an incomplete inguinal hernia, but its  charac-
ters may  be determined by the passage of the finger up the canal, which will be
found to be free, and the hernia can only be felt through its posterior and  infe-
rior wall.    After reducing a femoral hernia, the  finger also can usually be pushed
into the inferior aperture of the crural canal, when the situation and sharp out-
line of the falciform process will determine the nature of the opening  through
which the protrusion has occurred.
 
742
FEMORAL HERNIA.
   The  diseases occurring in the groin, with which femoral hernia  may most
 readily be confounded, are—1st.  Enlarged lymphatic glands in this situation.
 From these it may be distinguished by the absence of impulse in the  glandular
 tumor, and by the simultaneous enlargement of several glands.  A small Strang,.
 lated hernia may however  co-exist with these, being subjacent  to, and covered
 in by them.   AVhen this is the case, and the local signs of hernia are obscure,
 whilst the symptoms of strangulation continue, an incision should be made into
 the part, and the dissection carefully carried through and underneath the glands,
 with the view of determining whether the hernia exists or not.   2dly. A small
fatty growth has been met with in the crural canal, simulating closely a hernia;
 the want of impulse on coughing,  together with its limited and doughy character,
 and the absence of circumscription in the tumor, will enable the surgeon to dis-
 tinguish it from hernia.  3dly. Psoas abscess not unfrequently points very nearly
 in the situation of femoral hernia;  from this it may however be distinguished
 by its fluctuating feel, soft, yet semi-elastic character, and by the general history
 of the case.   The impulse on coughing, which is very distinct in the abscess, is
 commonly more forcible and direct  than that  of a hernia; and although the
 purulent collection may in  many cases be squeezed back into the abdomen when
 the patient lies down, yet it returns without a gurgle, and without that distinct
 slip which accompanies the reduction of a hernia.   5thly.  Varix of the saphena
 vein is in some  danger of being confounded with hernia.   It may, however, be
 distinguished from this by the impulse in it being less distinct, and by the en-
 largement of the lower part of th% vein being marked in the varix, but not exist-
 ing in the rupture.
   Femoral hernia most commonly occurs in women  and very seldom under the
 age of twenty ;  differing in both  these respects from the inguinal rupture.  Sir
 A. Cooper states that he had only seen three cases under the above age.  It very
seldom becomes strangulated at an early period  of life, even when  existing.  I
have lately had a girl of nineteen under my care with femoral hernia, in whom
strangulation had already occurred on four occasions, reduction however having
been happily effected each time.
   The treatment of femoral hernia when reducible  must be conducted in the
ordinary way by the application of a  proper truss.   A cure, however, is never I
believe  effected by the  pressure  of  the pad, as  sometimes  happens in inguinal
hernia, owing probably to the  rigidity and incompressibility of the tendinous and
aponeurotic structures through which this rupture protrudes.  It is difficult to
keep this  form of hernia up by means of a truss.    The best instrument for this
 purpose, is I think, the " Mocmain truss," which I have found succeed when all
others have failed.  AVhen the hernia is irreducible it should be supported by
means of a truss with a concave pad.
   AVhen a femoral rupture is strangulated, reduction  should  be  effected either
by taxis or operation as speedily as possible, gangrene more rapidly ensuing in
this than  any other form of hernia.  In attempting  the  taxis the structures in
the groin  should be well relaxed by bending the body forwards  and  flexing the
thigh upon the abdomen ;  if it do not succeed with the assistance of the means
recommended at page 715  the operation should be proceeded with at once.   The
operation  for strangulated femoral hernia may be undertaken earlier  and with a
better prospect of success than that for any other form of rupture ; this is owing
to the stricture  being so commonly seated outside the  sac,  that the operation
usually admits of being completed without implicating  the  peritoneum.   The
advantage of this mode of procedure in femoral hernia has been fully  pointed out
by A. Key, Luke, and Gay, and is now, I think, pretty generally recognised and
practised.  Mr. Gay more particularly in  his  work on Femoral  Hernia, has
pointed out that the stricture may commonly be divided without opening the sac,
by making a  very limited incision on  one  side of the neck of the tumor ; and 
OPERATION  FOR FEMORAL  HERNIA.
743
he justly observes that the operation undertaken in this  manner is  little more
than the taxis with the addition of a superficial incision.
  The stricture in femoral hernia is often found to be occasioned by the pressure
of the crural arch.  Lawrence states that it may be most effectually relieved by
dividing the thin posterior border of this arch  near the pubes.   Other surgeons
recommend that the sharp edge of Gimbernat's ligament  should be divided,  and
others again that the division should be made at the junction of Gimbernat's and
Poupart's ligament through those ligamentous bands that go by the name of
Hey's, or the ilio-femoral ligament, or, at  the inner edge of the falciform process.
And indeed it is in this situation that both Lawrence and Hey direct the division
to be made.  In operating for femoral hernia, I have certainly most  frequently
found the stricture still to continue after  the division of these ligamentous struc-
tures, and to be occasioned by fibrous bands often very distinct, narrow, and glisten-
ing, lying across the neck of the sac in the fascia propria of the hernia ; and I
agree with the opinion expressed by Sir A. Cooper, that the neck of the sheath
is the  common  seat of strangulation in the  femoral hernia ; these transverse
fibres which sometimes appear to  be partially reticulated, consisting  probably of
a condensation of the tendinous fibres that are  normally found in the sheath of
the vessels.   In order to expose them it  is commonly necessary to draw the neck
of the sac well down,  when they will be seen deeply to indent and constrict it.
   The operation without opening the sac, may most conveniently be performed,
when the tumor is of small size, in the way recommended by Air.  Gay, by making
an incision alone the inner side of its neck  and then dissecting through  the
superficial structures until the sharp inner edge of the falciform process is  ex-
posed ; under this, a  flat director should be pushed, and the  hernia-knife being
carried along this, the stricture must be  divided, to a limited extent, for a  line
or two,  upwards and inwards.  The reduction  may now be  attempted, and often
effected ; should any  obstacle  exist, the neck  of the sac must  be well   drawn
down and exposed, and any transverse bands situated upon it dissected through
with the scalpel and forceps.   I have on most occasions found it necessary to do
this before reduction could be effected.
   The operation performed in this way is certainly a very simple procedure,  and
adds little to the danger of the patient.  If it be thought desirable to open  the
sac, the operation must be performed in a different manner, the  parts requiring
to be pretty fully exposed ;  and indeed, if the tumor be of any considerable
magnitude, even  though the  sac be not opened, it will be better to  expose  the
part somewhat more freely in the way to be described.   An  incision should be
made parallel to Poupart's ligament, by pinching up the  skin, and then a trans-
verse cut from the centre of this carried over  the  tumor so as to  present  the

following shape   I    ^T  :  the dissection must then be carried through  the

superficial fascia, when the septum crurale or fascia propria will  be exposed  ; in
some cases, especially if the hernia be a  large  one, this is thin,  and requires to
be carefully slit up  on a director.   In many instances,  however, it is so dense,
laminated,  and changed in structure, as  scarcely to be recognised for what it is.
It not unfrequently happens that after the superficial fascia has been divided, an
oval, smooth, and firm body is exposed, which at first looks like  the hernial  sac,
or a lump of omentum;  this is in  reality  the fascia  propria, thickened by the
long-continued  pressure of the truss,  and congested perhaps by the  attempts at
reduction ; and in the midst of this the  sac will at last be found after the dissec-
tion has been carried through several layers  of this tissue.  In it  occasionally
cysts containing bloody serum may be found, and then the difficulty in  the re-
cognition of the structures is greatly increased.  Though the mobility  of  this
mass, the facility of tracing its neck, and the roundness  of its general outline,
often cause it to be mistaken for sac or omentum, it  may be distinguished from 
744
UMBILICAL HERNIA.
the first by the absence of the characteristic  vessels upon  its surface, and from
the second by its more rounded, solid feel, and uniform appearance.   W hen the
sac has been reached, it must be very carefully opened, there being usually very
little, if any, fluid between it and  its contents ; the finger-nail must  then  be
passed under the sharp edge of the stricture, which should be divided in a direc-
tion upwards and  inwards.  The reason why this line of incision  is  universally
chosen by surgeons in this country at the  present day is, that it is the only direc-
tion in which the  stricture can be divided, without risk of inflicting serious in-
jury upon neighboring parts.   If the section be made outwards, the femoral vein
would be in danger ;  if upwards and outwards, the epigastric artery ; if directly
upwards, the spermatic cord :  hence the only direction  is either inwards,  or up-
wards and inwards.   If the cut be made inwards, the sharp edge of Gimbernat's
ligament alone will be divided, and the crural arch not sufficiently liberated.  But
if the division be made upwards and inwards, the  ilio-femoral  ligament will be
divided, and thus the tension of the whole of the arch lessened; the only danger
that can occur from the division of the stricture in  this  direction  is the very
remote one of the division of the obturator artery, when it takes the anomalous
course round the inside of the neck of the sac.  Mr. Guthrie states  that he has
known some of the best surgeons in London lose  patients by hemorrhage after
the operation for femoral hernia.  This accident, however,  must be of extremely
rare occurrence, and might in a  great measure be  guarded against by slightly
blunting the edge of the hernia-knife before  dividing the  stricture, so  that  the
tense fibrous bands constituting the  constriction  would yield, but  the  artery
probably escape, being pushed before the  blunted edge.  If the division  of the
stricture is limited to a line or two, there  will be but little danger of wounding
the vessel even when it takes the abnormal course.
   It will generally be found that the intestine  contained in the sac of a femoral
hernia is dark colored and tightly nipped  ; it requires to be treated in accordance
with the general principles that guide us  in the management of hernia.

                           UMBILICAL  HERNIA.
   By umbilical hernia or exomphalus is meant a' protrusion through the umbili-
cal aperture.  This is sometimes congenital, and when so, it has happened that
the protrusion has been included in, and accidentally strangulated by,  the liga-
ture applied to  the  umbilical cord.   More frequently, however, it occurs a few
months after  birth in consequence of the child straining or crying.   In these
cases it is  readily recognised by a  smooth, rounded, and  tense tumor, starting
forwards at  the umbilicus, readily reducible on pressure.  The  treatment should
consist in  keeping the tumor reduced by the application of the  apparatus in-
vented by M. Bourgeaud, which consists of an elastic India-rubber belt with an air-
pad that presses firmly upon the aperture; or should such contrivance as this not
be at hand, the reduction may readily enough be effected by applying a piece of
soap-plaster spread on amadou, over the aperture, upon  which a well-padded slice
of cork may be tightly strapped.   It most  commonly happens that after pres-
sure has in this way been kept up for some months, a radical cure results.
   Umbilical hernia in adults most  frequently occurs in women, especially those
who have borne many children, or who are loaded with internal fat.   It is by no
means unlikely that the tendency to this disease is often established in childhood,
but does not become developed until the abdominal muscles have been weakened
and the umbilical  aperture relaxed by the pressure of the gravid uterus.
   The umbilical rupture usually attains a considerable bulk, and often  acquires
an  enormous size; when large it is commonly irregular or semilunar in  shape,
sometimes appearing to be composed of two distinct tumors.   It is usually partly
doughy and partly tympanitic to the  feel, has a distinct impulse on coughing,
and is readily  reducible; not unfrequently it happens, however, that a portion of 
VENTRAL  AND OBTURATOR HERNIA.
745
the rupture continues irreducible, owing apparently to the existence of adherent
omentum.  The coverings of an umbilical rupture are usually extremely thin,
consisting merely of the peritoneum, a layer of condensed fascia, and the integu-
ments containing the umbilical cicatrix, which is expanded over the part.
   The treatment consists, if reducible, in wearing a properly constructed truss;
if irreducible, in applying a hollow,.cup-shaped pad supported by a bandage  over
the part.  It not unfrequently happens that an irreducible  umbilical rupture in
old women becomes obstructed, being attended with  tension of the protrusion,
nausea, and constipation.  In these  cases much discrimination will be required
to avoid confounding this condition of the tumor with strangulation of it.   This
maybe done by attention to the rules laid down (page 714), when by local blood-
letting, fomentations, and aperients, relief may usually be afforded.  Should,
however, the bowels not speedily act, and should the tumor continue irreducible,
it will, I think, be better to  cut down upon  it, and  treat it as a strangulated
hernia, dividing adhesions and reducing the swelling; for if it be left obstructed
and unreduced  the whole tumor may run into a state of gangrenous inflammation,
under which circumstances operative interference will be of little use.
   When an umbilical hernia is strangulated the taxis seldom succeeds, and an
operation consequently becomes necessary.  If the stricture can be divided out-
side the sac, as sometimes happens when it is situated in  the aponeurotic struc-
tures, no great danger results; but if  the sac requires to be open recovery rarely
takes place.   The  operation  may best  be done by making a semilunar  incision
five or six inches in length by the  side of the tumor; this  must be carried to a
depth of two or three inches through subcutaneous fat and the dissection should
be directed so as to expose  the linea alba; this must be cautiously opened, and
a director having been passed  down towards the neck  of the sac, under the
stricture, the section  should be made with  a probe-pointed bistoury.   If the
stricture cannot be divided in this way, the sac must be kid open, and then the
constriction must be cut across from within.   Sir A. Cooper mentions an umbili-
cal hernia forming two tumors, having a  communication  between them;  and
South relates a case in which the tumor resembled a figure of 8, a  dense cellular
band binding down the middle of the sac.  In such cases  as these, of which an
instance occurred some years ago  at the  Hospital, under  the late Mr.  Morton,
the central constriction may require to be divided  as well as the stricture at the
neck of the sac.   Adherent  omentum had, I think, better be  left in the sac in
case of umbilical hernia, and gangrenous intestine or omentum must be treated
upon general principles. It is not often that strangulation of an umbilical hernia
occurs during  pregnancy, but should  this happen, the operation  must be  per-
formed as usual;  that condition not complicating the case much, and instances
are recorded by Sir A.  Cooper, Lawrence, and others, of its successful performance
at this period.

                       OTHER VARIETIES OF HERNIA.
    Ventral Hernia.—By ventral herniae, are  meant those protrusions that  occur
through any part  of the abdominal wall, except  the inguinal, the femoral or
umbilical apertures;  they most commonly occur in  the  mid-line between the
recti muscles, the  linea alba appearing to have given way in this situation during
parturition, and here they may attain an immense  size.   A case was lately sent
to  me from the country in which there was  a long triangular gap through  the
upper part of the abdomimal wall, extending from the umbilicus to the ensiform
cartilage, through which a protrusion had taken place that was nearly as  large
as an adult's head.  These ruptures have also been met with in the lineae  semi-
lunares, the hypochondriac  and  iliac regions; and Cloquet describes a case occur-
ring in the lumbar  region.  AVhen these herniae occur in the vicinity of  the
stomach, they are apt  to occasion dyspeptic symptoms and much gastric  irrita- 
74G
VARIETIES OF  HERNIA.
tion; but Lawrence is  doubtless right in thinking  that  these symptoms do not
arise  from the  implication of the  stomach, but simply from irritation  of it.
These different protrusions  have occasionally been met with as the  result of
injuries, by which the anterior abdominal wall has been  lacerated;  indeed they
seldom, if ever, occur below the  umbilicus, unless arising  from a directly trau-
matic cause.
   The treatment of  ventral  hernia  must  consist in supporting  the  tumor by
means of a  broad belt and properly  constructed  pad.   Should they become
strangulated, which,  I  believe, very rarely happens, owing  to the width of the
neck of the sac, the operation must be performed in  the same way as for umbili-
cal rupture, care being taken to divide cautiously the  integuments,  any aponeu-
rotic investments, and the  peritoneal sac : the stricture should always be divided
upwards in the mesial line.
   A rare kind of ventral rupture has been described, principally by the German
surgeons, in which the abdominal wall has yielded to a considerable extent, form-
ing a broad and expanded  tumor, without  any distinct neck or pedicle.  Some-
times these tumors may attain an immense size, stretching perhaps  down to the
knees, and containing even the gravid uterus.
   Obturator Hernia.—The occurrence of this form  of hernia is extremely rare,
and its  existence has  still  more rarely been determined until after death.  In
fact, Lawrence seems to doubt the possibility of the recognition of this complaint
during life, in  consequence of the small size which the tumor attains, and its
being covered  in  by  and  compressed under  the  pectineus  muscle.    Two
instances have, however, lately been recorded,  one by Air. Obre, the other by
Bransby Cooper, in  which a strangulated  hernia of  this  kind was recognised
during life.   And these instances are probably the only on record in which an
operation has been successfully performed;  almost all  the other cases mentioned
by writers having been accidentally discovered  after death,  which had occurred
from internal strangulation, the precise seat of which could not be detected.  In
Mr. Obre's case, the  patient was  seized with symptoms of strangulation, but no
tumor could be detected in any of the ordinary  seats of hernia.   " On uncover-
ing  the  upper part  of both thighs at the  same time, the eye detected a  slight
degree of fullness in Scarpa's triangle on the right side :  this triangle of  the
opposite limb was well marked  with a hollow, or  depression passing down its
centre, but this was  lost on the affected side, and the whole contour of this part
of the limb was visibly fuller than that of the corresponding one.  There was no
tumor or circumscribed swelling, but on  standing  over the patient,  and  using
firm pressure with the ends of the fingers over the neighborhood  of the femoral
artery, and a little  below the saphenous opening, a distinct hardness could be
felt (slight in its extent), giving  an impression  as if  the sheaths of the vessels
were being  pressed on."   Taking  the dangerous state of the patient into  consi-
deration, Mr. Obre, acting in accordance  with the best rules of surgery,  and
thinking that there might be a hernia deeply strangulated  in the femoral  canal,
made an incision downwards in  this situation, but was disappointed  on finding
when the saphenous opening was exposed  that  there was no intestine confined
there; but as a hardened  structure could  be  deeply  felt at the inner border of
■ the opening, the fascia lata was exposed, and the pectineus divided to the extent
of about two inches,  when a hernial sac about  the size  of a pigeon's egg,  and
containing intestine  came into view.  In  this  operation the saphena vein gave
some trouble, lying as it did in the course  of the incision.   The sac  having been
laid open, the stricture was divided upwards, during which part of the procedure
the vein was accidentally cut, and required ligature;  no other vessel was tied.
The operation, which reflects the greatest  credit on Mr. Obre's diagnostic skill
and dexterity, was perfectly successful, the  patient making an excellent recovery.
   Besides the obturator, various other pelvic hernue may take place, such as a
protrusion into the perineum, the vagina, or through the sciatic  notch.   These 
DIAPHRAGMATIC  HERNIA.
747
 various forms of rupture are of extreme rarity, and present many difficulties in
 their diagnosis.
   Perineal Hernia commonly occurs in the middle line, between the rectum and
 the bladder in men, or the rectum and vagina in women, but sometimes the pro-
 trusion has been known to take place by the side of the anus, or even in front of
 this.  Of these various forms of  rupture many instances have  been collected by
 Lawrence from different writers.   The treatment of such a hernia would consist
 in supporting the protrusion by means of a  pad and bandage; as  the mouth of
 the sac is very large in these cases, it is  not  probable  that any  strangulation
 would occur.
    Vaginal Hernia has occasionally been met with, the tumor protruding through
 the posterior or upper wall of the vagina, and presenting the ordinary characters
 of this disease, such as impulse on coughing  and reducibility.   It may most
 conveniently be kept up by means of a sponge pessary.
   Pudendal Hernia has been described by Sir A.  Cooper as very closely re-
 sembling vaginal rupture.   The  situation of the tumor may cause it to be mis-
 taken for an inguinal  hernia, but from  this it may be recognised by the upper
 part of the labium, and the ring being completely free, whilst a tumor presenting
 the  ordinary characters of a rupture is situated in the lower part of the labium^
 and forms a prominence extending along the side of the vagina.
   Sciatic Hernia.—This  rare form of hernia has  been  described by Sir A.
 Cooper as passing through  the  sciatic  notch, where it  lies between the lower
 border of the pyriform muscle and the spine of the ischium.  It lies in close
 relation with the sciatic nerve, and with the  internal  iliac vessels.  In  the case
 related by Cooper, the  obturator  artery passed above, and the  vein below the
 neck of the sac.   From the depth at which such a hernia would be seated, and
 its small size, it would  probably escape observation during life, but if  detected
 it might  readily be retained  by  means of proper bandages and a pad.   Should
 operation ever be required in case of strangulation, the deep incisions must be care-
 fully conducted, on account of the great importance of the parts surrounding the sac.
   Diaphragmatic Hernia.—This form of hernia is of unfrequent occurrence, and
 I believe always results in consequence of a wound or laceration of the diaphragm.
 It usually attains a large size, and commonly contains the stomach or the trans-
 verse colon, with a portion of the omentum, which form a tumor in the thoracic
 cavity, encroaching upon the lungs, and pushing the heart to one side.  These
 herniae are not enclosed in a peritoneal
 sac,  but have  been found  partially en-
 veloped by the pleura, and have, I be-
 lieve, only been met with in the left side
 of the chest;  the situation of the  liver on
 the right side preventing their formation
 there.   The  following  case, which oc-
 curred at the University College Hospital,
 affords a very good  instance of this  very
 rare  affection.
  A man  seventy-four years  of age was
 admitted  into  University  College Hos-
 pital.  About  twelve months before, he
 fell into an area about ten feet deep and
 believes that he injured his chest and
 head, as from that time he has suffered
 much from shortness of breath and occa-
 sional sensation of suffocation, has a hack-
 ing cough, and  cannot  lie down without
feeling some difficulty in breathing.   At
the time of the  accident he coughed  up about three spoonfuls of blood.  Ever
Fig. 240.
 
74S
INTESTINAL OBSTRUCTION.
since the accident he suffered much from dyspeptic symptoms and  constipation,
though before he met with the injury he had  experienced  no inconvenience in
this respect.   About a month ago the difficulty in breathing increased ; and four
days ago violent pain in the abdomen came on, and  his bowels  ceased  to act,
although he took a variety of aperient medicines  and had enemata containing
croton  oil administered.
  On admission, the abdomen was found much distended, tense, and tympanitic,
with pain around  the umbilicus;  the   tongue was coated with  whitish-brown,
moist  fur;  the  pulse  was  small, quick, and somewhat resisting; there was
nausea, but no vomiting.   The skin was cool and the countenance anxious; the
bowels have not acted for seven days, but he has frequent desire to go to stool.
Ordered an aperient  draught  every third hour.   As this had no effect, he was
directed to take calomel and elaterium  pills, and  to  have  turpentine enemata,
which  afforded him some  relief, though they brought away no  faeces.   The
patient became more restless, the skin cold  and flabby, the countenance more
anxious, the breathing shorter, and  the  abdomen  more tympanitic, and he died
two days after admission, and nine from the commencement of the obstruction.
  Examination of the body twenty-four hours after death.—The abdomen was
distended and tympanitic, and the peritoneal sac contained  about six ounces of
fluid, with  here  and  there  patches of  recently-effused lymph.  The small in-
testines were not distended; the large  were  greatly distended with flatus, the
ccecuin extending into the cavity of the pelvis : the ascending and the transverse
colon were much distended, and it was found that  a large loop of the transverse
and of the descending colon had passed  through an  opening in  the cordiform
tendon of  the diaphragm into the pleural sac,  and  was there strangulated (Fig.
240).  The colon  below the stricture was contracted, and  entirely empty.  On
opening the thorax, the loop of intestine, fourteen  inches  in  length, of  a pale
slate color, and distended with gas, was found  in the left pleural sac. It reached
as high as  the fifth  rib, touched the  pericardium, and was overlapped by the
free margin of the left lung.  AVhere strangulated, it was of a darker color than
elsewhere.   The opening in the diaphragm, through which  it  had passed,
admitted little more  than the point of the forefinger, and  had a  thin tendinous
margin.  The tenth and eleventh ribs, on the left  side, were found to have boon
fractured; the latter  was united  by osseous  matter, but the  tenth rib, at the
seat  of fracture, had formed  a false joint.  Connected with this and with the
intercostal space  below it, was a firm adhesion about an inch broad, and an inch
and a half  long,  united by its other extremity to the protruded meso-colon and
,the diaphragm.  The protruded meso-colon was  firmly adherent to the upper
surface of the diaphragm close to the opening in  it; the lungs  were tolerably
healthy.   The right pleura contained three ounces, and the left eight ounces of
serum.
                         CHAPTER  LIII.

                    INTESTINAL  OBSTRUCTION.

  Intestinal obstructions may be of two distinct kinds, the  acute  and the
chronic, which should not be confounded with one another, as they are usually
dependent upon very different conditions,  and require different lines  of treat- 
SYMPTOMS AND DIAGNOSIS OF  INTESTINAL OBSTRUCTION.  749

ment to be adopted for their relief.  The acute intestinal obstruction may arise
in various ways.   When of a mechani-
cal origin, it most commonly occurs in
consequence  of  the formation of an
internal hernia,  which  becomes  sud-
denly strangulated, a portion  of gut
slipping through an aperture  in the
mesentery, or omentum (Fig. 241), or
becoming  constricted  by bands, adhe-
sions, or diverticula, stretching across
from one side of the  abdomen to the
other.   In other cases, again, it  may
occur  from  invagination,  the upper
portion of the intestine  slipping into
the lower, or by a portion  of gut be-
coming twisted  upon itself, and  thus
forming a volvulus, owing to the mesen-
tery, or meso-colon, being unusually long, and allowing a half-twist to take place in
consequence of which  complete  obstruction  occurs.   In other instances, again,
as Air. Phillips has pointed out, the same train of symptoms may arise in con-
sequence  of  a malignant stricture gradually closing, and then at last becoming
suddenly occluded.  AVhen the obstruction occurs by the formation of an internal
hernia, the same changes take place in the constricted intestine that happen  in
ordinary ruptures, peritonitis supervening, and  gangrene rapidly resulting.   It
is of much importance, however,  in practice, to bear in mind that severe, and
even  fatal intestinal obstruction may occur, simply from spasmodic causes, or as
the result of inflammatory affections of the abdomen, without the existence of
any mechanical lesion.
   The symptoms of acute intestinal obstruction, when arising from a mechanical
cause, such as the formation of an internal hernia, or volvulus, are always  cha-
racterized by very marked vital  depression.   There is  constipation, it is true,
from the very first, but this symptom is not  the most prominent one, and those
that result are evidently, as in an ordinary case of strangulated  hernia, the con-
sequence  of the injury  inflicted  upon the intestine,  rather than of the mere
mechanical obstacle to the  onward passage  of the faeces.   At the moment of the
occurrence of the attack, the patient is usually seized with a sudden feeling of
something wrong having taken place in the abdomen ; or he is  struck with in-
tense pain  at one point.   There  may be sudden  syncope, though most usually
the depression of vital power does not amount to this.  Aromiting speedily occurs;
at first of the contents of the stomach, but after a time of a stercoraceous cha-
racter; sometimes it assumes this form almost from the very first. The abdomen
becomes swollen and tender, the intestines being blown up with flatus, so as  to
give rise to immense tympanitic distension,  rolling over one another, and occa-
sioning a  loud rumbling and gurgling noises.   If the abdominal walls are thin,
the rolling of the intestines may be distinctly felt, and in many cases seen through
them; and  may sometimes be observed to be continued up to one spot, where
they cease.   At this point an intumescence may sometimes be indistinctly felt,
corresponding to the seat of strangulation.   If relief be not afforded, the suffer-
ings of the patient become very considerable, and his mental distress agonizing;
the vomiting, perhaps, becomes less frequent, but the depression increases, and
at last death results, usually about the sixth to the tenth day, though sometimes
sooner from exhaustion, peritonitis, and gangrene conjoined, the mind being clear
to the last, and the patient's attention being intently and distressingly riveted
upon the possibility of getting relief from the bowels.
   When the intestinal"  obstruction  is  of  a  more chronic character, it usually
 
750                   INTESTINAL OBSTRUCTION.

arises from the gradual obliteration of the inferior portion of the large intestine,
in consequence of the  malignant degeneration of its walls,—from the compres-
sion of the gut by a tumor growing near it,—or from the obstruction of its cavity
by the accumulation of large masses of hardened, feculent matters.  The synip.
toms, in the  earlier stages of  these cases, are commonly those that will be
described as indicating stricture  of  the large intestine;  but when  once complete
obstruction has come on, the constipation becomes the most prominent symptom.
There may  be comparatively little constitutional disturbance at first, but the
bowels cannot be made to act, and any attempt at forcing their operation  by the
administration of purgatives, gives rise to sickness  and much distress.   During
the progress of the attack eructations, retchings, and vomitings are of frequent
occurrence, but  it seldom happens that this is stercoraceous till  the very last;
there may be  much tympanitis,  with rumbling and gurgling of the intestines,
but  most frequently the abdomen fills slowly and gradually, and  the symptoms
do not occur until after some days have elapsed.   In many instances life is pro-
longed for several weeks, for five or six, even after complete obstruction  has set
in; and in some cases  recovery may take  place even though a considerable time
have elapsed from  the occurrence of the obstruction.   In a  lady whom I at-
tended some time ago,  with Dr.  Powell of Guildford Street, recovery took place,
although there had been complete obstruction for upwards of five weeks.
   The diagnosis of the causes of  the obstruction is of great importance; attention
to whether it assumes the acute  or chronic form will throw some light upon the
conditions that occasion  it.   It  is  often difficult to determine whether the ob-
struction is of a mechanical nature, or whether  it depends upon  spasmodic or
inflammatory affection  of the intestine.  The practice to be adopted in any par-
ticular case must at last be determined by a history of the symptoms, by a careful
exploration of the abdomen and rectum, and by the light that can thus be thrown
upon the question, as to whether the obstruction  in  that particular case be
dependent  on causes that are removable  or not by medical means.   In many
instances, the history of the case, the assemblage of strongly marked symptoms,
and the result of abdominal and  rectal exploration, enable the surgeon to deter-
mine, without much difficulty, that the obstruction is  dependent on causes that
are not removable by any means short of  operative interference.   But, in other
cases, no means  that we possess enable  us to arrive at a correct, or even an
approximate diagnosis.  Cases are recorded that have ended fatally from obstruc-
tion  in forty-eight hours, without sickness, fixed  pain  in  the abdomen, or tym-
panitis.  These  cases,  however,  are certainly exceptional, and do not bear upon
the question as to the  propriety  of  performing  gastrotomy in those instances in
which it can be satisfactorily determined that a mechanical  obstacle, not  remov-
able by medical means, exists.   That the  diagnosis may so far  be effected with
tolerable certainty is evident,  from the fact that in all those cases of gastrotomy
that have been of  late  years practised in this country, by Air. Luke, Mr.  Avery,
and myself, mechanical obstruction, irremovable by any but operative interference,
was fouhd.
  The most prominent symptoms, and those that will chiefly engage the surgeon's
attention, are the duration of the constipation, the occurrence of fixed local pain
in the abdomen, and the character of the vomited matters.   The mere duration
of the constipation does  not  throw much  light  upon the cause.   Indeed if pa-
tients be  naturally costive, constipation may last for a  considerable number of
days, or even weeks, without  producing any very serious or fatal  consequences.
Most practitioners must have seen cases in which the constipation  has continued
for three or four weeks, without  destroying the patient.   Dr. Johnson mentions
a case in which it lasted for forty-five days.  In  these cases, however, constipa-
tion  has usually come on gradually, being, as it were, an  aggravation of the pa-
tient's natural condition.  In  cases of acute internal strangulation, the constipa- 
             CAUSES OF  INTESTINAL OBSTRUCTIONS.           751

tion  is always sudden, and  is speedily followed by other symptoms, indicating
intestinal obstruction.
  The occurrence of fixed pain is common to many conditions of the abdomen;
though, when taken in conjunction with the sudden supervention of obstruction
to the onward passage of the faeces, with more or less tumefaction corresponding
to the seat of pain, and more especially with the next symptom to which I shall
advert, it is not without considerable value in the diagnosis of these cases.  AVhen
the obstruction is not dependent on complete mechanical occlusion of the bowel,
there maybe incessant vomiting, and the stomach may reject its contents as often
as anything is introduced into it; but the vomiting will not be feculent in the
majority of cases, however obstinate the constipation may be, and  however long
it may last.   If, however, there be complete mechanical occlusion, feculent vomit-
ing most commonly sets in early, frequently by the third day, or even sooner;
and will continue, with perhaps  occasional intermissions, until the  cause of occlu-
sion  be removed.  It is ti-ue that feculent vomiting is not sufficient, by itself, to
determine the diagnosis; and that it may occur in cases of pure spasmodic ileus,
in which the obstruction is removable by medical means.  A remarkable case of
this kind (for which  I am indebted to Dr. Basham) occurred, a few years ago, at
the AVestminster Hospital, in the person of a  black woman, who was  admitted
for haematemesis with catamenial suppression.  The stomach was very irritable,
with occasional  colicky pains in the  abdomen for the first  two weeks.  The
bowels, although torpid, were not completely occluded till within forty-eight hours
of the stercoraceous vomiting.   This latter  condition  continued  for five weeks
altogether, with an  interval, in which  the bowels acted.  Indeed, towards the
latter period; of the  case, feculent vomiting occurred  on the  same  day that  a
small alvine evacuation was obtained.   She  suffered  during the greater  part of
this period from dysuria.  There was also frequent spasmodic constriction "of the
rectum; and altogether much hysteria was mixed up  with the symptoms.  The
stercoraceous vomiting  gradually abated, the natural  order  of things returned,
and she left the hospital sufficiently well to walk to Portsmouth in three days.
It is therefore as necessary to bear in mind the occasional dependence of feculent
vomiting on pure spasmodic  ileus, or on other conditions that are removable by
medical aid  alone, as that it may be absent in cases  in which the obstruction,
whether seated in the small or in the large intestine, is not under the influence
of medical  treatment, and  can  only be relieved by surgical assistance.   But  I
believe  that a careful  exploration of the abdomen and rectum, and  a proper
inquiry into the history of the case, will most generally prevent the surgeon from
being led into any serious error by trusting too  implicitly to the presence or ab-
sence of this one symptom.
  After determining whether the  obstruction be dependent on causes that are
removable or not, the next most important point is doubtless to ascertain whether
the obstruction is seated in the large or in the small intestine.   In general, there
may  be no great difficulty in coming to an  accurate opinion on this point, if it be
borne in mind that obstructions of the large  intestine are most generally chronic,
whilst those of the small are, in by far the majority of cases, acute in their cha-
racter.   The earlier occurrence  of feculent vomiting when the obstruction  is in
the small intestine, the  greater tympanitic distension and bulging in the  course
of the ccecum and colon when seated in the  large intestine,—the amount of uri-
nary  secretion being, as was  pointed out by Air. Hilton and Dr. Bird, less in the
former than in the latter case,—and the result of careful exploration of the rec-
tum,  will most commonly enable the surgeon to decide this question with sufficient
precision to guide him  in the  choice of an operation.  Yet, cases do occur, in
which, though the obstruction be seated in the large intestine, the symptoms are
acute, and evidently not dependent on chronic obstructive disease, the vomiting
of early occurrence, the  distension of the abdomen slight, and in which explora- 
752
INTESTINAL  OBSTRUCTION.
tion by the  rectum yields no result; and it is in cases of this description, pre-
sentino- a train of symptoms of mixed and uncertain character, that the diagnosis
of the precise seat of the obstruction cannot be made.
   The question as to whether the cavity of the peritoneum should be opened or
not, will altogether turn, in any given  case of intestinal obstruction, dependent
on causes that cannot be removed without operative interference, on the point,
whether  such obstructing cause implicates the bowel  above  or below the lower
end of the descending colon.  AVhen the obstruction is situated below this point,
exploration  of the rectum will usually determine to what cause it is more imme-
diately referable.  Thus it may be  owing to  strangulation of internal  piles, to
compression of the rectum by an over-distended bladder, or to_ an enlarged uterus,
engorged and tilted  backwards so as to compress and constrict the rectum, and
thus to  lead  to the supposition of the existence of tumor.  If the intestinal
obstruction  be owing to one or the  other of these causes, it may readily be re-
lieved  by appropriate treatment.  It, however, more commonly  proceeds  from
other conditions in this situation, that do not admit of relief  except by operative
interference;  as from constriction, simple or malignant, of the upper portion of
the rectum,  or of the lower  part of  the sigmoid flexure of the colon, in conse-
quence of the pressure  of a  pelvic tumor, or of a stricture from  fibrous or can-
cerous degeneration of  this  part of  the wall of the gut.   Under these  circum-
stances, the  obstruction may be as complete as  in a case of internal strangulation,
and the patient will  inevitably perish  unless  relieved by operation.   But there
is this  important difference between  the operative interference that may be called
for by  these obstructions that are situated below the descending colon, and those
at a higher point in the intestinal canal:—that in the latter case the  peritoneum
must be  opened; whilst in the former, relief may be given without  interfering
with the cavity of the peritoneum, by the operation of opening the  descending
colon in  the left, or the  coecum  in the right lumbar region, between the reflex-
ions of the  peritoneum at the part where the gut is not covered by that mem-
brane.
  When the obstruction is situated above the  descending colon, it almost always-
occurs  in the small intestine, rarely in the ccecum, or transverse colon, and  may
be dependent on various causes, some of which are removable, and  others not,
and of which preparations may be found in all the large pathological  collections
in London.   Thus, it may be the result of internal  strangulation, either occa-
sioned  by the small intestine falling into a pouch, formed by the meso-colon, or
by the constriction of the gut by the passage  across it of adventitious bands of
fibres.   It may be occasioned by intus-susception, by the lodgment of biliary or
other  similar  concretions, or by mere  spasm of the small intestine, which  may
be so persistent as to prove fatal.   This is, doubtless, a rare occurrence; but cases
of the  kind  are on record, in which  the only post-mortem appearance that could
be discovered has been a spasmodically contracted ileum.  The  great practical
difficulty in  all these cases of obstruction, above the  sigmoid flexure of the colon,
is to determine the cause of the obstruction, wrhether it  is of such  a nature as
may be removed by operation or not.   In some of the  cases mentioned, there
may be special symptoms, which lead to a tolerably correct  diagnosis.  Thus, in
intus-susception, bloody or mucous stools may give a clue; in malignant or fibrous
degeneration of the  colon, the chronic  nature of the disease, the history of the
case, and the appearance of the patient, may indicate the nature of the obstruct-
ing cause.
  The treatment of acute obstruction must necessarily be in a great measure
determined by the diagnosis  that is made as  to its cause.   Before proceeding to
the employment of any  measures, whether medical or surgical, in  these cases, the
surgeon  should, however, never omit to institute a careful examination of the
various abdominal and  pelvic apertures for some of the more obscure forms of 
 TREATMENT OF  INTESTINAL OBSTRUCTION — GASTROTOMY.  753

 external hernia; for in cases of supposed internal strangulation ,it has occasion-
 ally turned out, after death, that  the patient had been laboring under a small
 femoral, obturator, or sciatic hernia.   If such a condition  be detected, it must,
 of course, be relieved by proper operative means.   In the event of no such pro-
 trusion  being detected, and from the general obscurity of the symptoms in these
 cases rendering an exact diagnosis in the earlier stages almost impossible, it  is
 generally expedient  to try the effect  of proper medical treatment,  which  will
 sometimes, even in  apparently hopeless  cases, afford relief.  The only plan  of
 treatment that appears to me of any value is an antiphlogistic one; the continued
 administration  of calomel  and opium, with venesection, if the patient can bear
 it; if not, the free application of  leeches to the abdomen, followed by fomenta-
 tions, will be of considerable service, and in some cases, even the most hopeless
 and complicated, will afford satisfactory results.   In  a very complicated case of
 intestinal obstruction which I attended with Dr. Garrod, this plan was eminently
 successful.   A patient was admitted into the Hospital, under Dr. Garrod, having
 symptoms of internal strangulation; he had  at the same  time double inguinal
 hernia,  and  a small  umbilical rupture, as well  as the remains of a fatty tumor
 which had been partially removed from the abdominal wall many years previously.
 There was peritonitis with  tympanitis, stercoraceous vomiting, and much depres-
 sion of power, but as  there was no strangulation existing about any of the external
 apertures, and as there was no evidence  as to  the precise locality of the internal
 mischief, it was not thought advisable to  have  recourse to operation.  The patient
 was accordingly treated with calomel and opium, together with other antiphlogistic
 means, when, on the tenth day, the obstruction gave way and the bowels acted,
 the case ultimately doing well.
   If, however, for any of  the various reasons that have already been mentioned,
 an internal strangulation of some kind be diagnosed, attended by urgent symptoms,
 and threatening the  life of the patient,  the great question to be determined  is
 whether it is advisable to have recourse to operative interference, and if so, when
 it is proper to undertake it ?   The solution  of these questions is fraught  with
 difficulty, and must always be a matter of the most anxious consideration to the
 surgeon.  It is not only that he knows that if the patient is left unrelieved, he
 must necessarily die; but that he is  aware that the only means of relief,  gas-
 trotomy, is  probably  nearly as fatal as the disease for which it is undertaken;
 no case  in which this operation has hitherto been performed for internal strangu-
 lation having  recovered.   But the difficulties that present themselves in  the
 solution of the question are much increased by the great obscurity in diagnosing
 the cause of the  obstruction; for  in  many cases it  is absolutely impossible to
 determine with certainty whether it be dependent on ileus, or arise from mecha-
 nical causes.  If, however, by attention to any of the points that have been pretty
 fully adverted to, it can be  satisfactorily made out that there is an internal stran-
 gulation, and more especially if the intumescence occasioned by it can be felt, it
 would evidently be the duty of the surgeon to give the patient his only chance
 by the division of the stricture.  With regard to the time at which this should
 be done, the only general  rule that can be laid down is probably the conclusion
 arrived at by Mr. Phillips, that operation  is justifiable when three or four days
 have passed, without  any relief from ordinary means, constipation being complete,
 and vomiting of faecal matters continuing.
  Gastrotomy may be performed in the following way:—The  room being well
 warmed, the patient  should be laid on a high table, his legs  being allowed to
 hang over the end of it, so  as to afford a  full view of the  abdomen.  The bladder
 having then been emptied,  chloroform should be administered; and the surgeon,
 taking his stand between  the legs of the patient, proceeds to make the incision
through  the  abdominal wall.   If a tumor can be felt, or the seat of obstruction
in any way diagnosed, this  must be made in a longitudinal manner directly over 
754                   INTESTINAL OBSTRUCTION.

the seat of mischief;  if there is no evidence to show where it is situated, it had
best be made in the mesial line.  It must be carried through  the abdominal wall
until the peritoneum  is reached; this must then be slit up by means of a probe-
pointed bistoury, guided by the forefinger of the left  hand.   The distended coils
of intestine will  now  probably  protrude  through the  wound, curling over its
edges; they must be  drawn to one side, and be carefully supported by an assist-
ant, who should press upon them with a  soft towel, whilst the surgeon goes in
search of the  obstruction.  If this be a hernial  constriction, he  may advanta-
geously imitate Mr. Hilton's practice, and  divide the band  that constitutes the
stricture  by means of the scalpel, or withdraw from the aperture in the omentum
or mesentery into which  it had slipped, the  constricted coil of intestine.  If it
be a case of volvulus,  the gut may be untwisted, as in a case on which I operated
(ride " Lancet,"  1850).   The  intestines having been returned, the  wound
should be closed by the continued suture, and the application of some transverse
strips of  plaster;  the patient  must then  have his knees bent over a pillow, and
should be  kept principally upon ice and barley-water.   Opium must also be
administered, and the case generally treated as one of strangulated hernia.
   The treatment of  chronic intestinal obstruction  must be  conducted upon
different principles.   Here the great  point is to remove the constipation.   With
this view the  rectum should be  explored, and if found to be blocked up by
impacted faeces, as may sometimes happen, these must be removed, and copious
enemata  administered.  At  the same time purgatives may have  a trial given
them, and  a drop or  two of croton-oil may be exhibited.  If the  constipation,
however, arise from  mechanical  causes,  this means will usually  considerably
increase the patient's  distress, and then it should not be repeated; but the patient
should be  kept quiet in bed, have a nourishing diet but one that leaves little
residue administered,  and the passage opened by enemata, and the  introduction
of the tube of  a stomach-pump.   If  these means do  not succeed, and if the ob-
struction, as is  almost always the case in these chronic instances, be seated in or
below the sigmoid flexure of the colon, the intestine must be opened at  a point
above the  seat of disease.  This may be required for acute as well  as chronic
obstruction ; for it may be observed that, although in  the acute form, the obstacle
is usually situated in  the small intestine, yet it is occasionally met with  in the
colon.  But ia  chronic obstruction it is always the large intestine that is affected.
The operation required to give exit to the intestinal contents is of two kinds; in
one the intestine is opened in the left iliac fossa, by cutting  through the perito-
neum covering it.  In the other it is opened in the left loin by cutting between
the layers of the  meso-colon, and thus opening it where it is uncovered by peri-
toneum.
   The first operation,—or Littre's, as it has been called, was proposed by a sur-
geon of that name, in  1710, who advised  that in these cases  the sigmoid  flexure
of the colon should be opened from the left iliac region ; but it was  not until the
year 1776  that any operation of the kind was performed; when Pillore, a surgeon
of Rouen, was the first to make an artificial anus on the adult, for relief of reten-
tion of faeces :  this he did, not according to Littre's method, but by opening the
coecum  from the  right  iliac  region.  Fine,  of Geneva, in  1797; opened the
transverse  colon from  the umbilical region, in a case of retention of faeces pro-
duced by scirrhus of  the upper part of the rectum.
   Although these operations serve to fulfil the indication of  relieving the reten-
tion of the faeces, they are all defective  in one most important respect, for, as
the peritoneum must,  in all of them, of  necessity, be wounded, an intense and
frequently  fatal peritonitis is  the inevitable consequence.  It was  to avoid this
serious complication  that  Callisen, in  1796, proposed opening the colon from
behind, in  the  left lumbar region, where it is not covered by peritoneum.  He
once attempted this operation on the  dead body of a  child, but failing in his en- 
   OPERATION  FOR  ARTIFICIAL ANUS  IN  LUMBAR REGION.  755

deavor to reach the intestine without wounding the serous  membrane, he seems
to have relinquished all further idea of it; and it was subsequently rejected as
impracticable by all those writers on surgery who have treated  of this subject.
   Amussat, at the time that he was attending the celebrated Broussais for that
scirrhous affection of the rectum of which he ultimately died, was led to reflect
on the resources that Surgery offers  in similar cases ;  and after  making some
experiments on the dead body, with the view of contrasting  the merit of the
different operations that have been  proposed for the formation of  artificial anus
in cases of obstruction of the large intestines, he  became convinced  that  the
operation proposed by Callisen,  if somewhat modified, was not only practicable,
but  safe.  He  soon  had  an opportunity of putting this opinion  to  the test of
experiment in 1839, and since this the operation has been performed forty-four
times.
   The following is a description  of the modified  operation  that  Amussat pro-
posed :   A transverse incision  is  to be made  two fingers breadth  above and
parallel to the crista ilii of the  left  side; or rather in the  middle of that space
which is bounded by the false ribs above and by the crista ilii below;  the inci-
sion should commence at the external margin of the  erector spinae, and extend
outwards for about four inches.   The spinous processes of the  lumbar vertebrae,
the crista of the ilium and  the last  false rib, are the principal guides.   The supe-
rior margin of the crista ilii is, however, the safest of these, and the transverse
incision may be said to correspond to the middle third of this part of the ileum.
After having divided the  skin  and all the more superficial  tissues,  the deep
layers are next  to be incised as they present themselves ;  if  necessary the ex-
ternal border of the quadratus lumborum may also be cut across.   The dissection
is then very carefully to be carried  through the layers  of cellular tissue, which
lie immediately upon the intestine,  and the colon sought for; this will, in general,
readily present itself, and may at once be recognised by its color and distended
appearance.  The operation may then be completed by  passing a  tenaculum, or
needle armed with a strong, waxed thread, into the most projecting  part of  the
gut; and, by this means, drawing it to the surface of the wound, in  order to
prevent it shrinking or sinking  back when opened.  It is  now to be punctured
with a large trochar or  bistoury,  and its contents having been evacuated,  the
sides of the opening in the intestine are to be fixed to those of the  incision in  the
skin by four or five points of suture, so as  to prevent the contents of the bowel
being effused into the cellular tissue of the wound.  It is of importance to.draw
the colon well  forwards before  opening it, in order to prevent  its  contents from
being effused into the loose  cellular tissue of the wound, where they may set up
considerable irritation and retard the union of the parts.  If the patient be very
fat, the operation will be much facilitated by dividing the deeper-seated tissues
in a  crucial manner, so as to give the operator more space.   When the operation
is practised on the dead body it will be found  on dissection that the following
are the parts cut through :   After the skin  and cellular tissue, the latissimus
dorsi will be seen divided  towards  the posterior third of the  incision, and the
obliquus  externus in the anterior two-thirds of it;  the obliquus internus and the
transversalis, ' sometimes the quadratus lumborum,  the cellulo-adipose tissue
which immediately covers the intestine, and finally the colon itself.  Very few
vessels or nerves are wounded, as they for the most part run parallel to the line
of incision ; whereas, if the vertical  incision of Callisen were adopted, they would
necesssarily be cut across.
  AVhen we compare the different operations that have been  proposed  for the
formation of an artificial anus,  it will be  found that Callisen's, as modified  by
Amussat, is the one to which the preference must be given, for by it alone the
peritoneum is not wounded,  and thus the inflammation of that membrane, which
is a necessary and so often a fatal consequence of the other operations, is avoided. 
756
INTESTINAL  OBSTRUCTION.
 Besides this  advantage, which is  of the  very greatest  importance,  Amussat's
 operation presents several other claims to our notice.   As  only one side of the
 colon can be drawn forward, and not a knuckle of it, as would be the case if the
 small intestines were  operated upon, it is evident that  the spur-like process
 which has been described by Dupuytren, must exist to a very small extent; and
 consequently, if the artificial anus should ever become useless,  the natural pas-
 sage for the faeces having been re-established, it could readily be closed up.   If
 however, the peritoneum should be accidentally wounded in the attempt to reach the
 colon from behind,  even then this operation would be preferable to that of Littre;
 for the cavity of the abdomen having been opened at its most depending part (in the
 recumbent position), the faecal matters would have much less tendency to be effused
 into it, than if it were opened in  front.  In respect of  not wounding the peri-
 toneum, this operation closely resembles that of puncturing the bladder above the
 pubes, and  below the reflection of that membrane.   There  is, however, one im-
 portant difference between the two operations, which may influence the result;
 for in the one case as the patient lies  upon his back the  urine has a tendency to
 stagnate in the wound, being obliged, in  order to escape, to mount against its
 own gravity;  whilst in the other case, the faecal matters find a ready exit from
 a wound situated in a depending part.
   Mr. Caesar Hawkins, in a most interesting and  valuable  paper,  published in
 the twenty-fifth volume of the " Medico-Chirurgical Transactions,"  has collected
 and analyzed forty-four cases, in which an  artificial anus has been formed  by
 opening the intestine;  in seventeen of these the artificial anus was made through
 the peritoneum, and in twenty-seven behind that membrane;  but for various
 reasons, which are stated at length in  the papers, Air. Hawkins  excludes five of
 the cases of peritoneal section, leaving only twelve to compare with the twenty-
 six cases of operation behind this membrane.  Of the  former, he finds that
 seven died  and  five recovered.   The recoveries amounting,  therefore, to only
 forty-one per cent,  in the  cases of this category  whilst of the  twenty-six cases
 where the peritoneum was uninjured, ten died and sixteen recovered ; the propor-
 tion of recoveries in the cases of this  category, amounting to sixty-one per cent.
 Though  the large intestine  was opened in all these cases, the operation was per-
 formed on  the right side in  ten instances; in four cases  the  right colon and
 coecum were opened  through the peritoneum, and of these all  died; whilst in
 the remaining six, in which the right  colon was  opened behind the peritoneum,
 four  recovered.    The preference,  therefore, as Mr. Hawkins observes, on  the
 right side, is certaiuly due to  the lumbar operation.  It is remarkable, however,
 that in the operations on the left colon, the results  are somewhat different;  for
 of eight cases in which this intestine was opened  through the peritoneum, five
 recovered and three died; whilst of twenty cases in which the lumbar operation
 was performed, eleven recovered and nine died.  Air. Hawkins observes, that the
 inequalities of the numbers appears,  however, to  leave  the question as to  the
 mode of operating on the descending colon, still undecided, and that an operator
 is justified in selecting whichever situation  he thinks best for the  formation of
 an artificial  anus on  the left side of the body; though, for the reasons that have
 already been given, I should  prefer Amussat's to  Littre's operation.   In  those
 cases in which death has resulted from Amussat's operation, peritonitis does  not
 appear to have exercised any material  influence, and the fatal result  seems rather
 to have depended on the influence of  previous disease on the constitution of the
 patient, or on changes taking  place in  the bowels,  than on  the operation itself,
 which appears occasionally to have  been uselessly done  at  the  last extremity.
 WTe  should,  therefore, have less  hesitation in performing the extra-peritoneal
operation in an early stage of those cases in which it is called for, than we should
if the section itself were attended with any serious risk to the patient's life. 
CONGENITAL  MALFORMATION  OF  THE  ANUS.       757
                          CHAPTER  LIV.

       DISEASES OF  THE  LARGE INTESTINE  AND ANUS.

  Congenital malformations of the anus and rectum are by no means of un-
frequent occurrence, and are of considerable importance; for, if unrelieved, they
must necessarily be the cause of speedily fatal intestinal obstruction.  They may
exist in various degrees, which I think may most conveniently be arranged under
the following heads :—
  1st. Narrowing of the anus  so as  partially to close it, the canal  continuing
pervious, but not sufficiently so as  to allow of the bowels  being  completely
emptied, the contraction usually merely admitting a full-sized probe;  in some
cases appearing to depend upon constriction of  the anal orifice, in others upon
an imperfect septum stretching across it.  The treatment of this variety consists
in notching the contracted anus with  a  probe-pointed bistoury, and  then  intro-
ducing a sponge  tent, so as to  dilate it to the  proper size, to which it must be
kept by the occasional introduction of a bougie.
  2d. The anus may be completely closed by a membranous  septum stretching
across it, usually having a raphe along the central line, and a slight depression,
through which the dark meconium  can be seen, and on which an impulse can
be felt.  In this variety, an incision must be made through  the septum along
the middle  line, and  this  again cut  across on either side, when the meconium
will freely escape.  The four angles that are left must now be removed, and the
aperture kept  open by the  introduction of a well-oiled plug.   This constitutes
perhaps  the most common form  of malformation that is met with.
  3d. The anus may remain open, but, at  a  distance of about half an inch or
an inch  from its aperture, the rectum will be  found occluded by a  perfect mem-
branous  septum, stretching across  it.  This  is a rare and somewhat  puzzling
kind of malformation; as in it the infant will be found to labor under  intestinal
obstruction, and yet, on  examination,  the anal orifice will  be  found perfectly
formed,  and thus  the surgeon might be  misled  as to the seat of the  obstacle.
He will, however, detect it by introducing a probe or the end of his little finger
into the anus.   In a case of the kind which  was brought to me some  time ago
at the Hospital, I opened the septum by puncturing it with a large trochar, and,
after the lapse of a few days, dilated the  aperture by means of a sheathed bistoury,
the case ultimately doing well.
  4th. The anus may be completely absent, being blocked up by a dense mass of
fibro-cellular structure, from half an  inch to an inch in thickness, above which
the rectum terminates in a kind  of cul-de-sac.  In such a case as this, an incision
about an inch in length should be carefully made, from the point of the coccyx
forwards, and the dissection carried down until  the gut is reached; this  must
then be  punctured, and the meconium  allowed to escape.   If the cut surfaee is
left to granulate, with a plug of lint  merely interposed between its sides, it will
gradually contract, and degenerate  into a fistulous opening, through which the
meconium will escape with difficulty, and as this track is not lined by  a mucous
membrane, the  probability is that the irritation set up along  it by the  intestinal
matters will ultimately prove fatal  to the child.  Indeed, it commonly happens
in these cases that death  results in a few days from  irritation occasioned by the
absorption of the excreted fluids.   In  order to obviate this  source of danger,
Amussat thought of bringing down  the  mucous membrane of the bowel to the
anal orifice, and to fix it there by sutures, so as to afford the meconium  a mucous
canal to  pass through, and thus to prevent the diffuse inflammation which is apt 
753     DISEASES  OF THE  LARGE INTESTINE  AND A
to take place in the cellular tissue of the pelvis, by the contact and absorption of
the effused matters.   This is a precaution which ought never to be omitted.
   5th. The anus may be closed, and the whole of the rectum absent, the intes-
tine (colon) terminating in an expanded pouch, situated high up  at the brim of
the pelvis.  Such cases as these only differ from the last in the extent of the occlu-
sion, and cannot indeed be distinguished from it until the surgeon has  made an
incision in the site of the anus, and has failed to reach the  gut at the usual dis-
tance from the surface.   In these cases the dissection requires to be carried with
caution to a  considerable depth  along the mesial  line, the_ surgeon taking the
curve  of the sacrum and coccyx for his guide, and bearing in mind the  relations
of the bladder and  large vessels  in the neighborhood, carefully  proceeding in
search of the gut,  which may be found at a considerable depth from the surface.
In  three  instances of this kind on which I  have operated, it was necessary to
proceed to a depth of at least one and a half  or two inches before the bowel was
reached, which, on account of the narrowness of the wound and  the small size
and important relations of the parts, is not an easy matter.  An attempt may be
made to bring down and fix  the  gut at the external orifice, as in the last case,
but, on account of the distance that it is from the surface, this  can rarely be
expected  to succeed.   As the perineal section seldom succeeds in  saving life in
these cases, it  might be a question whether the descending colon  should not be
opened in the iliac or lumbar regions.
  In these cases three courses present themselves to the surgeon.  1st.  The colon
may be opened in  the left iliac region; 2dly.  It may be reached in the left lum-
bar region; and, 3dly.  An opening may be made into it through the perineum.
  The only advantage that the  iliac incision, or  Littre's  operation,  presents is,
that it is an operation easy of performance, and that whether the surgeon reaches
the colon, or not, he is certain to hit upon some part of the intestinal tube which
may be drawn forwards and opened.
  The objections to this operation are, the inconvenient situation of the artificial
anus;  the great danger that must necessarily result from  wounding the peri-
toneum ;  the chance of not finding the sigmoid flexure ; and, as has often hap-
pened, of being obliged to  open that portion of the small  intestine  which first
presents itself.
  The mortality after this  operation is  very great.  Amussat states,  that of
twenty-one children thus operated  on, only four ultimately recovered; and it is
worthy of remark, that all the successful cases occurred in the town of Brest.
  The lumbar incision, or Amussat's operation, has  not as yet, to my knowledge,
been practised on  an  imperforate child.
  The advantages of  this operation consist not only in the  artificial  anus being
situated at a more convenient spot than in Littre's operation, but more especially
in the possibility of opening the colon in  this situation without wounding the
peritoneum.
  The objections to this operation, as applied to imperforate children, lie in the
frequent co-existence of malformation or malposition of the  colon, with absence
of the rectum, and in the impossibility in many cases of determining, before pro-
ceeding to operate, whether the anus is only occluded by a membranous septum,
or whether the rectum is absent as well.   If it could be ascertained  beforehand
that, though  the  rectum be absent, the  descending colon  occupies its  normal
position in the  left lumbar  region, I think it probable that  the lumbar incision
would be attended with less danger than any  other operation that could  be prac-
tised ; but in the absence of this knowledge, it would scarcely appear to be justi-
fiable to have  recourse to it, as the colon might not be found, and the anus might
merely be covered by a dense membranous septum.
  The perineal incision has the  advantage of being in the natural  situation of
the anus, and of being easily practised and perfectly successful in all those cases 
STRICTURE  OF THE  RECTUM.
759
in which the anus only is imperforate, the rectum being present.  It is in those
only in which there is congenital absence  of the rectum  that this  operation is
difficult of performance, and uncertain in its results.   If it could be ascertained,
before  proceeding to operate, that the rectum be absent, it might be wiser to
search for the bowel in the lumbar region.  But as the surgeon  has no means of
ascertaining, before making his incision, whether the rectum be one inch or three
inches from the surface, he must cut into  the perineum in order to obtain the
necessary information;  and if once he has penetrated  to such a depth as to get
beyond the levator ani muscle, or into the deep fasciae in  this situation,  a great
portion of the immediate danger of the operation  will  have been  incurred, and
few would think it advisable to leave the perineal operation unfinished, and  ex-
pose the child to the additional  risk of opening the colon in the lumbar region.
  There is  one point in connexion with the perineal operation  to  which it is of
much importance especially to attend, not only as  respects  the  immediate result
of the  operation, but as regards the  ultimate success  of the procedure,  I mean
the bringing down of the mucous membrane of the gut, and fixing it to the lips
of the  external wound.  Unless this be done, the tine of incision between the
termination of the gut and the aperture in the integuments will degenerate into
a fistulous canal, which, like all fistulae, will  have a tendency to contract, and will
be a source of endless embarrassment to the surgeon and to the patient.   If the
mucous membrane can be brought down and fixed to the opening in the integu-
ment, this source of inconvenience will be removed, and the patient will be saved
all that danger which results from the passage of  the  meconium over a surface
of recently  incised cellular  tissue.   This, however, can only be done when the
intestine terminates  at a  short distance from the surface.   If the perineal inci-
sion be two or  three  inches  in depth, there would be little probability  of the
surgeon being able to bring the  intestine down to  such an extent.  In the case
that I have related I attempted to do so,  but found that the gut was too firmly
fixed to be moved by any traction  that it  would have been safe to have employed.
  6th.  The anal orifice may be  absent, and the gut may  open into one of the
neighboring mucous canals, as the vagina, the urethra, or into the bladder.  In
such anomalous cases as these there is usually, I  believe, but little  to be done,
except  to restore the anal orifice,  and then  to take the chance of  the other pre-
ternatural communication closing.  In a  case in which I was recently consulted,
there was imperforate  anus and rectum, and the bowel protruded as a red, fleshy
tube, about four inches in  length, from the end of which in the anterior abdo-
minal wall,  just below the umbilicus, and immediately above an  extroverted
bladder, the meconium escaped.   In such a complicated malformation  Surgery
could evidently do nothing.

                 STRICTURE OF THE LARGE INTESTINE.
  Stricture may occur in any part of the rectum or colon, and is of two kinds,
the simple,  consisting  of mere thickening of the bowel, with fibrous degeneration
of its coats  and contraction of its canal; and the  malignant, dependent  on can-
cerous degeneration  of, or formations in the bowel.
  The simple fibrous stricture, though occasionally occurring in the transverse or
descending  colon, is most frequently met with  at the junction of the  sigmoid
flexure  and the rectum, or at the upper part of  this gut, from four to six inches
from the anus.   Not  unfrequently a very tight  annular stricture is found in
otherwise healthy subjects at the lower part of the rectum, about an inch and a
half from the anal orifice, appearing almost as if it were the remains of a septum,
or a thickened annular fold of the mucous membrane in this situation.
  Stricture of the large intestine commonly occurs in elderly people and with
special frequency in women; that form which occurs low down  I  have however
several  times seen in young women, otherwise perfectly healthy.
ft 
760     DISEASES  OF THE LARGE INTESTINE  AND  ANUS.

  The symptoms of stricture of the rectum consist  at first of some difficulty in
defecation, the patient being obliged to strain at stool.   The faeces will also ap-
pear to be flattened or narrowed, and in many cases, more especially as the stric-
ture advances, are passed in the form of small scybala, with occasionally a kind
of spurious diarrhoea, consisting of the passage of the more fluid intestinal contents,
whilst the solid matters  are left behind.  At the same time there is very com-
monly pain in defecation and the occasional passage  of some mucus or blood, and
dyspeptic symptoms, with flatulent distension  of the abdomen  are apt to come
on.   If the stricture is within four or five inches of the anus it may be reached
with the finger, and its  precise situation and diameter  ascertained.   If  above
this point it  must be examined by the introduction of  a well-greased bougie,
attention being paid to the curve which the  rectum makes from side  to side, as
well as from  before backwards.  In introducing bougies in order to ascertain the
presence of a stricture above the upper  end of the rectum, but little information
can be gained in many cases, as the point of the instrument is apt to hitch in
folds of the mucous membrane, or opposite  the  promontory of the sacrum, and
thus its onward passage being prevented,  an appearance of  constriction may
present  itself, which  in  reality does not occur,  and unless  care be  taken the
mucous membrane may actually be lacerated, and the instrument forced through
it into the peritoneal cavity.   In other  cases again the bougie will appear to pass,
when in reality its point meeting with an obstruction  curves  downwards into
the rectum.
  The progress and  termination  of a  simple stricture vary in different  cases.
In some, the  contraction of  the stricture may go  on  increasing until at last com-
plete occlusion takes place with retention of faeces and all  the symptoms of ob-
structed bowels.  This condition usually comes on slowly, and after the obstruc-
tion is complete life may continue for several weeks; but in  some instances the
obstruction appears to take  place rather suddenly, and with all  the symptoms of
acute intestinal strangulation, with death  in  a few  days.   Abscess occasionally
forms in the  neighborhood of the stricture and passing down into the pelvis may
either burst  into the ischio-rectal space, into the vagina, or present upon the
nates.   The discharge of pus from this  source, as well as  from the mucous  mem-
brane lining the stricture which falls into an ulcerated state, may induce extreme
emaciation  and hectic, to which the impairment of nutrition consequent upon the
disturbance  of digestion adds materially.   In some cases peritonitis will at last
ensue either in consequence of ulcer or abscess  communicating with  the serous
cavity, or else from the extension of the irritation outwards.
  The treatment of  simple  stricture of  the rectum must be conducted on the
principle of dilating the canal  at  its constricted  point.   If this be within  reach
of the finger, the dilatation can be readily carried out.   If it is above the  upper
part of  the rectum, and  the stricture be tight, it is extremely  difficult to  intro-
duce the proper instruments  with certainty.   AVhen the stricture is low down so
that the end  of the finger can be introduced into  it,  it may readily be  dilated by
introducing a rectum bougie  every second day and gradually increasing the size
of the instrument.  If the stricture yields but slowly, and is very tight and in-
durated, I have found it  a convenient plan to introduce a  sheathed probe-pointed
bistoury into  it and to notch  it towards its posterior aspect, where this may be
done without danger  to  the peritoneum.  A tent of compressed sponge should
then be introduced and left in for twelve hours.  On its withdrawal bougies may
more readily be passed, or the dilatation may be  carried on by means of tents of
compressed sponge.   When  the stricture is above the reach of the finger a good
deal of management  will be required to get the bougie into it.   This is best
done by laying the patient on  his  left side  and using a moderate-sized wax or
elastic bougie, which must  be passed without  the employment of any  force.
When once the surgeon  has  got one through, others can  readily be got to  follow
f 
CANCER OF  TnE RECTUM.
761
in the  same track.  The great danger in introducing the bougies high up, is to
mistake the obstruction offered by their point coming in contact with one of the
valvular folds of mucous membrane, that occur in this situation, for that of the
stricture, and pushing on the instrument to perforate it—an accident that would
probably occasion  fatal  peritonitis.  During the  introduction of bougies, the
bowels must be kept regular by means of lenitive electuary and the occasional use
of emollient enemata,  If much pain or irritation  should be occasioned by their
presence, opium should  be administered internally or in the form of supposito-
ries.  Though a simple stricture of the rectum may be much relieved  by the use
of bougies, it is seldom I think cured by this means, there being a great tendency
for it to contract so soon as the treatment is discontinued.
   If complete obstruction occur, an endeavor should be made to relieve  the pa-
tient by the use of enemata of gruel and linseed-oil, and the strength should be
supported by a diet that is nourishing, at the same time that it leaves little  or no
solid residue;  the bowels may eventually act after a considerable lapse of  time,
the stricture apparently giving  way.  In a  case which  I attended with Dr.
Powell, and to which reference  has already been  made, the stricture gave way
after obstruction  had lasted  for about five  weeks, some  hardened faeces  with
bloody mucus being discharged, which were speedily followed by abundant fecu-
lent motions.  Should the obstruction,  however,  continue, and  the patient conse-
quently be  in imminent danger of  death from this cause, the intestine should be
opened if possible by Amussat's operation, performed in the way already described.
This may require to  be  done either on the right or left side, according to the
seat of the stricture.  In  the majority of instances this will be situated below
the descending colon, so that relief may be given by opening this intestine in the
left loin.   But if it is impossible or even very difficult  to determine the precise
seat of the obstruction, the operation may as readily be performed in the  right
lumbar region.   In those rare cases in  which the stricture is seated in the trans-
verse colon, there would  probably be considerable distension of the right  loin,
without any corresponding  enlargement of the left;  under these circumstances,
the proper  plan would be to open the ccecum.

         CANCER AND  MALIGNANT STRICTURE OF THE RECTUM.
   Cancer of the rectum usually occurs  in the form of degeneration or infiltration
of the  substance of the wall  of the  gut, giving  rise to considerable  induration
and contraction of the bowel.  In other cases a flat cauliflower growth springs
from the inner surface of the intestine, being hard, nodulated, and presenting all
the ordinary characters of scirrhus.  And sometimes even this is somewhat pe-
dunculated, so as  to resemble a hemorrhoidal protrusion;  and lastly a scirrhous
tumor  may form in the cellular tissue external to  the  rectum, and at last press
upon and implicate the gut.
   Alost usually cancerous disease is seated from three to five inches  above the
anus, and may implicate  a considerable portion of the bowel, extending upwards
rather than downwards, and giving rise to  considerable induration and contrac-
tion, with complete occlusion of the interior of the gut.
   The  symptoms of cancer of the rectum are  pain and weight in the gut, with a
sensation as if the bowels  had  not been completely relieved, together with the
discharge of mucus, blood, or pus, and some flattening of the faeces.   On ex-
ploring the parts with the finger, the lower portion of the rectum will  usually be
found considerably expanded, whilst the tip of  the finger will come in  contact
with the contracted, hardened, and rugged  scirrhous mass.  The patient expe-
riences most suffering during defecation,  in consequence of the passage of faeces
over the raw and  ulcerated surface.   This pain is not confined merely to the
diseased part, where the sensation is of a hot and burning character, but usually
radiates round the loins and down the  thighs, and is so severe, that the patient 
 7G2     DISEASES  OF  THE  LARGE INTESTINE AND  ANUS.

 looks forward to each action of the bowels with the greatest possible dread, and
 restrains it as long-as possible.  The whole nervous system at last participates in
 this continually recurring suffering, the countenance becomes anxious, the spirits
 depressed, sleep and digestion destroyed.   The patient's condition is indeed truly
 miserable between the dread of excessive suffering when the bowels act, on the one
 hand, and the fear of impending obstruction on the other, and in many instances
 he is worn out by this suffering, together with the constitutional cachexy induced
 by the contamination of the system with the cancerous matters.   Not unfrequently
 the misery is much increased  by the formation  of fistulous openings in the neigh-
 borhood  of the  bowel,  and communication  between it and neighboring parts,
 such as the vagina, bladder, or urethra, with cancerous implication of them.   In
 other instances, though more rarely, death occurs from fecal obstruction, as in
 the case  of simple stricture.
   The treatment must necessarily be of a palliative kind ; large doses of opium
 being required after each action  of the  bowels to  lessen the patient's distress.
 Little good can be expected from more active measures; dilatation only irritates
 the disease, and would tend to increase the mischief.   The application of caustics
 such as potassa fusa, does not offer much  prospect of advantage, as only a super-
 ficial slough could in this way be formed, without very serious risk to the patient,
 and  it is an  excessively painful remedy.   Amussat has proposed to  crush and
 break down the morbid mass  by means of the finger  and  forceps.   But from
 such  treatment  as this  little good can be  anticipated.   The recommendation
 to excise the  cancerous mass, as made by  Lisfranc and other  French surgeons,
 is contrary to every principle of good  surgery, as it is impossible  to  extirpate
 the whole of the disease, without  either laying open  the  peritoneal  cavity, or
 destroying the  patient by the  profuse  hemorrhage which  could scarcely be
 arrested.   If palliative  means fail in affording the requisite relief,  and  the
 patient suffers much local pain and constitutional irritation during defecation,
 the  propriety  of  establishing  an artificial anus  in the left lumbar region might
 be discussed, not with  a view of saving life, but rather in the hope of prolong-
 ing  existence, and lessening suffering by  preventing the exhaustion and agoniz-
 ing  pain  that attends  the passage of the feculent matter  over the  ulcerated
 surface.  In one case Amussat afforded much relief to the patient by such a pro-
 cedure as this.
   Polypi sometimes  form in  the rectum, constituting large pendulous tumors
 of a fibro-mucous character; they may most conveniently and safely be removed
 by the application of a ligature to their neck.

                           DISEASES OF  THE ANUS.
   Cancer of the anus is not a very common affection and when met with usually
 occurs in  consequence  of scirrhus of the rectum spreading to and involving
 the margin of the  anus.   AVhen  it occurs as  a primary disease it is usually of
 an epithelial  character,  and may then form  about the  anus just as it  does at
 other muco-cutaneous apertures.  If  limited and detected in the early stage it
 might advantageously be excised, but at a more advanced period of the  disease,
 such a practice  could  scarcely be adopted  with any  prospect  of  success,  in
 consequence of the impossibility of removing the whole of the structures impli-
 cated.
   Ulcer and fissure  of the anus.—This disease though trivial in point of size
and in its pathological relations, is  of great practical importance on account of
the excessive local^ pain, and  great  constitutional irritation to which a patient
laboring under it is often subject.   Ulcer and  fissure  commonly exist  together
in this situation, though it by no means unfrequently happens that  the two con-
ditions occur separately;  the  ulcer is  usually of small  size,  seldom larger than
a silver threepence, of a  circular or longitudinal shape, situated between the folds 
ULCER  AND  FISSURE  OF THE ANUS.             763
of the mucous membrane  in the upper part of the anus, or rather  the lower
part of the rectum, just above the ring formed by the  sphincter, and is  usually
met with towards the  posterior part  of the gut on one  side  of or opposite to
the point of the coccyx.  Occasionally more than one ulcer exists in this situation.
If a  fissure accompanies the ulcer, it commonly leads from this across the face
of the sphincter  to the verge of the anus; but in many cases one or two fissures,
sometimes even three or four exist, without any ulcer.   The fissures are  usually
slightly  indurated and cord-like,  and  not unfrequently their external termination
is concealed by a small pile or flap of integument.
  The existence  of the ulcer may usually be determined by exploring the  rectum
with the finger,  which if practised in these examinations,  will  detect a  small,
soft,  and velvety patch at the  diseased  spot; on  touching which the  patient
will usually complain of  acute  and  burning  pain.   In some  cases  the ulcer
may  be  brought  into view by examining the rectum with  the speculum ani, such
as here  delineated (Figs.  242 a and  243).  The fissure may always  readily be
Fig. 242.                             Tig. 243.
detected  by everting the mucous membrane of the anus, and by lifting up or
turning aside the pile  that  covers the  lower end of the  crack.  During this
examination it will usually be found that the sphincter  ani  is in a more or
less spasmodically  contracted  state, admitting  the finger and  instrument  with
difficulty.
  The symptoms of ulcer or fissure in the anus are very characteristic.  The patient
complains of pain usually of a  severe  burning character on the passage of a
motion, occasionally at the time of defecation, but more frequently commencing
a few minutes afterwards and continuing for half an hour or an hour.   This
pain is very severe and peculiarly wearing and burning; it is generally most felt,
opposite the sacro-iliac articulation, but not unfrequently  radiates round the pel-
vis or down the thighs.  In  many cases  it produces a good deal of continued
irritation about the genito-urinary organs, giving rise to symptoms of spasmodic
stricture;  a frequent desire to urinate, tenderness about  the prostate, and semi-
nal emissions.  Very commonly in women,  the  pains produced by the rectal dis-
ease simulate those  occasioned  by uterine  irritation; and, in  both  sexes, they
may after a time become continuous, and  be attended by a good deal of con-
stant uneasiness in sitting, so that the patient  is obliged  to raise  the affected
hip.   There is often a  discharge of a streak of pus or blood on the faeces, and
commonly a good deal of mucous exudation, with some tenesmus on defecation;
but in  some instances these symptoms  are  altogether absent,  and the patient
never suffers any local inconvenience except from the pain. 
764
DISEASES  OF  THE  LARQE  INTESTINE  AND  ANUS.
    The constitutional irritation is often very great, the  nervous system generally
 sympathizing with the local mischief.   The countenance becomes pale, anxious,
 careworn, and the expression is indicative of constant suffering.
    This affection most  commonly  occurs  in  women, especially in those of an
 hysterical temperament and weakly constitution.  AVhen met with in men it is
 most frequently seen in enfeebled, cachectic, and debilitated subjects, and appears
 to be the result of a broken state of health.
    The treatment of fissures or  ulcers of  the anus, when the disease is met with
 in the  early stages, may sometimes be  successfully conducted by the application
 of nitrate of silver to  the  fissure, and the use of an anodyne or astringent sup-
 pository.  I  have found a very excellent and useful  suppository in this and many
 other painful affections of the anus  to be composed of 2 grains of extract of
 belladonna, 2 grains of the acetate  of lead, and 4 of tannin, made up to a proper
 consistence with a little wax and lard.    This  may be introduced into the  rectum
 every night and allowed to dissolve there; the bowels should at the same time
 be kept gently open with castor-oil, or the lenitive electuary.   In those cases in
 which the disease has been of some standing these means will not suffice, and it
 becomes necessary to have recourse to  a  very simple operation to effect a cure.
 This consists in dividing  the affected  mucous membrane through the ulcer or
 fissure, with some of the subjacent  fibres of the sphincter muscle, by which the
 part is set at rest and cicatrization speedily takes place.  Indeed after this simple
 operation  a  patient who  has  been suffering  severely for months or years, will
 often get complete and almost  instantaneous relief.   The  merit of introducing
 this  plan of  treatment for the cure of  ulcer and fissure of the anus into surgical
 practice is due to Sir B. Brodie.   Boyer had previously recommended that the
 sphincter should be  completely cut across in order that its action  might  be
 paralysed, but Sir B. Brodie found  that the ulcer could be got to heal  as readily
 by the  limited incision  above  mentioned.   The operation is readily done by in-
 troducing the left  fore-finger into  the rectum, guiding along it  a probe-pointed
 bistoury, and then cutting downwards and outwards, carrying the  knife about the
 eighth of an inch in depth.  The section may either be made through the ulcer
 and fissure,  or on  either side of  the coccyx.  It  is  doubtless better, when
 practicable, to cut through the  diseased structures, though  it is not necessary to
 do so;  and it is  always better to make  an incision on both sides of the sphincter,
 so as to be sure that the muscle is set at rest.   No dressing is required  after this
 operation, but if the incision do not readily heal at  the end  of a  fortnight  or
 three weeks,  it should  be  touched from the  bottom with  the nitrate of silver.
 Ihe patient s bowels should be  well opened before  the operation, and a dose  of
 castor-oil may be given on the second or third day after it.   During the process
 ot cicatrization it will often be advantageous to give iron, and to put the patient
 on a very nourishing diet.
   Spasmodic contraction of the sphincter ani  is usually associated  with fissure
 or ulcer of the anus, but occasionally it occurs without this  complication and  in
 all  cases it may be associated with a neuralgic  condition of  the part.   In
 hysterical women this neuralgia and spasm are especially apt to occur, though it
 is not improbable that in many  of the so-called cases of neuralgia  of  the anus
 some positive  disease may be  detected  on close  examination, as  I have had
 several occasions  to verify.  The treatment of  spasm of the sphincter, whether
 associated with neuralgia or not, consists in the employment of  local  sedatives
with, it necessary, the division of a few of the muscular fibres, together with the
mucous membrane.
  Abscess not unfrequently occurs in the  vicinity of the  rectum  and anus.   It
may either be superficial, being confined to the muco-cutaneous structures, and
presenting the ordinary characters of acute subcutaneous abscess, or it may be 
VARIETIES OF  ANAL  FISTULA.                 765
deeply seated, forming in  the ischio-rectal fossa.   It is these rectal abscesses
that are  of most practical importance.  They may be of two kinds—acute and
chronic.
  The acute ischio-rectal abscess forms  deeply in the  fossa, with throbbing,
shooting, and  stabbing pains  through the anus, rectum, and perineum; on ex-
amination, a hard, brawny substance may be felt in the  cellular tissues by the
side of the gut, either by examination from without,  or by exploration through
the rectum, which speedily softens, and will, unless an outlet be made for it,
either  burst externally, or into the cavity of the gut, or both ways.  This acute
form of abscess usually occurs in persons of otherwise strong and healthy con-
stitutions.
  The chronic ischio-rectal  abscess, on  the  other hand,  occurs  insidiously in
persons of cachectic, broken, or phthisical constitutions, and without much pain
or local inconvenience will form a large  collection denuding the  gut  to a con-
siderable  extent, in fact,  almost surrounding  the  rectum, and then spreading
widely on the nates or  hip, presenting all the  ordinary characters of a chronic
abscess.   This kind of  purulent collection may form in  this as in any other
situation of the body, as the result of congestion, or some local  irritation.   But
there is reason to believe that in  some instances at least, it occurs as the result of
perforation of the gut, either by ulceration from within, or by some foreign body,
as a fish-bone, for instance, transfixing it, and thus inducing inflammatory action
in the  cellular tissue outside the  rectum.
  In the treatment of these abscesses the principal point to be attended to is the
extensive denudation of the gut.   In order  to prevent this they must be opened,
so soon as the formation of pus can be ascertained to have taken place, by making
a free, and if necessary a deep incision into the ischio-rectal space  by the side of
the bowel.  Unless this be done, they may  either burst into the interior of the
gut, or spread widely upon the  nates, and then give way.   The pus that is let
out  of these  collections is always extremely offensive, even though  not mixed
with any feculent  matter, the near neighborhood of the  bowel  appearing to
determine some change in it that renders its smell peculiarly  stercoraceous.
After the evacuation of the abscess the patient feels easy, and thinks that all is
well, the discharge gradually  lessening and the  cavity contracting; but  it does
not close, and a fistula will be left, which continues to exude a thin watery pus,
in which feculent matter, perhaps, accumulates from time to time, giving rise to
fresh outbreaks and extensions of the disease.

                             FISTULA IN ANO.
  The sinus left by the contraction of the cavity of an ischio-rectal abscess  con-
stitutes a fistula in ano ; an affection that has attracted a good deal of attention
from the frequency of its occurrence, and the difficulty  of curing it without
having recourse to  operation.
  Fistula in ano may vary as  to extent and  kind.   Some fistulae are very limited,
being merely the sinus left in the submucous cellular tissue  of the  anus after the
bursting of a  superficial abscess in this situation, extending to a  short distance
up the gut inside the sphincter.   This form of fistula constitutes, however, a kind
of spurious variety  of the disease, for the true fistula in ano is outside the sphinc-
ter in the surrounding cellular tissue, extending always as high  as the upper
margin of that muscle, and frequently stretching to a considerable distance up
the side of the gut.  Alost frequently the lower  aperture of the fistula is some-
where  in the perineum or ischio-rectal fossa, just beyond the sphincter ; but not
unfrequently sinuses extend from this outwards to a considerable distance, under-
mining the integuments about the buttocks, stretching away towards the trochan-
ters and opening at a  great  distance from the bowel.  These extensive fistulae
and sinuses are frequently connected with stricture of the gut. 
766
DISEASES  OF  THE  LARGE  INTESTINE  AND ANUS.
    Fistula in ano varies also as to kind.   It is said to  be complete when it  com-
  municates by one end with the interior of the  rectum,  and opens by the other
  upon the external surface.   It is said to be incomplete when it has only one aper-
  ture, whether that is external or internal.
    The complete fistula is the most common, and probably arises in the majority
  of cases from some source of irritation  seated within  the bowel,  by which the
  mucous membrane of the rectum has been perforated, and an abscess has formed
  in the cellular tissue outside the gut.  The external opening in this form of fistula
  is usually from half an inch to an inch  from the margin of the anus, though it
  may be seated at a greater distance  than this, as upon  the hip.   It is commonly
  of small size, and has  a vascular granulation projecting from, or occluding it •
  and a thin purulent discharge usually  drains away from it  in  small quantities'
  moistening the  surrounding  integuments.  The internal  opening  is usually
  situated just above the sphincter, where the rectum begins to expand.   But the
  fistula does not terminate at this internal aperture, for in the majority of cases it
  runs up into a kind of cul-de-sac,  to a considerable distance further.   The inter-
  nal aperture may readily be  detected by introducing a blunt curved probe into
  the fistula, when by a little management it may be carried through the  inner
  opening.   In some cases the existence of this may be ascertained  by examining
  the interior of the bowel with a speculum ani.                              °
    The incomplete or blind fistula may be of two kinds, and commonly arises from
  constitutional causes.   AVhen there is no internal perforation, a mere sinus having
  been left by the bursting of an  abscess, the fistula is termed blind  external
  When there is only an  internal aperture it is called blind internal.  The  blind
  external fistula is readily recognised  by its being  found  that the probe  does not
  penetrate the interior of the gut.   The blind internal is not so readily detected,
  but m this case  it will  generally be  found that the patient  suffers from an  oc-
  casional and tolerably abundant discharge of pus from the interior of the bowel;
  that  there is a good deal of tenderness, with some brawny induration on one side
-of the anus ; and that the pus may be  made to well out in some quantitv by
 pressing upon this  part.   On passing the  finger  into the rectum the rago-ed in-
 ternal aperture in the gut may readily be felt through which  the pus exudes.
   In the treatment of fistula in ano,  operative interference is usually necessary.
 It is  true that in some rare instances the canal may be got to close  under the
 influence of constitutional management, aided perhaps by  stimulating its interior
 with  the nitrate of silver,  or by touching it with a probe dipped in nitric  acid.
 ihis  kind of treatment is however only successful in  the  blind external fistula,
 several instances of which I have seen get well in this way, but it can never  be
 expected to answer in any other variety of the disease.   When the fistula is com-
 plete, the only plan of treatment that offers  any chance of  success, is the division
 of the sphincter, so that  this muscle which  tends  to prevent  the  closure of the
 sinus, may be paralysed, and the fistula being laid open from the bottom, made
 to heal by granulation.   Various plans have been devised  for the division of the
 sphincter, and  much ingenuity has been expended in attempts to discover simpler
 and less painful modes of effecting this than by the knife, but hitherto  without
 success, and the only plan of treatment that deserves any attention is the division
 ot the sphincter with a curved bistoury.
   The operation for fistula in ano should not be  performed indiscriminately in
 all cases and at all  periods  of the  disease.   If the fistula be dependent upon
 stricture of the gut,  and more especially if this be of a malignant character,  it is
evident that no operation can be  attended by a chance  of success,  and none
should be attempted   So also if the patient be cachectic and broken in health,
it is well to improve his  constitutional powers before undertaking an operation,
lest the wound that results may not readily cicatrize.   It is also well  to wait until 
OPERATION  FOR FISTULA  IN  ANO.
767
the disease has assumed a somewhat  chronic  form before proceeding  to the
division of the sphincter ;  if this fee done early after the bursting of the abscess,
or at any time if there be much inflammatory action going on, the wound is apt
to assume a somewhat sloughy condition, and to heal with great difficulty.  The
most important question usually connected with the operation for fistula, is the
propriety of performing it in  phthisical subjects.   It is a well-known fact that
fistula in ano is especially apt to occur in consumptive individuals, and it is often
a nice point to determine whether  an operation should be performed or not in
them ;—how far the drain from the fistula  may keep up or even  generate the
tendency to phthisis, or how far it  maybe salutary in acting as a counter-irritant,
and in preventing the morbid condition of the lung developing itself.  Dr. Theo-
philus Thompson states that the co-existence of fistula with phthisis appears to
retard the progress of the latter disease, acting  as a derivative, and  doubtless in
some instances this  may be so.  I have, however, in several cases found con-
siderable advantage result by operating for fistula in the early stages of phthisis,
or in suspected cases of that disease, the patient's health having  considerably
improved after the healing of the fistula.  In such cases it may be  of use to put
an issue in the arm or side of the  chest.   But  in confirmed, and stilMess in ad-
vanced phthisis, no operation should ever  be  practised,  as the wound will not
heal, and the patient must be weakened by the  additional  discharge.
   The operation should be performed in the following way :—The bowels having
been well cleared  out the day before with a dose of castor-oil, and  an enema
administered  on the morning of the operation,  the patient should be
laid on his left side, with the nates projecting over the edge of the
bed; a probe must then be passed through  the fistulous  track into
the rectum, and the surgeon introducing the forefinger into the gut,
feels for the end of the instrument,  he then passes a short strong-
bladed probe-pointed bistoury, about the size and shape  of that re:
presented in  the adjoining figure (244), through the fistula, using the
probe as a guide, though in some cases this may conveniently be dis-
pensed with.   When he feels the end of the knife projecting into the
rectum, through the internal aperture of the  fistula, he  withdraws
the probe, and hooks his forefinger  over it (Fig.  245), and by a sweep-
ing and pressing cut, raising the  handle of the instrument at  the
same time that he pushes down its  point, brings both finger and blade
out at the anal aperture, cutting through the whole thickness of parts
between this  and the fistula, so as to lay the  two cavities into one.
In performing this operation, the surgeon  must cut with his  left
hand if the fistula be upon the left side ; and in either case should
be careful not to wound his own finger, as such cuts often  prove
troublesome in healing.  If sinuses stretch from the fistula along the
nates or hip,  he may, if he pleases, slit these up with a probe-pointed
bistoury, before dividing the sphincter.   But  if they be  extensive,
such an operation may be of a somewhat serious character, and it will
then be better to make a puncture into the  sinus  near  the external
margin of the anus, and divide this  stricture in the usual way.   If
the fistula be  a blind external one,  it  must at the time of the operation
be made complete, by scratching with the end  of the knife through the thinned
structures that intervene between its extremity and the interior of the gut; and
the operation  must then be completed in the way described.  If it be a blind in-
ternal fistula, a puncture must be made through the integuments into the canal,
with a sharp-pointed bistoury, and the operation then concluded in  the ordinary
way.                                      i        i •
   When there is an internal aperture into  the gut, this will usually be found
 
  768     DISEASES  OF  THE  LARGE  INTESTINE AND  ANUS.

  just  above the sphincter; but the  fistula does not  terminate  here, frequently
                                    extending up by  the side of the gut for an
                                    inch or two.   Under  these circumstances,
                                    what should be done with the cul-de-sac above
                                    the inner  aperture ?  If it be laid  open, an
                                    extensive and  deep wound will be inflicted,
                                    which may implicate some of the hemorrhoi-
                                    dal vessels, and thus give rise to a dangerous
                                    degree of  bleeding.  Hence, surgeons gene-
                                    rally content themselves  with the division
                                    of the sphincter and all the parts interveninw
                                    between the inner aperture of the fistula and
                                    the verge  of the  anus; the  sinus which is
                                    left usually contracting and  closing without
                                    difficulty when this has  been done.   In some
                                    cases it happens,  however, that this  cul-de-
                                    sac is not  readily  obliterated, but gives rise
                                    to a good deal of  trouble, in consequence of
                                    the occasional accumulation of pus in it, and
                                    the thickening of its aperture into the bowel
                                   giving rise to  spasmodic contraction of the
 sphincter and a kind of rectal stricture.   This inconvenience gradually subsides
 in most cases;  should it continue, it may be obviated  by introducing a sheathed
 bistoury into the track and dividing it.
    The after-treatment should be as simple  as possible,  consistently with securing
 closure of the wound by granulation from the bottom.   A narrow slip of oiled
 lint should be introduced between the lips of the wound, and  this must  be left
 in for forty-eight  hours, during which time the bowels are kept confined  by the
 administration of a grain or two of opium  immediately after the operation.  On
 the second day  a dose of castor-oil may be administered, which will not only act
 upon the bowels, but bring  away the piece of  lint.  The wound  must  then be
 lightly dressed  from the bottom, a poultice applied, and  care taken at the daily
 dressing, by the introduction of a probe, to prevent the bridging over of granu-
 lations.   After  the  wound has completely united, a notch will usually be left by
 the side of the  anus, which gives  rise to some  inconvenience for a time by the
 occasional involuntary discharge of  a  little intestinal  mucus, and some  flatus.
 This especially happens in those cases in which  the incision has been made ante-
 rior to the anus into the perineum, and when incontinence of  fteces may, for  a
 time, be left.  Should  the  operation be followed by abundant hemorrhage of  a
 dangerous character, the rectum must be securely plugged, either with compressed
 sponge or with a bougie surrounded by lint.

                         HEMORRHOIDS,  OR PILES.
   By hemorrhoids  or piles, is meant a morbid  condition of the bloodvessels of
 the anus and lower part of the rectum, more especially of the veins of the sub-
 mucous and subcutaneous cellular tissue, giving  rise  to more or less intumescence
 of the part, which may or may not be attended  with a  discharge of blood.   Sur-
 geons are commonly in the habit of classifying piles, according as they bleed or
 not, into open or blind; or,  according  as they are situated  above or below the
 verge of the anus, into internal or external; the internal being always within
 the  gut, the external habitually protruding out of or around the anal aperture.
 The first may either  bleed or not; the latter are always blind.  To this division
into external and internal, Mr.  B. Cooper has added an  intermediate variety, the
intero-external, which is partly within and partly without  the anus.  These divi-
 
CAUSES OF PILES.
769
 sions are of much practical moment, as the treatment is very materially modified
 according as the hemorrhoid is situated above or below the anal verge.
   We must look to the peculiar arrangement of the veins of the  rectum as di-
 rectly predisposing to  the  occurrence of piles.  The lower  part of the rectum
 and the verge of the anus are  composed of a plane of muscular fibre and a muco-
 cutaneous surface, with an intervening stratum of  dense cellular tissue.   In this
 cellular membrane is situated a close interlacement or network of tortuous veins.
 The blood from this plexus of hemorrhoidal veins, finds its way into the general
 system through two distinct channels.  By far the greatest  portion of  it is car-
 ried into the inferior mesenteric vein and thence into the vena porta through the
 medium of the superior hemorrhoidal vein, which may be looked upon as the
 extreme  radicle of the portal system; and  secondly, a certain quantity passes
 into the internal iliac vein through branches that accompany the middle hemor-
 rhoidal artery.  AVe may therefore look upon the hemorrhoidal plexus as being
 placed midway between the portal and general venous systems, being the point
 indeed at which they touch;  but as belonging rather to the portal  than to the
 systemic veins.  In these  arrangements we see all the elements that would  pre-
 dispose to congestion, and consequent dilatation of the vessels of a part.   There
 is a large and intricate  plexus of veins in which, as in all similar networks, there
 is a tendency for the blood to  circulate slowly at times; the natural tendency to
 stasis of the blood being, much increased by the dependent position of the  part
 and by the anatomical  fact that in consequence of the absence of valves  in the
 superior  hemorrhoidal vein and in the vessels  into which it pours its contents,
 the whole pressure of the column of blood in the  portal system may be brought
 to bear upon the hemorrhoidal plexus.  The circulation through  the portal  sys-
 tem is likewise subject to much interference in consequence of hepatic and intes-
 tinal obstruction, and in these  changes the blood in the hemorrhoidal plexus also
 participates; and were it not for the provision which exists by which this plexus
 may free itself to a certain extent from over-distension by its communication with
 the internal iliac through the medium of the middle hemorrhoidal vein, patients
 would suffer from piles much more frequently, than they now even do, as a  con-
 sequence of obstructed portal circulation.   Another great cause of hemorrhoidal
 enlargement is to be found in  the want of support that the veins  of  this plexus
 experience on their mucous aspect during defecation.  Situated as they are in
 cellular tissue, between a plane of muscular fibres  on one side, and yielding  mu-
 cous membrane on the other, when distended by the constriction which they
 undergo during and after the expulsion of the contents of the rectum, they neces-
 sarily give way on that side on which they have the least  support, being forced
 down and elongated, together with  the mucous  membrane under which they
 ramify, and which has  a natural tendency to become slightly everted during the
 act of defecation.   It will  be  found  that all  the  more immediate  or  exciting
 causes of piles act by unduly increasing one or other of those natural tendencies
 that exist in  the system, by favoring the local congestion  or determination of
 blood at the  same time that they produce a lax state of fibre.
  Age exercises considerable influence in predisposing to piles.   This disease is
 not very unfrequently met with in young men of eighteen or twenty years of  age,
 more especially if they be of a  relaxed and phlegmatic temperament with languid
 circulation, and are obliged to lead a more sedentary life than  is natural or proper
 at that age.   After this period the liability to the  disease diminishes until mid-
 dle age is reached, when the tendency to hemorrhoidal affections is again in-
 creased, and becomes more marked than at any former period of  life, owing to
 the  more active operation of those causes that tend to impede the return of  the
 portal blood.
  Sex  appears to exercise more influence on the occurrence of hemorrhoids at
particular periods of life,  than on the general liability to  the disease.  It  cer- 
 770      DISEASES OF  THE  LARGE  INTESTINE  AND  ANUS.

 tainly appears to be more frequently met with amongst men at an early age, than
 in young women;  but at a later period of life, so far as my observation goes, the
 disease  occurs with nearly equal frequency in  both sexes.   The  comparative
 exemption of young women is readily accounted for by the periodic  discharges
 from the uterus preventing the congestions that might otherwise occur in the
 parts in its vicinity.   The greater frequency at a later period of life is attributa-
 ble not  only to the tendency induced  during pregnancy by the pressure of the
 gravid uterus, but also, after the cessation of the menses, to  the determination
 that  is apt  to be  set up in certain organs of  the  female economy, and to the
 retardation of the portal circulation by the  accumulation of fat and other causes;
 these  conditions chiefly occur  in women  of a  sanguine  and  plethoric habit of
 body.
   A sedentary life with indolent  habits constitute, perhaps, the most powerful
 predisposing cause  of the disease;  more  especially  if habitual  high living is
 conjoined  with want of proper and sufficient  exercise.   Indeed  the artificial
 and luxurious  habits of the  more  opulent classes, by diminishing tone at the
 same time that they occasion plethora and a tendency to abdominal engorge-
 ment, exercise a considerable influence on  the occurrence of this disease,  which
 is much more frequent amongst  them than in persons in the humbler walks
 in life.
   There are a number  of minor conditions which are commonly looked upon as
 predisposing causes of this disease, though it is extremely difficult to determine
 the precise share that each has in its occurrence.  Amongst these may be men-
 tioned intemperance in food and drink; residence in  warm, moist, and relaxing
 climates; the use of soft and warm beds; or, the opposite condition of  sitting on
 a cold stone or damp cushion.  Over-excitement of the generative organs  will
 also occasion it.
   Among  the  exciting  causes  may be mentioned local irritation of any kind.
 Thus in some people  hard riding has been known to bring on an attack of piles.
 The habitual use of drastic purgatives, more especially of aloes, rhubarb, &c, is
 well known to occasion the disease; though it must be observed that individuals
 who make habitual use of these remedies, often labor under some of  those ob-
 structions of the abdominal viscera that have already  been noticed as conducing
 to piles.   The existence of other diseases about the rectum  and anus such as
 fistula, ulcer or stricture, by inducing local  congestion and irritation,  may excite
 the disease;  so also uterine affections and various diseases of the  genito-urinary
 organs may give rise to this affection.
   The most direct exciting cause of piles is certainly a retardation to the return
 of the portal blood.   Any impediment to the  onward  current of the  blood
 through the hemorrhoidal  or mesenteric veins, the trunk or ramifications of  the
 vena porta, exercises  a marked influence on the tendency to congestion of  the
 hemorrhoidal plexus.   Habitual  constipation;  the  accumulation  of hardened
 feculent masses in the  large intestine; the want of due secretion from the mu-
 cous surface; obstruction to the proper action of the  liver, and consequent con-
 gestion of that organ ; the pressure of abdominal tumors, or of the gravid uterus,
 are all active exciting causes, interfering as they do  with  the proper  return of
 the portal blood.   In some cases even the existence of  an obstacle in the systemic
 veins may occasion this disease.  Thus it will arise  from the pressure of an
 aneurismal tumor on some of the larger venous trunks within the chest.
   Structure  of Piles.—A pile, whether external or internal, consists essentially,
 in the  first instance, of a varicose condition  of a portion  of the hemorrhoidal
 plexus, or,  rather, of the small veins of the submucous tissue  that  pour their
 contents into this.  This varicose condition becoming prominently developed at
certain points, gives rise to small knots or tumors.  A pile, in this state, is quite
eoft and compressible, and can readily be emptied by pressure, and when cut into, 
              STRUCTURE  AND  VARIETIES  OF PILES.           771

will be found to be composed of one or more cells filled with blood, and sur-
rounded by areolar tissue.  The appearance of cells is, however, deceptive, and
is occasioned by a section of the sacculated and dilated veins that enter into  the
composition of the tumor.   After the piles have existed for some little time, or
after  they have once become inflamed, the tissues that enter into their com-
position  undergo modifications  that induce corresponding alterations in  the
character of the tumor.   The coats of the veins become thickened,  their cellular
dilatations are filled with coagulated blood, the investing  areolar tissue is hyper-
trophied or thickened by plastic deposit, and on being cut into, the pile is seen
to be composed of a spongy kind of tissue filled with blood.  External piles,
when examined after removal, often resemble in structure a mass of hypertro-
phied cellular tissue, infiltrated with plastic matter,  in which a number of small
vessels of uniform character ramify, but without any appearance of  cells.  Inter-
nal piles, on the contrary, contain more of the venous, and less of the  cellular
element.   They are also  commonly furnished with a small central artery, which
is apt to bleed freely, or  even dangerously, if the tumor is cut across;  hence,
provided they are  not clogged with  coagulated blood, they may readily be in-
jected from the inferior mesenteric artery.
  In  studying the  structure of hemorrhoids, it is of importance to observe that
they occur under two  different forms : one in which  there are distinct  tumors,
within or external to the anus, and the other in which there is merely a varicose
condition of the veins of this region,  without distinct intumescence.
  In  those cases in which there is merely a general  varicose state of the veins of
the submucous cellular tissue of the anus, without any distinct tumor springing
above the level of the membrane, it will be found that the smaller branches of the
hemorrhoidal plexus, and the small twigs that enter these from the submucous cel-
lular tissue, have undergone varicose dilatation, being apparently greatly increased
in number as well as in size.  The mucous membrane is of a  deep mulberry or
port-wine color, and becomes everted  after each motion.  There is usually some
mucous secretion about the anus, rendering the part moist: and the patient com-
plains at  times of weight  and  of bearing down, with pains either in the part
itself, the sacro-lumbar region, or the thighs.  The motions, more especially if
hard,  are streaked with blood, and more  or less  of this  fluid drops in a rapid
manner after the passage of the faeces.  There is  seldom much blood lost, but at
times there is an exacerbation of all these  symptoms, and  the hemorrhage, as will
more  particularly be  mentioned hereafter, may become very abundant.  This
condition  of the mucous membrane  may precede,  and  is frequently found  to
accompany the true pile,  whether external or internal, and may be  looked upon
as constituting the  first stage of this disease.   If this state of things is allowed
to„continue unrelieved the  tendency to  congestion increases;  more  and more
of the mucous membrane becomes everted and protruded after defecation ;  the
submucous cellular tissue  becomes stretched and lax, and the case is apt to become
one of prolapsus ani.
  External hemorrhoids  are those that are situated below the verge of the anus,
and that are invested by cutaneous, or at most, by muco-cutaneous tissue. Before
appearing as defined tumors, they usually constitute  longitudinal forms that sur-
round the anal aperture, or radiate from it as from a centre.   In color, they vary
from that of the natural structures to a pink or purplish hue, and their tegumen-
tary covering consisting of the thin skin of the part, they resemble folds of this
tissue rather than  of mucous membrane.  Their size varies, according to the
state  of congestion,  and  hence  the same tumor may  at one  time be  soft,
flaccid, and  loose, apparently nothing more than  a  fold of integument, and  at
another may become tense, tumid, and ready to burst.   When of small size and
recent formation, they do not in general give rise  to much distress, merely some
local heat, pricking and itching, with a sense of fulness after defecation; but when 
772     DISEASES  OF THE  LARGE INTESTINE AND  ANUS.

of large size, and  inflamed or irritated,  they may occasion very acute suffering.
There is not only deep-seated, dull, aching and throbbing pain in the pile itself,
but this shoots up the side of the rectum, through  the perineum, and into the
nates, and  is much increased when the patient stands  or walks.  After a few
days these  symptoms subside ; suppuration either taking place in the pile or the
blood contained in it coagulating.  The parts are, however, left in a thickened
and indurated state, and do not readily resume their former soft and flaccid con-
dition, effusion of plastic matter taking place into  the cellular  tissue, and the
contained blood perhaps coagulating, so that the tumor can no longer be emptied
by pressure, assuming the form of a broad, rounded, or indurated mass.
  Internal Piles.—AAThen the pile is situated altogether within the verge of the
anus it is "called internal; of  these there are two principal varieties, the longitu-
dinal and the globular.
  The longitudinal, or as it is sometimes called, the fleshy pile, or by Abernethy
" protruded and  thickened plaits of the bowels, " is generally met  with about
an inch or  two up the rectum.   It is spongy, elastic, firm, or tougb, of a dark
reddish, or dusky brown  tint tapering upwards from a broad  base.  It seldom
bleeds or varies much  in size; between these piles are found  small curtains,
valves, or folds  of mucous membrane, forming sacculi, or pouches, with their
convexities looking upwards.   These sacculi  are apt to become distended and
pressed downwards by the faeces, more especially if the motions are hard and
the bowels  have been constipated, thus giving rise to a tendency  to prolapsus.
  When the  hemorrhoid assumes a globular form it  constitutes  the  ordinary
bleeding pile.  It may be situated on  a  broad base,  or, as  not  unfrequently
happens, its point of attachment  to the mucous membrane becoming elongated
it  assumes a pedunculated shape,  hanging downwards into the cavity of the
rectum.  It is of a dark  bluish color and numerous small vessels  of a brighter
hue than the body of the pile may be seen ramifying on the mucous membrane
investing it.   Its surface is  at  first smooth  and shining,  and may continue so
throughout, being covered with  a thin and' delicate  prolongation of the lining
membrane  of the gut.  Not  unfrequently, however,  superficial ulceration takes
place, and  then it has a granulated strawberry-like appearance.
  Internal piles are usually attended by a sensation of heat, itching, pricking, or
smarting about the anus, and a feeling as if there were a foreign body within the gut.
After defecation these sensations are increased  and  are often accompanied by a
bearing down, as if the bowel was not emptied of its contents, that is peculiarly
distressing and sickening.  This is occasioned by the piles  or the elongated and
condensed  mucous membrane to which they are attached,  protruded during the
expulsion of the faeces, and not returning sufficiently quickly, being grasped by
the sphincter ani and constricted by it.  This feeling of discomfort and bearing
down is much increased if the patient stand  or walk much after having had a
stool, or by a confined state of the bowels.  If this state of things is not properly
attended to the symptoms become increased in severity, the bearing down sensa-
tion amounts to true tenesmus, and the act of defecation becomes so painful that
the patient defers it as long as possible, and then when it does take place, in con-
sequence of the accumulated excreta and their indurated character, the suffering
is much increased.   Internal piles  now usually make  their appearance if they
have not existed before, the mucous membrane of the rectum becomes prolapsed,
and an increased secretion of thin mucus takes  place from the orifice of the gut,
moistening the part  and  soiling the patient's linen.  Irritation  in  neighboring
organs is frequently set up, and occasionally to so great an  extent as to mask  the
original complaint, the patient referring his principal pain and discomfort to these
sympathetic  disturbances. There is often a dull aching fixed pain at the lower
part of the lumbar spine, and more frequently opposite the sacrum or the sacro-
iliac  articulations on either  side; this is sometimes very  severe, perhaps down 
INTERNAL  PILES — HEMORRHOIDAL FLUX.         773
   the thigh, or round the groins; irritability of the testicles may come on, or irritation
   about the neck of the bladder, causing frequent desire to micturate,  and increas-
   ing the patient's suffering by the straining that takes place.  The general health
   now suffers, the patient may become emaciated, and the countenance often pre-
   sents a peculiarly  anxious, drawn and  care-worn look.
     The ^ symptom,  however,  that  first of all  and most prominently  fixes the
   patient's attention is hemorrhage.   This varies greatly in  quantity; at first it
   may merely consist of a few drops falling after the passage of the motion, or the
   cylinder of fasces  may be stained  on one  side by a streak or spots  of blood,
   or it may amount  to several ounces or  even pints.
     AVhen  moderate in quantity it often  affords relief to the other local symp-
   toms, and  seldom  proves  injurious from the quantity lost  at one time, but if
   profuse and occurring at short intervals, its effects on the constitution may be
   alarming.                                                             J
     The hemorrhoidal flux is  connected with, and  in the great majority of cases
   dependent upon, the existence of distinct  hemorrhoidal  tumors.   Occasionally,
   however, it appears,  to occur when there  is no distinct separate  tumor prelect-
   ing above  the surface of the membrane; but in these cases there is general
   intumescence and  congestion  of the  whole of the mucous membrane  of the
   lower  part of the rectum, from which the blood exudes in drops
   mnnlvSfl^nCrently  ^"^ ?  bj ** exacerbation  of those symptoms that com-
   the Its   C^P   ' T  aSlSeDSati0„ of M™*> weight and tension about
   tne parts   But the symptoms that precede its occurrence are often much more

   ThfS Tafbe tHan ]S TI1J ^^ a0d  ^ fre^ ^ntTtogeZ
    ihe nux may be periodical, occurring every month, or  at  intervals  of two
  ^u« TST^r^ " !ntenH«»»*^_ea once it has set Yo, it t^j
  CnTtnTl^ring.8" *** "^ m ***** ^ t0 thethi^r fouii

  to ^ZftHf^l '^ Sh°rtin _Urati0n'itis often a ^ree of relief

  tinuance than by its excessive quantity at any one timef  T_7 TJ.f ^




 apoplex/and y^^S^ ^S^Z^ ^ a «*&«* from
 ring in  plethoric and corpulent  perlfwCS
 cases it may be considered as critical, more especially whin 1    "   t °ther
 cessation of the menstrual period.           specially when occurring about the
   The  color of the  blood most generally is florid  is if it „„   *
 arteries  or capillaries  of the part rathe/than the  veins   It I U ' ^ "^
 if in  consequence of  the over-distended and varicLe  condit,     , 'P*"' aS


 £»_. the, partes gave  way, Z?_ &«_££_,_

   A ery  commonly the  internal  piles when hrmm-U  a
 &Tular surface/in  consequence of ulratISt^r^ * ^^
 whole surface will be seen to exude blood in drops   Tn H? -^T'  &nd the
the blood appears to  come from  a cavity in oneTde of f   lnsta"ces *S™,
rupture hadI occurred  from over-distensioLt Zt part   O   ^j^ as if
the flow  of blood is so rapid and copious  that it Ifd  nn, °kCCasiona% however,

  The hemorrhoidal  flux Zy be J^S^Z 2^£% 
774      DISEASES  OF THE LARGE  INTESTINE  AND ANUS

glairy mucous discharge  from  the rectum and diseased  structures;  this would
appear to be nothing more  than hyper-secretion of the  membrane, in conse-
quence of the irritation  set up by the pressure of the piles; it is seldom in
sufficient quantity to produce much annoyance, or to be of much moment to the
patient.
  Piles are not commonly complicated with other diseases of the rectum, such as
fissures, fistula, or prolapsus; when connected with fissure, the hemorrhoid often,
as Air. Syme has  remarked, assumes a peculiar  form and appearance, presenting
itself as  a small  red-colored body, like a pea  in  size, firm, and seated at the
base of the  fissure, which it often conceals;  to a practised eye, however, the
presence  of a pile  of this peculiar color and  shape is sufficient to indicate the
existence of the fissure.
  In that form of fistula in which the  aperture is near the anus, one or more
external  piles of  small size are often found situated at the orifice of the fistula,
and  prolapsus rarely, if ever, is  met with in adults, without the simultaneous
occurrence of piles.
   Terminations.—Hemorrhoidal  tumors may  terminate  by subsidence, coagu-
lation, suppuration, and sphacelus.   Complete subsidence of  the  pile can only
take place when  the disease is of recent occurrence.   AVhen of long standing,
and after it has  been  exposed to successive attacks of inflammation and tur-
gescence, it never subsides completely,  and the cellular tissue and  muco-cuta-
neous structures becoming hypertrophied, form elongated pendulous flaps around
the margin of the anus.
  Coagulation of the contents of the pile is the  result of inflammation having
taken  place in it, and  probably  terminating  in plastic effusion, by which  the
vessels leading from it are obstructed.   When it  takes place, the tumor, after
more or  less active inflammation, becomes hard,  incompressible, and indolent,
permanent in size, and of a purplish or plum-color.   The coagulum thus formed
may remain persistent, may excite suppuration, or  may be absorbed, the hyper-
trophied  tissues  forming one  of the  usual  anal folds.  In some rare instances
the coagula  may be converted into structures resembling phlebolites.
   Coagulation more frequently takes  place in  external than in  internal piles,
owing to the great  impediment in the return of the  blood from  them, and to
their greater liability to inflammation, their exposed situation leading them to be
bruised or otherwise Injured;  when  it occurs in  internal  piles,  it most com-
monly affects those that are of a columnar or  longitudinal shape, and least fre-
quently the globular variety.
   Suppuration is not an uncommon termination, if acute inflammation have been
set up in external piles, more especially in those that have previously  been coagu-
lated ; when the abscess is discharged, small coagula  escape with its contents,
the cavity granulates, and becoming obliterated, the pile is cured.
   In some  rare cases, when there is much elongation  of the mucous membrane
from which the pile springs, prolapsus of that  membrane and of the piles may
take place, which being grasped after it has descended by the contraction of the
sphincter, the same effect may be produced as if  a ligature were applied; the
tumor becomes much swollen, hard, livid, and tense, there is much constitutional
disturbance and  restlessness, but after a few days  all the symptoms  are relieved
by the part that  is constricted  sloughing and dropping off.
   The diagnosis must be regarded in two points of view :—1st, as concerns the
hemorrhoidal tumors;  and, 2dly, with reference to the hemorrhoidal flux.
   Hemorrhoidal  tumors must be diagnosed from  prolapsus  ani, polypus of the
rectum,  and condylomata about the anus.
   From  prolapsus, the diagnosis is not always easy;  indeed, the two diseases are
so generally associated, that it  is of little moment to attempt it.
   In true prolapsus, ocular examination will suffice to distinguish the membra- 
              DIAGNOSIS,  AND  TREATMENT OF PILES.           775

nous wall of the intestine, forming a smooth, rounded, and somewhat lobukted
annular protuberance, from the isolated tumors of piles.  In polypus, the history
of the case, the pedunculated and solitary character of the tumor, its large size,
and comparatively slight tendency to periodical hemorrhage, will enable the sur-
geon to make the diagnosis.   From  condylomata the diagnosis is easy;  the soft,
flat, mucous, and wart-like character of these growths, their history, and their
occurrence at  other points, as the perineum, scrotum, vulva, and buttocks, will
enable the surgeon to distinguish them without any difficulty.
  The hemorrhoidal flux  must be  distinguished from other  intestinal hemor-
rhages.  This may be done by attention to the character of the blood, which will
enable us in many cases to determine its source.   AArhen from piles it is liquid,
of a more or less florid color, and not unfrequently is quite bright, and staining
or coating the faeces rather than  being mixed up with them.  When, on the
contrary, the blood is poured  out  at some higher  point in the intestinal canal
than the usual seat of hemorrhoids, it is of a dark sooty character, mixed up with
liquid faeces either in a diffused form, or in small black coagula, and no fresh or
bright blood will be visible.   Digital exploration of the rectum in cases of piles,
and  the presence of symptoms indicating the existence of mischief at a higher
part of the intestine than the  anus in cases of melaena, will also serve to point to
the seat of the flux.
   Treatment of Piles.—In conducting the treatment of a case of piles,  that sur-
geon will succeed best who looks upon the disease not as a local affection, merely
requiring manual interference, but as a symptom, or rather an effect, of remote
visceral obstruction and disease, the  removal  of which may alone be sufficient to
accomplish its cure, without the necessity of any local  interference ;  or  should it
be thought necessary to have recourse to operative  procedure, that this must be
made secondary to the removal of those conditions that have primarily occasioned
the congestion and  dilatation of  the  hemorrhoidal vessels.   The treatment  of
piles, therefore, must be considered, 1st, as regards  the removal of those consti-
tutional  conditions or  visceral obstructions that occasion the disease, together
with  any topical  applications  that may be considered necessary; and, 2d, with
reference to the operative procedures that may be required for the removal of the
affection.
   The constitutional management of piles necessarily varies considerably, accord-
ing to the condition of the patient in which they occur, and the visceral obstruc-
tion to which  they may  be  referable.   Thus, when occurring in  debilitated
persons, apparently from  relaxation  of  the vessels, most benefit will  be derived
by a mild tonic and nutritious plan, at the same time that the bowels  are  kept
regular by some of the aperients that will immediately be  mentioned.   In these
cases, also, much  advantage  is  often obtained by the administration of the con-
fection of black pepper,  which acts  as a useful local stimulant to the vessels of
the rectum.   In the great majority of instances, however, more particularly when
occurring about the  middle period of life, piles  are connected with a plethoric
state of the system, and obstruction  of the abdominal viscera.  Under these cir-
cumstances, our efforts should be directed  to  the reduction of the  plethoric con-
dition, by putting the patient upon a proper regimen, prohibiting  the use  of
stimulants, and  lessening  the quantity of animal food that he is in the habit of
taking. AArhen the piles arise from the pressure of a gravid uterus, or other abdo-
minal tumor, little can be  done, except, by local  palliatives and mild aperients,
to moderate the inconvenience attending them.
  In  all cases of pile, but more particularly in those arising from hepatic ob-
struction, mild aperients are of essential service ; by removing feculent accumu-
lations and  establishing a free  secretion from the intestinal  surface, they tend
materially to prevent congestion of the portal system.  At  the same time, drastic
purgatives of all kinds should carefully be avoided.  The most useful  aperients 
776     DISEASES OF THE LARGE  INTESTINE  AND ANUS.

are the electuary of senna,  sulphur, and castor-oil, one or other of which should
be taken regularly, twice or thrice a week at bed-time, in as small a quantity as
will be sufficient to keep the bowels free.   In many cases the confection of senna
may advantageously be given in combination with precipitated sulphur and the
bitartrate of potass, equal parts of each of these being made into a mass with
twice their quantity of the confection and a little syrup.   Of this electuary a
dessert-spoonful may be taken every night or every second night.   If there be a
relaxed condition of the rectum and anus  conjoined with the piles, as not unfre-
quently happens, in old as well as in young people, the admininistration of an
electuary composed of equal parts of the confections of senna and of black pepper,
or of cubebs, will be found  very useful.   In fact, in all cases in which the black
pepper is administered, an aperient should be given from time to time to prevent
its accumulation in the large intestine.   AVhen the liver is much obstructed, the
treatment  should be specially directed to the relief of this organ.   AVith this
view, a course of Plummer's pill,  followed by taraxacum, and, in relaxed consti-
tutions, the mineral acids, will be found especially serviceable, at the same time
that the bowels are kept free by gentle aperients.
   The habitual use of lavements, consisting either of soap and water or  thin
gruel, will be found advantageous in many  cases  of piles, though in some they
appear to irritate, and rather to increase the  disease.   AVhen  the  piles occur in
relaxed constitutions, the lavement should be used cold;  but  when the patient
is of full habit of body, a tepid one will usually be found to agree  best.   In the
general management of piles it need scarcely be observed  that any habits which
favor the disease should be  sedulously avoided.
  The local treatment of piles is of considerable importance.  The parts should
be regularly sponged with cold water, morning and evening.   If there be much
relaxation, and the  piles are  internal, benefit may result from the employment
of some astringent injection, such  as a very weak solution of the sulphate of iron,
or of the tincture of the  sesquichloride, a grain of the first, or ten drops of the
second to an ounce of water;  of  this about  two ounces  may be injected every
night, and left in the rectum.  The application of  an  astringent ointment, such
as the unguentum gallae comp. will be attended by much benefit, or the employ-
ment of the anodyne and astringent suppository already recommended.
  If the piles become inflamed the patient should keep  his bed; and leeches
should be freely applied around, but not upon the tumors.   Tepid  lotions, poul-
tices, and  poppy fomentations, must be assiduously used, a very spare diet en-
joined, and the bowels opened by  mild saline aperients.   If a  coagulum form  in
an  external pile, as the result of inflammation, the tumor should be laid open
with a lancet, and its contents either squeezed, or turned out with the flat end
of a director.  If abscess form it must be punctured in the usual way,  and the
part afterwards poulticed.  Should strangulation  of the piles take  place, the
protruded  swelling must  be returned by gentle steady pressure and the  part
afterwards  well poulticed.
   Operation.—The means above indicated are usually sufficient in ordinary cases
of piles;  but if in consequence of the inconvenient size that the disease attains,
the general irritation and  local uneasiness to which it gives rise, or the abundance
of the hemorrhage  being such as  seriously to interfere with the health of the
patient, it will become necessary at last to have recourse to operative interference,
with a view of removing the diseased structures.   No operation should  ever be
undertaken whilst the pile is in an inflamed  state, lest unhealthy inflammatory
action  to an undue extent be set up in the  part;  it  is  also  well  to get the
patient's health in a good state, as erysipelas may otherwise follow these opera-
tions, and before proceeding to them, care should always be taken that the bowels
have been well opened.   There are three plans of treatment adopted by surgeons
for the removal of piles, viz., the excision of the tumor, its strangulation by liga- 
TREATMENT OF,  AND OPERATIONS FOR PILES.       (II
ture, or destruction by caustics.   These  methods  of treatment should not be
employed  indiscriminately.  The first is  alone  applicable to external piles, the
two last may be adopted in the internal form of the disease.
  The removal of external piles is readily effected.   The tumor should be seized
with a vulsellum,  or hook, drawn forwards, and snipped off with a pair of knife-
edged scissors, curved upon the flat.   At  the  same time that the external piles
are removed in this way, any pendulous flaps of the skin in their vicinity should
be excised, lest they become irritated, and constitute the basis  of a fresh pile.
After the excision  of external piles there is usually but trifling  hemorrhage,
which may readily be  arrested by the application of cold lint, or  a pad and "J"
bandage;  should  any small artery bleed, it may be pinched and thus stopped.
  Internal piles should only be removed by the  ligature.  In fact it may be laid
down as a rule in surgery, that all external piles should be cut off, and all internal
piles tied.   The reason of this difference in the practice to be adopted, according
as the pile is situated  above or below the margin of the anus, is the dread of
hemorrhage in the one case, but not in  the other.   The  bleeding  that follows
the excision of an external pile is not only most generally small in quantity, but
may readily be arrested by cold or pressure.  With internal piles, however, it is
different;  these tumors  are not  only more vascular, being often fed  by a large
arterial twig,  but  are deeply seated, and do not readily admit of the application
of means for the arrest of the flow of blood from them.   So difficult is it to stop
the bleeding from an internal pile in some  cases, that patients have actually lost
their lives from this cause after its excision, even in the  hands of some of the
most  distinguished  surgeons.   The  excision  of internal  piles  has  consequently
been very properly abandoned.
   The operation  for  the ligature of internal piles  may most conveniently be
conducted in  the  following manner :   The patient having had his bowels cleared
out by a dose of castor-oil  on the day preceding that fixed  for the   operation,
should have  an abundant lavement of warm water administered about an hour
             before the surgeon arrives,  and he should
             then be directed to sit for half an  hour on a
             bidet,  or  over a pan  containing hot  water,
             bearing down at the  same time so as to cause
             the  piles to protrude.   When all is ready, he
             should be laid on  the bed on his left side,
             with the nates well projecting,  the surgeon
             then seizes the most prominent  pile with a
             vulsellum, or broad-ended forceps (Fig. 246),
             draws  it well forwards, and  ties its base as
             tightly as  possible  with  a   thin  whip-cord
             ligature.  He does the same  to one pile after
             the other, until all that can be met with have
             been strangulated in  this  way.  In  some
             cases the pile is so broad at the base that the
             ligature  will not  include  it  without  trans-
             fixion ; when this is required, it  may usually
             be done readily enough by means of a nevus
             needle, or  by the  instrument represented in
            the  annexed figure  (247), Bushe's  needle,
            which consists of  a steel shank,  fixed in an
            ivory handle, and  having its  free end  perforated for the reception
            of a needle eyed near its point.  The advantage of this instrument
            is that not only is the angle formed by the needle and the shank a
very convenient one for  passing  a ligature through a pile inside the anus, but
more particularly  that as the  needle can be  detached, it  may  as  soon  as it is
Fig. 246.
Fig. 247.
 
 778      DISEASES  OF  THE  LARGE  INTESTINE AND ANUS.

 carried across the base of the tumor, be separated and so withdrawn more readily
 than it otherwise could.  In whatever way the ligatures are applied, care should
 be taken that they are tied as tightly as possible, so that the piles  may be effec-
 tually strangled at once, as in  this way they separate much more readily, and
 with far less pain  to the patient than if loosely tied.   AVhen all  the  tumors
 requiring ligature have been tied, the ends of the threads must be cut off close,
 and the strangulated mass pushed back into the bowel.  If there be any external
 piles, these must now be cut off, for unless this be  done they become irritated,
 swollen, and inflamed by the presence of the ligatures, and constitute a source
 of much distress.  The patient must now return to  bed, and  should  keep the
 recumbent  posture until the ligatures separate, which usually happens from the
 sixth to the eighth day, when an ulcerated surface will be left, which, however,
 speedily closes and contracts.  In some cases this process may be facilitated by
 the application  of the nitrate of silver through a speculum  ani.  On the second
 day after the operation, the  bowels may be opened with a dose of castor-oil.  In
 the after-treatment of the case, care must be taken to prevent the recurrence of
 those causes that  gave  rise to the affection in the first instance.   After piles
 have been  tied, more particularly if they are seated towards the anterior part of
 the rectum,  there is  frequently  great  irritation set up  about the neck of  the
 bladder, so that the patient experiences difficulty in passing his urine, and some-
 times suffers from complete retention;  a warm hip-bath, and a full dose of
 hyosciamus  and nitric ether  will usually relieve this, and enable the urine to
 pass.
   In certain kinds of internal piles, the application of nitric acid  has been  re-
 commended by  Mr.  Houston of Dublin,  and Mr. H.  Lee, and may certainly
 advantageously  be adopted.   It must not, however, be applied  to the external or
 the intero-external pile, as it will produce extreme irritation, nor can it be looked
 upon as a substitute for the ligature in internal piles  generally.   It is especially
                   in the granular pile, having an  ulcerated  surface, that  this
                   mode  of  treatment is useful, as in these cases it appears, by
                   destroying a portion of the mucous  membrane, not only to
                   cure the pile  to which it is applied, but by producing  an
                   ulcer to give rise to a cicatrix, which by contracting, consoli-
                   dates  the parts in  its vicinity,  and so lessens the relaxed
                   state of the rectum, which favors the hemorrhoidal tendency.
                   The acid  may most conveniently be applied through a specu-
                   lum ani, having a circular aperture on one side (Fig.  248).
                   This should be introduced well-oiled, until the pile project in
                   the opening in it, when it must be freely rubbed with a piece
                   of stick, or a glass rod or brush,  dipped in the acid; the sur-
                  face is then immediately wiped with a piece of lint saturated
                  with prepared chalk and water, and the instrument removed.
                  A thin slough separates, leaving a raw  surface, which gra-
                  dually cicatrizes and contracts.   The  application of  the acid
                  occasions but little pain when  made fairly within the rectum,
but if a drop of it accidentally come in contact  with the muco-cutaneous surface,
a vast deal of irritation and  inflammation are excited.  This plan of  treatment,
though useful in particular forms of pile, as when the tumor is granular or flat,
so as  not to  admit of  ready removal by the ligature, should  not I think be prac-
tised  when the ligature can be employed, as it is by no means so certain a mode
of treatment.  It cannot be considered  altogether  devoid  of risk, for I have
known one instance in which fatal erysipelas followed the cauterization of piles
with nitric acid.
   Pruritus  ani is  often  an extremely troublesome  affection,  the  itching  and
general irritation about the anus being almost unbearable.  In many instances it
 
PROLAPSUS  ANI.
779
appears to be a  true  prurigo of this part.   In  other  cases  it appears to be
connected with  the  irritation of external piles, worms, or some similar  affec-
tion.   The  treatment  must  in a great measure  have reference to.the cause.
If there be  an external pile the removal of it, or if worms their expulsion, will
probably cure the disease.   If it arise from prurigo, it will require some special
treatment.   In some cases the arsenical preparations will be  found useful, toge-
ther with the local application of chlorinated  lotions, or those containing hydro-
cyanic acid.

                             PROLAPSUS ANI.
   Prolapsus ani consists in a protrusion of the mucous membrane of the rectum
through the anal orifice.   The cellular tissue  that lies underneath  it being also
in the majority of instances  much thickened and  elongated.  In  the  ordinary
prolapsus the muscular structures of the gut  are not protruded, but yet it has
occasionally happened that the muscular coat has descended with  the  mucous
membrane, an invagination of the bowel taking place, which  constitutes a dif-
ferent and far more serious condition than the ordinary prolapsus.
   Prolapsus not unfrequently occurs in children, especially those who are feeble,
or who suffer from much irritation of the digestive or urinary organs. In weakly
persons generally there is a natural tendency to prolapsus, the  slight protrusion
of the mucous membrane that takes place during defecation  being increased by
any  constitutional condition that gives  rise to atony of the muscular  system,
more especially if irritation  of the intestinal mucous membrane be conjoined
with this, as in dysentery, chronic diarrhoea, &c.  So again the habitual consti-
pation often occurring  in persons of a relaxed habit of body, apparently  pro-
ceeding from want of power in the rectum to expel  its contents, and  requiring
constant straining at stool, predisposes to this affection.   It is especially common
in those who labor under stricture, stone, or any other disease about the urinary
organs that requires a considerable effort to be made in expelling the contents of
the bladder.  In persons whose  constitution  has been  relaxed  by a long resi-
dence in India, this disease also  frequently occurs.   In other cases again, and
indeed most usually, the prolapsus  is  associated with piles, the  weight  and
dragging of the hemorrhoid drawing down the mucous membrane with it.  This
is especially apt to happen when  there  is  general hemorrhoidal  tendency about
the anus.   In fact the causes of prolapsus may be summed up under three heads.
1st. As dependent on simple relaxation of tissue, such as is met with in children
and  weakly  persons.   2d.  As
owing to sympathetic irritation,
as in chronic tenesmus, stone in
the bladder, &c.  And  3d,  as
being associated with a  hemor-
rhoidal condition of the vessels
of this part.
   Prolapsus  is   readily  recog-
nised.  It  consists in the pro-
trusion  of a  ring of  mucous
membrane of a red or purplish
color, and  having a  somewhat
turgid look, rather lobukted in
shape and varying in size from
half a walnut to  a small orange
(Fig.  249).   The mucous membrane  covering this ring will  be found to be con-
tinuous with that investing the sphincter, and this constitutes  the  mark of dis-
tinction between the  ordinary prolapsus and the invagination that has occasionally
been met with of the whole thickness of the gut;  for in this affection, which is
extremely rare, there  is  a deep and distinct  sulcus between  the  protrusion  and
 
 780     DISEASES  OF THE  LARGE INTESTINE AND  ANUS.

 the margin of the sphincter.   In prolapsus there is, when the protrusion is down,
 a dragging and smarting sensation often attended with a  good  deal of spasm
 about the  neck of the bladder, and not unfrequently with symptoms of stricture.
 In chronic cases the anal aperture will appear to be permanently relaxed, and on
 introducing the finger into it, it will be  found to be widened and  weakened.
 The folds  of skin in its neighborhood will be  seen to be relaxed and elongated,
 radiating from it as from a centre.   They are commonly bluish, soft, somewhat
 swollen  and pendulous, and  often the seat of a  good deal of irritation.  The
 protrusion  at first occurs only after  defecation and  then  readily  goes back of
 itself, or is reduced by the exercise  of steady pressure upon it.   After a time,
 however, it will come  down at other periods; thus  it may protrude  after  riding
 walking, or even standing, and is returned with much difficulty.
   Strangulation of the prolapsus may occasionally occur if  it is allowed to pro-
 trude  for  a  considerable length  of time  without a proper  attempt being made
 to push it back.  It then becomes swollen and livid with great pain and tenesmus,
 discharges  a fetid  ill-conditioned pus, and may  eventually fall  into a  sloughy
 state.
   The treatment of prolapsus  may be said to  be palliative  and  curative.   The
palliative  treatment consists in the first place in reducing the tumor when pro-
 truded.  This, under  ordinary circumstances,  the  patient does for himself, but
 if it becomes congested it requires the help of the surgeon to put it back.  This
 may occasionally be readily done by laying the  patient on  his side, or making
 him lean over  the back of a chair,  and then  greasing the  mass with some oil"
 seizing it  with a soft  towel, and gradually  compressing it,  work it  back.  It
 may be kept up by the  patient wearing a belt with a pad  and  elastic support.
 Olive-shaped pewter pessaries are occasionally employed, with the view of pre-
 venting  that protrusion, but I have never seen  them of any service, the sphincter
 being  usually too relaxed to keep them up, and their pressure appearing to excite
 irritation.
   The regulation of the bowels is as  important in  cases of prolapsus as in piles.
 It is usually best done by the administration of those  laxatives  that have been
 recommended for the  latter disease.  It is a good plan in prolapsus to get the
patient to have his daily motion at bed-time instead of at the usual hour  in the
morning, the recumbent position and  the  uniform temperature of the bed pre-
venting that irritation  of the sphincter and spasm of the anal muscles  that com-
monly continues for some time after the reduction of the prolapsus, and which is
a source  of great discomfort when occurring in the early part of the day.
   The relaxation of the mucous  membrane of the rectum  that essentially con-
stitutes prolapsus may  often be obviated by astringent injections or suppositories.
The best injections  are those of the sulphate of iron in the strength of from one
to three grains  in an ounce of water thrown up in small quantities sufficient for
the bowel to retain.  In children, injections of this kind, conjoined with regula-
tion of the bowels by mild aperients, the administration of a  moderate quantity
of unstimulating food,  and afterwards the  employment of tonics, will commonly
remove the disease, unless it arise from stone in the bladder, or some other affec-
tion inducing much  continued straining.   In mild cases of prolapsus in adults,
conjoined with a relaxed state of the mucous membrane  of the  rectum  and
relaxation of the sphincter, the use of the iron injections will be found particu-
larly beneficial, at the same time  that the  action of the bowels is regulated by
means of an electuary taken in the morning or at night.   By thus  giving tone
to the  bowel, at the same time that constipation is prevented, the disease  will
occasionally undergo a  cure, provided it be not associated with any affection in
other organs.
  In those  cases in which the prolapsus is hemorrhoidal, the protrusion  being
dragged down by the weight and  strain of the pile, the same treatment must be 
RECTAL FISTULAE.                        781
adopted as has been recommended for the latter  disease, and usually after the
ligature and removal of the pile the prolapsus will be cured.  In slight cases of
prolapsus, in which the disease appears rather to be owing to the  relaxation of
the sphincter and of the tissues external to it, the muco-cutaneous integument
hanging in  loose and pendulous folds around  the  anus, considerable benefit will
commonly result by snipping off these pendulous  flaps of skin; the cut surface
that is left cicatrizing,  and by its contraction bracing up the part, and thus pre-
venting the further protrusion.  These pendulous flaps are best removed  in  a
radiating manner from the anal orifice, with curved knife-edged scissors.
  When the prolapsus is  considerable, and if the ordinary palliative treatment
has, after a proper trial  being given  it, failed in effecting  a cure, it  will be
necessary to remove the protruded mucous membrane by operation.   This should
always be done by  the  application of the ligature; excision, though easy, being
objectionable in this  as  in  the  case  of  piles, on account  of the  danger  from
hemorrhage.   The  ligature  should  be  applied  in  the following  way:  The
patient having had the bowels freely opened on the preceding day, and an enema of
tepid  water on the  morning of operation, should be directed to sit over a pan of hot
water, in order to make the prolapsus descend; it may then be  seized with a
pair of broad-ended forceps, such as are  represented, Fig. 246,  and drawn  well
forwards.   The base must next be firmly tied with a strong piece of whip-cord,
and a similar process repeated  on the  opposite side of the anus.   Should there
be any difficulty on account of the shape of the protrusion in ligaturing the  base
firmly, this may be obviated by transfixing it with a hemorrhoidal needle, and
tying  it on  either side.  I think,  however, that  it is better, if possible, to avoid
doing this.   The ends of the ligature must then be cut short, the whole protru-
sion returned into the bowel, the external flaps of skin cut off, and an opiate pill
administered, so as to arrest all peristaltic action  for a few days.   Should the
ulcerated surface show any difficulty in healing, it should be  touched with the
nitrate of silver.   This operation always leaves a permanent cure.
   The ligature of prolapsus, like that  of internal piles, is not very painful, and
for it  chloroform need  not be administered;  indeed, it is, I think, better that it
should not be given in these cases, as the protrusion is apt to slip up under its
influence, the  patient  not being  able  to  exercise the proper expulsive efforts.
But as the  excision of the  external  flaps and piles is attended by very sharp
suffering, it is as well  to administer the anaesthetic at the time that  they are
being removed.
   Should a prolapsus become strangulated, it would be necessary to try to reduce
it through the sphincter by the employment of the taxis; if this cannot readily
be accomplished, free incisions may be made  into it.  If it be not reduced, it will
slough away, and thus undergo permanent cure.  In some  rare cases, a portion
of invaginated intestine descending through the anus  has become strangulated.
In  such cases as these, reduction  must be  effected if possible without, but if
necessary with division of the sphincter.

                             RECTAL FISTULA.
   Fistulous openings occasionally occur  between the rectum and the bladder in
men;  or between this gut and the vagina in  women.
  The recto-vesical fistulae are  of very rare occurrence, and  usually result either
from  organic  disease  of a cancerous  character, establishing a communication
between these viscera,  or by a wound of the gut during the  operation of litho-
tomy.   In these cases the  urine escapes per anum in greater or less quantity, occa-
sioning constant irritation or  excoriation of these parts, with a sort of liquid
diarrhoea, and the wet state in which the patient is kept by the dribbling of urine
gives rise to an offensive ammoniacal  odor about him.  If the communication
between the rectum and  bladder be a free  one, feculent matter and flatus get 
782
RECTAL FISTULX
 admission  into the urinary organ, and escape from time to time by the urethra;
 perhaps even more abundantly than the urine does per anum.   This is especially
 the case when  the fistula is carcinomatous, and it is remarkable how little irrita-
 tion is often set up by this admixture of faeces with urine in the bladder.  The
 fistulous aperture in the rectum can always readily be  detected by passing the
 finger into the  gut, or examining its interior with the speculum ani.
   If the disease be of a cancerous character, nothing can be done in  the way of
 treatment beyond keeping the parts clean; but if traumatic in its origin, of small
 size, and more  especially if it be  recent, its  closure may not unfrequently be
 accomplished by touching it with the nitrate of silver, or a red-hot wire, through
 a speculum ani.   In these cases, the platinum  loop made red-hot by the galvanic
 current, according to  Mr. Marshall's  plan, might advantageously be employed.
 If, however, the fistula be of old standing, and the aperture large, cauterization
 would probably not succeed, and then perhaps the only  mode of treatment that
 could be  adopted would  be to introduce a grooved staff into the urethra, and
 cut through the  sphincter upon this, thus laying the parts into one, and con-
 verting the  anal into a  perineal fistula;  then  by keeping the  catheter  in  the
 bladder, and emptying this, granulations will spring  up,  and deep union be
 accomplished.
   Recto-vaginal Fistula.—It has happened  that a communication has been set
 up between the small intestine and the vagina, an artificial anus in fact forming
 in this cavity.   These cases, however, are very rare, and may indeed  be  looked
 upon as incurable; for though  some of the French surgeons, as Roux and Casa-
 mayor, have endeavored to  establish by a deep and difficult dissection a commu-
 nication between the small and large intestine,  the operation, as might have been
 expected, has proved fatal to the patient.
   Recto-vaginal fistulae  are usually the result of sloughing of the posterior wall
 of the vagina, in consequence of some undue pressure exercised upon it during
 parturition.  The size of these fistulous openings varies greatly; sometimes there
 is  merely a small perforation, at others  there may be loss of the  greater portion
 of the posterior wall of  the  vagina.  AVhatever their size, they are necessarily
 sources of very great discomfort and annoyance, both physical and mental, to the
 patient.  The recognition^of the disease is of  course at  once made; the  escape
 of faeces and flatus into the  vagina being obvious, and digital or ocular examina-
 tion through the two-bladed  speculum at once  detecting  the seat and  extent of
 the aperture.  As there is just  the possibility of the communication existing
 between  the vagina and the small  intestine, it  may be useful to bear in  mind
 that when this has been the case, the feculent matter that escapes has been found
 to  be yellower and more stercoraceous than when the rectum is opened.
   If the fistula be small  and recent, it may occasionally be closed by attention to
 cleanliness, at the same time that its edges are  touched with the nitrate of silver,
 a hot iron wire, or the platinum  loop.  If it be very large, the greater part of
 the posterior wall of the  vagina having been destroyed, it will probably be  incu-
 rable ; but even here  the patient should not be left to her fate, and  some  opera-
tion should be attempted which might lessen its size, even if it do not completely
 close it.  The operation  for the closure of a recto-vaginal fistula consists, after
emptying  the patient's bowels by purgatives  and an enema, in introducing a
bivalve speculum  into the vagina and through the opening in it, freely paring
the edges of the  aperture.   The next point is to bring its edges into apposition,
and in doing this, the recommendation made by Copeland and Brown, of dividing
the sphincter ani, should always be acted on, as it is a most important auxiliary
to  the success of the  operative procedures that are required; for as there is
always loss of substance in these  fistulae, there  is necessarily a great tendency to
tension on their sides  when any attempt is made to draw them together; and it
is also of importance that any muscular movement about the parts in the neigh- 
TAPPING  THE ABDOMEN.
783
borhood of the fistula should be arrested, as this  might  otherwise break  down
union after it had taken place between the edges.   The sides of the fistula must
then be  drawn into apposition by sutures introduced by means of the cork-screw
needle, and knotted as in the operation for cleft palate, or by means of the bead
suture.  The success of the operation depends not only on the proper completion
of the steps of the operation, but greatly on the  after-treatment.  This should
consist in the administration of opium, to prevent the bowels acting  for several
days; indeed, until union has  taken place between the edges.   They may then
be moved by means of laxatives and oleaginous enemata carefully given.   During
the treatment, the  parts should be disturbed as little as possible, and the  urine
drawn off  every sixth hour.  The patient must  be kept upon a very moderate
diet, and the stitches may be  left in for six or eight  days, when they must be
cut out  and carefully removed.   Should any point of the fistula not be closed,
the application of the nitrate of silver may induce proper union of it.
   [An ingenious operation for the cure of a case of recto-vaginal  fistula is re-
ported by Dr. J. Rhea Barton, of this city.   The rationale of the  proceeding
is the conversion, by means of a  seton, of the recto-vaginal fistula into an ordi-
nary fistuk-in-ano,  amenable to the usual treatment.   See Amer. Jour, of Med.
Sciences for Aug.,  1840.—Ed.]

                         TAPPING THE ABDOMEN.

   The abdomen often  requires tapping  either for ascites  or encysted dropsy.
The operation, which is perhaps the simplest  in surgery, may be performed as
follows : The bladder having been emptied, the patient is seated on the edge of
the bed or of a large chair, and has a broad  flannel roller, split at either end to
within six inches of the middle, passed  round the body in such a way that the
untorn part covers  the front of the abdomen, whilst the ends which are crossed
behind are given to an assistant on either side, who must draw tightly upon them
as the water flows.   The surgeon then seating himself before the patient, makes
a small  incision with a scalpel  into the mesial  line about two inches below the
umbilicus, and through the opening thus made, he thrusts  the trochar; as the
fluid escapes, the patient often  becomes faint, but this may commonly be guarded
against by continuing to draw  upon the  bandage so as to  keep up good pressure
in the abdomen.   After all the fluid has  escaped, the aperture must be closed
with a strip or two of plaster supported by a pad and bandage.
   The incision  through  which the  trochar is thrust need  not enter  the peri-
toneum, though if  it does it matters little.  The  trochar itself must be of full
size with a well-fitting canula ; should the particular  character of the  accumu-
lation of fluid in  encysted dropsy not admit of its withdrawal by an aperture
below  the  umbilicus,  the abdomen may be tapped  in  any other  convenient
situation, except in the course  of the epigastric vessels. 
784
DISEASES OF THE BLADDER.
        DISEASES OF  THE  GENITO-URINARY ORGANS.


                           CHAPTER  LV.

           DISEASES OF THE BLADDER  AND PROSTATE.

                                 CYSTITIS.

   Idiopathic inflammation of the bladder is extremely rare; this disease most
 commonly originating either from traumatic causes, as from the passage of instru-
 ments, the irritation of broken fragments of calculus, &c, or it may arise from
 irritation produced by the application-of blisters, the administration of diuretics, or
 directly from the extension of gonorrhoea to the interior of the organ.
   The symptoms of cystitis consists not only in the local pain and weight about
 the hypogastric and iliac regions, with tenderness on pressure in these situations,
 and a good deal  of constitutional irritation; but  in  the  existence of extreme
 irritability about the bladder.   So soon  as a few drops of  urine collect they ex-
 cite such extreme irritation in this viscus that they cannot be retained, and they
 are expelled by a kind of spasmodic or convulsive effort, often accompanied by a
 good deal of tenesmus and great suffering.  The urine will be found to be high-
 colored, mixed with more or less mucus or pus, and often tinged with blood.
   An acute attack of cystitis usually terminates in the chronic form of the disease,
 and thus gradually undergoes resolution ;  occasionally, however, it terminates
 fatally,  and when this  is the case the  patient's symptoms usually assume  an
 ataxic character, the tongue becoming brown and dry, the  pulse rapid and weak,
 and the 'urine  very offensive.   On examination after death, it will commonly be
 found that the inflammation of the bladder has gone on  to gangrene of the mu-
 cous membrane, to diffuse peritonitis, or to the formation of abscess either'in the
 substance of the wall of the bladder or between the bladder and the rectum, with
 perhaps infiltration of urine in the deep  cellular tissue  of the  pelvis or the
 perineum.
   The treatment of cystitis is of a very simple character, the disease admitting of
 little being done in the  way of medicines.  The free application  of leeches to
 the neighborhood of the inflamed organ, long continued soaking  in warm hip-
 baths, the application of poppy fomentations or  of laudanum and linseed-meal
 poultices, the injection of  emollient enemata and the  copious administration  of
 barley-water or mucilaginous drinks, will subdue the inflammation and afford the
 patient great comfort;  to these means may be added the administration of anti-
 monials with henbane or opiates.   The only salines that are of much use are the
 citrate and nitrate of potass, and these must be given  largely diluted.
   The acute cystitis commonly degenerates into the chronic form of the disease, or,
as ft is frequently called, the irritable bladder, though this may set in originally
in a subacute form as the result of gonorrhoea, or from the presence of  calculi.
The symptoms in  this affection are much the same as in the acute variety, though
necessarily in a minor degree : there is pain and weight in holding the water,
with a frequent desire to pass it;  tenderness about the region of the bladder, and
the early supervention of inflammatory fever of a typhoid character.   This disease
not unfrequently lasts  almost  an  indefinite time, eventually  degenerating into
vesical catarrh.  This form  of irritation of the  bladder, though  inflammatory,
partakes of the asthenic form of that disease, and is principally characterized by
an abundant muco-puriform discharge from its interior.  It commonly occurs in
men, as the result of local irritation and disease, and frequently complicates other
affections of the urinary organs, as stricture, enlarged prostate, or stone. 
TREATMENT OF CYSTITIS AND VESICAL  CATARRH.    785
Fig. 250.
^3®
f 0m>
  In vesical catarrh the symptoms are made up of local irritation and constitu
tional debility.  There is frequent  desire to
make water,  which is usually  ammoniacal
and fetid, and is mixed with a large quantity
of glutinous, stringy mucus, which gives it
a turbid appearance.  The urine, on stand-
ing separates into two parts, the upper being
clear, but the lower consisting of a thick,
viscid, slimy or gummy mucus, often semi-
opaque and purulent in appearance; it sticks
tenaciously to the bottom of the  pot, and
when poured out hangs  from the  edge  in
long, stringy masses (Fig. 250).   It is often
mixed with urinary  deposits, more especially
of a phosphatic kind.
   This chronic form of inflammation of the
bladder is not unfrequently fatal, death re-
sulting eventually with symptoms of a ty-
phoid  character  ;  the  tongue  becoming
brown and the  pulse feeble, and these  are
usually associated with urinary poisoning  of 4. ^organf^Groh'uies,^met1v^h'in3u,eUunne.
the  blood, the  mental  manifestations  be-
coming dull and obscured, and the body emitting a strongly urinous odor, with
a dense, clammy sweat.
   On examining the bladder after death  in such cases, great thickening of the
muscular coat and of the mucous membrane will usually be found, together with
a dilated and  tortuous condition  of the veins  ramifying upon it,  the blood con-
tained within which is peculiarly black.   Abscesses may be found in the walls
or outside them,  circumscribed  and bounded by plastic matter.   The mucous
membrane is thrown into folds and ridges, which become thickened and hardened,
having irregular depressions between them, so as to cause the interior of the
bladder to resemble somewhat the inside  of one of the cavities of  the heart with
its projecting columnae carneae.  This fasciculated condition is almost an invariable
accompaniment of  long-continued  chronic inflammatory
irritation of the bladder.   As the  organ  becomes hyper-         Fig_ 2n.
trophied, in consequence of the continuance of the disease,
it usually becomes  sacculated, the  cysts forming at its
posterior or lateral parts.   The sacculi are  of two kinds,
both of which are formed by projections between the
fasciculi  of the wall of  the bladder.  In the first and
least common kind,  the muscular as well as, the mucous
coat is pushed outwards.  In the second form  of cyst,
the mucous coat alone forms a kind of hernial protrusion
(Fig. 251).   In the cysts thus formed, accumulations  of
various kinds may take place ; mucus, pus, sabulous matters, and  even calculous
concretions not unfrequently being met with  in  these  situations.  It is the re-
tention of urine, mixed with mucus or  pus in these cysts, where it undergoes
decomposition, that is a common cause of the great fetor of the  urine in such
cases.                   v
   The  treatment  of chronic  cystitis must be of a moderately antiphlogistic cha-
racter, so long  as inflammatory action keeps up; when once this subsides and
the disease falls into an  asthenic condition, or degenerates into vesical catarrh,
the management of the disease must to a considerable extent be modified.  In
the early  stages, whilst there is tenderness  and inflammatory action,  leeches,
warm hip-baths, poppy fomentations, mucilaginous drinks with  henbane,  and
                                    50
 
7*6
DISEASES  OF  THE  BLADDER.
  some alkaline  remedies,  especially the liquor potassae largely diluted, will be
  found most useful, the  bowels at the same time being kept open with castor-oil
  and enemata.
    AVhen vesical  catarrh  has  come on, and the disease has lost its inflammatory
  character, appearing rather to consist of atonic exudation from  the mucous mem-
  brane, a different plan of treatment will require to be adopted.   In such cases as
  these the administration  of vegetable astringents, as the uva ursi or the pareira
  brava, with henbane and  liquor potassae will often be of service.  In many cases,
  however, most benefit  is derived from the administration of  copaiba in small
  doses.   It may either be given with  the liquor potassae, or may advantageously
  be administered in combination with  a few  drops of spirits of turpentine;  in the
  more advanced forms of the disease, when typhoid symptoms come on, senega
  and ammonia will be found most useful, together with the administration of the
  brandy-and-egg mixture  and a moderate supply of unstimulating nourishment.
  In these cases also it is of great importance to empty the bladder by means of the
  catheter of the  viscid mucus  that  accumulates  in it, and the  putrefaction of
  which tends to engender the depressed state into which the patient sinks.   In
  some cases this may advantageously be done by washing it out  with warm water
  injections through a double-current catheter.   In this stage of the disease ad-
  vantage  may occasionally be derived from the  employment of very slightly astrin-
x gent injections.  Amongst the  most  useful of these will be found the nitrate of
  silver, in the  proportion  of one grain to four or  six  ounces of tepid  distilled
  water.   Sir  B. Brodie has advantageously employed water very slightly acidu-
  lated with nitric  acid, and some of the French surgeons speak favorably of the
  injection of balsam of copaiba.
    A peculiar  form of  chronic  inflammation  of the mucous membrane of the
  bladder is occasionally met with in strumous children, and appears to be an affec-
  tion closely allied to the congestive and subacute inflammatory  conditions of the
  different  mucous membranes, as of  the eyes, nose, and throat, that commonly
  occur  in such subjects.  In this disease  the child makes water with great fre-
  quency and with much pain, the urine is offensive,  and usually phosphatic, and
  not unfrequently there  is a  good  deal of  uneasiness complained  of about  the
  groins and along the penis.   On sounding the bladder it will be found roughened,
  fasciculated, and often containing sabulous matters mixed  with mucus.   Occa-
  sionally there is a good deal  of gastro-intestinal irritation, and  not unfrequently
  worms are present.   The treatment  should consist in attention to the general
  improvement of the health of the patient, in the removal of intestinal irritation,
  and in the  administration of copaiba  in small doses, either alone or  conjoined
  with a few minims of liquor potassae, at the  same time that general anti-strumous
  treatment must be  properly carried out.
    Irritability of the bladder  in women not unfrequently occurs, and simulates
  stone so  closely  that it is  only after very  careful  sounding that the surgeon is
  satisfied  that no calculus  exists.  This condition appears  to be dependent on a
  morbidly sensitive state of the mucous membrane of the urethra and bladder;  in
  some cases, in  fact, to be a truly neurotic  or hysterical condition, and then re-
  quires the  administration of liquor  potassae,  copaiba, and henbane.   In other
  instances it is sympathetic, being connected with some local disease of the genito-
  urinary  organs, or  a vascular  tumor  at the  meatus of the urethra,  or some
  affection of the uterus,  which will require removal before the bladder can be got
  into a sound state.   Prolapsus of the anterior wall of the vagina, drawing down
  the corresponding portions of the bladder,  to which attention has been directed
  by Dr. Golding Bird, will keep up this condition.   If so, the prolapsus must be
  cured by some plastic operative procedure.   Under all circumstances, however,
  when this state has once  been set up, it is very difficult to remove. 
PARALYSIS OF THE BLADDER.
787
                        TUMORS OF THE BLADDER.

  Fungous growths or polypi are occasionally met with  in the bladder, flat, pe-
dunculated, or pyriform in shape; they may occur  at all ages, and usually give
rise to a certain degree of irritation in this organ, which is especially marked
when they occur in the vicinity of its neck;  where they may even cause reten-
tion of urine and some of the symptoms of stone.  These  fungous  growths occa-
sionally  are of a malignant  character, and then give  rise  to bloody urine, in
which cancer-cells and debris  may be found on microscopic examination, thus
serving as a diagnostic mark of the nature of the disease.  Malignant fungus or
cancer of the bladder is usually associated with  similar  diseases of the  prostate
or neighboring structures, and in  women may be secondary to cancer of the
uterus.  According  to Walshe  it does not appear  before  the  fortieth year.
These tumors, whether simple or malignant, occasionally become encrusted with
calculous matter deposited upon  them by the urine;  and then they will resem-
ble still more closely a calculus when the bladder is sounded; from it, however,
they may be distinguished by their fixed character, and by the  impossibility of
getting a sound around them.  Some  difficulty  is often experienced in examin-
ing the bladder in these cases, for as the fungous mass pushes back the posterior
wall  of the viscus, it has a tendency to elongate the prostatic  portion of  the ure-
thra and the neck of  the bladder, so that a very long instrument  is required to
reach it.   Little can in general be done in the way of treatment in this disease,
though the example of Civiale might, in some cases, be  advantageously followed,
who removed  a small growth seated at the neck of the bladder by seizing  and
twisting it off with a lithotrite.   And AVarner has recorded a case in  which a
tumor of this kind,  the size of an egg, was tied in the bladder of a woman after
dilating her urethra.

                      PARALYSIS OF THE BLADDER.

   Paralysis of the bladder may occur in the opposite conditions of retention and
incontinence of urine, according  to the part of  the organ that has lost its con-
tractile power.  AVhen the body of the bladder is paralysed, whilst the  neck
preserves its contractility, retention of urine will ensue in consequence of simple
inability on the part of the organ to expel its contents, and  not from the existence
of any mechanical obstacle to the  outward flow of the urine.  AVhen, on the other
hand, it is the neck of the bladder that is paralysed, whilst the body of the viscus
retains its contractility, the urine cannot be retained, but  dribbles  away involun-
tarily, thus constituting incontinence.
   Loss of tone in the body of the bladder, leading eventually to its paralysis, not
unfrequently occurs in old age as the result of simple diminution of muscular power;
or it may happen as a consequence of fever, or as one of the symptoms  of para-
plegia, from whatever cause arising.  It may occur suddenly in cases of injury
in which the lower part of the spinal cord is paralysed.
   When  coming on  slowly as the result of disease, the patient usually  finds
that  the water escapes in a dribbling manner;  that there is some difficulty in
emptying the bladder completely; and that there is not  that forcible ejection of
the last drops of urine that is characteristic of a healthy  tone in the organ; at
the same  time there  is not unfrequently a tendency to  the dribbling away of a
few drops towards the end of the emission of urine, and after its apparent cessa-
tion.  There is  also  an  occasional escape of urine at  night.  When complete
retention occurs,  whether this takes  place  gradually or suddenly, the bladder
slowly enlarges, rising at last out of the pelvis  into the  abdomen,  stretching up
into the hypogastric region, reaching even as high as the umbilicus. On examin-
ing the lower part of  the abdomen, the organ will be felt hard, elastic, rounded,
and pyriform  in  shape,  projecting above the  pubes, and  feeling much like an 
788
DISEASES  OF  THE  BLADDER.
enlarged uterus.  In this  situation, also, percussion will  elicit a dull sound, and
on exploring the part through the rectum the bladder will be found to projection
this direction also, and on tapping with the fingers above the pubes, fluctuation
may be felt through the wall of the gut.   After the bladder has once become
distended, it commonly happens that a quantity of urine continues to dribble out
of it;  in fact the amount that escapes in this manner may be  very considerable,
though the retention  continues unrelieved.  This  retention with dribbling is a
condition of much practical importance, as the  continued escape  of urine may
lead the patient, and even the surgeon, to overlook the true nature of the disease;
the more so as in elderly people retention slowly induced often occasions but little
inconvenience.   I  have drawn off nearly  a gallon of urine from  a  patient in
whom  it was not suspected that retention  existed, in consequence of the  conti-
nuance of this dribbling.  In women, retention  is not by any means so common
as in men, but the bladder will sometimes attain an enormous size, rising as high
as the  umbilicus; and such enlarged bladders have been tapped under the suppo-
sition of the tumor being an ovarian cyst or some  similar growth.  I once wit-
nessed such a case in  which the surgeon, to his surprise, on tapping the tumor
drew off a quantity of clear and  healthy urine  instead of ovarian  fluid;  fortu-
nately no bad effects followed.  This kind  of " retention with  dribbling " occurs
in consequence of  the bladder, as it rises out of the pelvis, elongating its neck;
and as the body becomes bent forward over the  pubes a sharp curve or angle is
formed at the junction of the  neck and body of the viscus, through which  a
small  quantity of urine continues to dribble away, and escape rather by its own
gravity than by any expulsive effort on the part of the patient.
   The  retention from paralysis  can readily be diagnosed from retention  from
obstruction, for  on introducing the catheter, when the patient is lying on his
back, the instrument will not only readily enter, but the urine will simply flow
out in  a uniform stream, not being projected  in a jet by the  contraction of the
walls of the organ, but rising and falling in obedience to the respiratory move-
ments.   The urine that escapes in a case of retention will always be found  to be
high-colored  and  very ammoniacal, its specific  gravity  is  also  considerably
increased in  consequence probably of the  absorption of its more watery consti-
tuents.
   The continuance of retention of urine from paralysis of the bladder will, pro-
bably give rise  to fatal consequences; a subacute inflammation  taking place in
the mucous membrane of the organ which falls into a sloughy condition accom-
panied by symptoms of a typhoid type.   Even though the retention be relieved,
this condition is apt to come on ;  vesical catarrh with fetid urine  supervening,
the tongue becoming brown, and  low fever setting in.  It is very seldom that
the bladder ulcerates or bursts when the retention arises from paralysis of that
organ independent of any mechanical obstacle, the continued dribbling preventing
this consequence.
   The treatment of this form of retention must have reference to the cause of
the paralysis  of the bladder; but under all circumstances the urine must  be
drawn off regularly, as the  over-distension of the  organ not only keeps  up its
paralytic state, but may occasion serious consequences by inducing chronic inflam-
mation of it.   A large catheter must accordingly be introduced regularly  twice
a day, even though retention be  not complete,  and in  doing  this,  care must be
taken  that the  back of the  instrument properly enters  the body of the bladder,
which is further removed from the pubes than usual;  for it will sometimes hap-
pen that it may get into the  dilated prostatic part of the urethra, or  elongated
neck of the bladder, when an ounce or two of urine escaping, it may be supposed
that there is no more left behind, though in reality the viscus is immensely dis-
tended.   In order to  get  the catheter well in, its point should be closely hooked
round  the pubes and  raised by depressing the  handle between the thighs.  In 
  INCONTINENCE  OF  URINE  AND  HYSTERICAL RETENTION. 789

cases of paralysis, the catheter should never be allowed to remain in the bladder
lest its point pressing against the mucous membrane increase the tendency to low
cystitis; or give rise to sloughing.
  If the retention arise  from paralysis dependent on injury or  disease of the
spine, it will occasionally be found that  strychnine either administered internally,
or applied endermically will tend to lessen it.  If from old age, the administra-
tion of cantharides, or the application of a blister to the sacrum may be of use.
In some  cases the  application of cold to the inside of the thighs or abdomen,
will facilitate the  contraction of the organ,  hence it is the custom of some old
men laboring under this affection to press the chamber utensil against the inside
of the thighs, and  I have  known  one patient find  more relief by sitting on the
marble top of his commode, than in any other way.
  Incontinence of urine arises from weakness of the neck of the bladder, in con-
sequence of which there is not sufficient power to hold the contents of the organ,
and the water dribbles out.  In most cases the sphincter-like  action of the  neck
is not perhaps quite lost, so that a small  quantity is ejected  from time to time,
the urine in fact escaping so soon  as  enough has accumulated to overcome the
slight resistance offered by the partial contractility of this part of the bladder.
Wnen there  is paralysis of the body of the  bladder as well as of the neck, the
urine dribbles out as fast as it is poured in by the ureters.
  Incontinence of urine, consequent upon weakness of the neck of the bladder,
may arise from a variety of causes; it is most  frequent in children,  in whom it
occurs during sleep, the patient losing the command over the sphincter  so soon
as a small quantity of  urine has accumulated behind it.   In  old  people  it may
arise from simple debility, and is commonly associated with a  tendency to reten-
tion.   In many cases it is  sympathetic,  dependent  on  the  irritation of piles,
stricture of the urethra, or stone  in the  bladder,  and occasionally results  from
nervous causes, more particularly in women of an hysterical temperament.  Over-
distension of the bladder will occasion incontinence of urine,  not from paralysis,
but from a kind of strain of the muscular structures of the part; in this way a
patient, who  from  circumstances  has been  unable to  empty  his bladder for a
considerable  time,  may  suffer from incontinence.  In children of  a  strumous
habit  incontinence of urine is  very apt to  occur, the child  wetting its bed an
hour or two after it goes  to sleep.   In such cases the urine will generally be
found to be loaded with lithic acid crystals.
  The treatment must depend upon the cause.  AVhen arising  in weakly children,
if it be not connected with worms or gastro-intestinal irritation which should then
be removed, the administration  of tonics will be found useful,—either quinine
or the tincture of  the sesquichloride of iron, alone or conjoined with tincture of
lytta.   If  there  be irritation  of the mucous  membrane of the bladder, the
administration of alkalies,  in conjunction with the  tonics, as the potassio-tartrate
of iron, or a  little copaiba mixed  with honey, will be found  a very serviceable
remedy; cold sponging, light clothing  at night, and means calculated  to break
the habit, such as waking the child at the  time at which it generally occurs,
changing his position in bed, &c, should not be omitted.   AVhen  occurring at a
more°advanced period of life, if there  be  any source  of  sympathetic irritation,
that must  be removed; if none  can be  discovered, tonics, especially iron and
lytta, with strychnine and galvanism, must be had recourse to, together with cold
douching or shower-baths.
  Hysterical retention and incontinence not unfrequently occur in nervous girls,
and require to be treated by anti-hysterical remedies, amongst  which the prepara-
tions of the sesquichloride of iron, either alone or with valerian,  will be found
most useful.   Cold  douches are  also of great service.   In cases of hysterical
retention, it may sometimes be necessary to use the catheter; but  under  such
circumstances it is well not to employ this instrument  too  frequently, as the 
790
DISEASES  OF  THE  PROSTATE.
 patients are apt to get into the habit of having it introduced, and will, with that mor-
 bid propensity that characterizes hysteria, continue for a length of time to require
 its introduction.   If left to themselves, though the bladder may become much
"distended, it will not burst, but will probably empty itself if the patient is put
 into a tub and well douched over the  hips  and loins with cold water.  In  some
 cases these morbid conditions in women appear to be connected with  some local
 irritation about the urethra or uterus,  and then proper treatment must be directed
 to these organs before the disease can  be cured.
   The bladder is often the  seat of severe  pain either continuous  or remittent
 without any disease being  discernible  in it  on the closest examination; the pain
 being either a kind  of neuralgic condition, especially occurring in hysterical or
 hypochondriacal  patients,  or else  being sympathetic with and dependent  on
 disease at a distance, as in the kidneys,  uterus,  rectum, &c.  At the same time
 it must be borne in mind that the secretion of  acid or  irritating urine  will, in
 some individuals, be a source of much  and constant suffering;  and that any
 disease seated about, or coming  in  contact with, the neck of the bladder, as
 tumor, stone,  &c, is especially apt to  give  rise  to severe suffering, and  will in
 many cases be accompanied  by frequent desire to micturate, with much spasm
 about the part.
   Extroversion of the bladder,  consisting in an absence of the anterior  wall of
 that organ with deficiency in the corresponding part of the abdominal parietes,
 is occasionally met with as a somewhat rare congenital malformation.   In these
 cases the posterior wall of the bladder being pushed forwards by the pressure of
 the  abdominal viscera behind, forms  a rounded tumor about the size of  a small
 orange just above the pubes.   The  surface of  this tumor is red, vascular, and
 papilkted, evidently composed  of mucous  membrane;  at its lower aspect the
 orifices of the ureters will  be observed to open  and to discharge the urine in
 drops or in a stream.   For  a full description of the  mechanism of the passage of
 the urine in these malformations, I  would  refer to  a  case that fell  under my
 notice, and in which I made a number of experiments on the rapidity of the
 passage of foreign matters through the kidneys, reported in the Aledical Gazette
 for 1845.*  This malformation is incurable.  Operations have been planned and
 performed with the view of closing in  the exposed bladder by plastic procedures,
 but  they have never proved successful, and  have terminated in some instances in
 the patient's death;  they do not therefore afford much encouragement for repeti-
 tion.   The patient should, however, wear a properly  constructed instrument to
 receive and collect the urine; consisting of a hollow shield strapped over the
 part, communicating by means of a tube with an India-rubber bottle that may be
 attached along the inside of his thigh.

                        DISEASES OF THE PROSTATE.
   The prostate is subject  to acute  and chronic  inflammation, to  hypertrophy,
 scirrhus, and  the formation of calculi.
   Inflammation of the prostate or prostatitis very rarely occurs as an idiopathic
 affection, but  is most commonly met  with  as the result of gonorrhoea, mote
 especially in middle-aged men,  rarely  in those under twenty-five or  thirty.  The
 symptoms of  prostatitis are deep-seated pain, heat and weight in the perineum
 with a frequent desire to make water, and  very great  and spasmodic pain accom-
 panying  the emission  of urine; in fact the irritability that is set  up about the
 neck of the bladder is perhaps  the most marked and  distressing  feature in the
 disease.  These symptoms are, however, common to various  inflammatory affec-
 tions  of the  urinary organs, and  they can only  be  distinctly referred to the
 inflamed prostate by rectal exploration.  On introducing the finger  into the gut,
 the  gland will be found much enlarged and exquisitely tender to the touch; and

        * [A similar case is reported by Dr. Gross in his treatise on the urinary organs.—Ed.] 
                PROSTATITIS--PROSTATIC  ABSCESS.             791

the patient often suffers considerably from the pressure of the inflamed  gland
upon the rectum during defecation.
  The treatment of acute inflammation of the prostate, should be of an active
antiphlogistic  character, so  as to prevent, if possible, the formation of abscess
in it.  The perineum must be cupped or  well leeched, warm hip-baths, and
poppy fomentations assiduously employed, and salines with antimony administered.
In this way the formation of abscess within or around the prostate may in  many
cases be prevented.
   Prostatic abscess may occur either as a consequence  of acute inflammation of
the gland  running into  the suppurative stage, and  in this way  it is  not very
unfrequently met with as a complication of gonorrhoea;  it may occur with com-
paratively little antecedent  inflammation—as sometimes happens in pyemia, or
if the gland is accidentally bruised  during lithotrity.  In  these  cases, abscess
perhaps as frequently forms  in the cellular envelope of the gland as  in  the
organ itself.  Idiopathic suppuration of the prostate, irrespective of any  of the
above causes, is, however, of  rare occurrence, but a case happened to  me some
time ago in which, without any apparent reason, after the operation for strangu-
lated hernia, a purulent collection formed in this situation.
   AVhen inflammation of the prostate  terminates in abscess, rigors with  throb-
 bing and perhaps  retention of urine occur.   In all cases the perineum becomes
brawny, or, tenderness of the gland, and deep fluctuation may be felt through
 the rectum.   AVhen  left to itself, this abscess most usually gives way into the
 urethra,  but  it may,  especially  when occurring in  the  capsule  of the  gland,
 open  externally into the  perineum  or into the rectum.   In many  cases the
 abscess presenting on the urethral surface of the prostate is burst during the
 introduction of the catheter, used for the relief of the retention of urine induced
 by the pressure of the tumefaction; the matter escaping along the side  of and
 through the instrument.
   So soon as  it can  be  ascertained  that abscess has formed in the prostate, the
 pus  should be let out by a  deep  incision  into any brawny or  indurated mass
 that can be felt  in the perineum.    The surgeon must not wait  for fluctuation,
 but must  cut deeply in  the  direction of the matter, keeping, however, in the
 mesial line.  Even if none  escape  at first it may  do  so if the part  is well
 poulticed for a few hours, and thus  communication  with  urethra  or rectum be
 prevented.
   In prostatitis, retention may occur from the swelling of the gland, the infiltration
 of exudative  matters around it, or the formation of pus in  it.   In these cases
 the  neck  of  the bladder  will  be carried to a considerable  distance from the
 surface, and may very probably not  be reached by an ordinary catheter, which
 may be buried up to the  rings and yet not  enter the  cavity  of that organ;
 under these circumstances a silver  prostate catheter should  be employed, and
 this must be carefully introduced lest by getting into  the  cavity of an abscess
 which has already burst per urethram, it might  be supposed to have entered
 the  bladder itself.   In  introducing the instrument under these  circumstances
 care should be taken to keep its  point  constantly  in contact with  the  upper
 surface of the urethra, and to  hook it round the pubes.   The upper  surface of
 the  urelhra is a  sure guide to the  bladder;  for any abscess, false passage, or
 irregularity of direction will always  affect the lower aspect of this canal, as being
 surrounded by yielding structures,  whilst the upper part being firmly  supported
 by bone and ligament cannot alter its direction.
   Chronic subacute inflammation  of the  prostate  not unfrequently occurs  in
 cachectic  and debilitated  individuals as  an idiopathic affection; but, in other
 cases it is connected with gonorrhoea, or some local irritation.   In this form of the
 disease, there is  not only  heat, weight, and  pain in  the region  of the  gland,
 with tenderness  on  rectal  exploration; but there is usually  a considerable dis- 
792
DISEASES  OF  THE  PROSTATE.
 charge from time  to time of  a viscid, ropy mucus, the morbid secretion of the
 follicles of the gland, which is frequently mistaken  for spermatorrhoea.   This
 discharge is occasionally ejected by the acceleratores  urinae muscles, which are
 irritated by extension of morbid action to them, and is at  other times squeezed
 out when the patient goes to stool, by the pressure of the faeces and the action
 of the anal muscles.   In most cases its continuance  is accompanied by a  good
 deal of irritability about the  neck  of the bladder, and debility of  the generative
 organs.  Its existence is a source of much  distress to  the  patient, whose mind
 usually becomes harassed by the dread of impotence.   The discharge, however,
 is  not seminal, and may always be distinguished from  true  spermatorrhoea by
 the absence of the  characteristic spermatozoa.
   The treatment of these cases must consist in the gradual removal of the  local
 inflammatory action by the application of leeches to the perineum,  by warm hip-
 baths, and if some chronic enlargement  of the prostate has taken  place, by the
 administration of small doses of the bichloride of mercury in  compound tincture
 of bark. Should the patient suffer much in making water, liquor potassae with a
 small quantity of copaiba and tincture of henbane will  be useful.  In some cases
 much advantage will be derived from the repeated application of blisters to the
 perineum.
   Hypertrophy of  the Prostate.—Chronic enlargement of the prostate  may be
 looked upon  as a senile disease, seldom  occurring before the age of fifty, and
 being commonly met with after this; at that  period  of life,  as Sir B. Brodie
 observes, when the hair becomes gray and scanty, when atheroma begins to be
 deposited in the coats  of the arteries, and when the arcus senilis forms on the
 cornea, the prostate usually, perhaps  invariably, becomes increased  in  size.
 At the same time, however, other changes  take place  in  the  genito-urinary
 system; thus  the urethra  becomes dilated  and the  bladder thickened,  and
 unless the enlargement of the  prostate advance in  too great a proportion to
 the other changes, so as  to interfere with the  free escape of the urine, no dis-
 ease can properly be said to be established.   And, if we look  upon the diseased
 enlargement  of the prostate as such an amount of hypertrophy of the gland as
 interferes seriously  with the discharge of the urine, we shall  probably not  find
 it so frequent even  in old men as is generally supposed.   Indeed, Guthrie states
 that it is not commonly found in the  pensioners at Greenwich Hospital.   But
 though age must be looked upon as the primary cause  of this particular hyper-
 trophy of the prostate, there  can, I  think, be little doubt that  it may be predis-
 posed to by any continued source of irritation of the urinary organs, as gonor-
 rhoea, strictures, hard living,  &c.
   Enlargement of  the prostate is  principally  due to fatty degeneration of,
 with phosphatic deposits in the gland, the texture of which is usually indurated,
 though sometimes it has been found to be looser and softer than natural.
   The  enlargement may occupy the whole  of the gland, causing  its size to
increase to that of a large egg or small orange;  or it may be confined principally
 to  the lateral  lobes which  may either  both or singly become hypertrophied.
 AVhen this is the  case, the  urethra becomes greatly  elongated  and tortuous,
 winding round the  promontories formed by these lobes, and sometimes assuming
 the form of  a sinus,  or being irregularly dilated;  a  complete change may
 take place, not only in the direction, but in the shape of the canal, which becomes
elongated from above downwards into a  kind of chink, or, is  else  flattened out
laterally.  In all cases  of enlarged  prostate, whatever be its  shape, the corre-
sponding portion of the urethra becomes  larger and wider  than natural.  The
 elongation of this canal, is owing  to the general enlargement of the gland, in
 which the canal that traverses it must  necessarily partake, and its expansion to
the outward growth of the gland.   So capacious does this portion of the urethra
sometimes become, that it may hold two or three ounces of urine, and in con- 
ENLARGEMENT  OF  THE  PROSTATE.
793
sequence of its elongation will carry the neck of the bladder upwards, and behind
the pubes to a considerable distance from the surface.
  The middle lobe of the prostate may become greatly enlarged in size, with or
without accompanying hypertrophy  of the lateral lobes.   It  usually assumes  a
nipple-like appearance, but sometimes  becomes constricted at the base and  ex-
panded above, so as  to be truly pedunculated (Fig. 253), constituting at last a
round and solid tumor overlapping the urethro-vesical  orifice.  Occasionally  the
verumontanum alone appears to be affected, forming a kind of thickened valvular
projection, which interferes materially  with the flow of the urine.
  These enlargements are  productive of various  inconveniences  with regard to
the passage of the water, giving rise either to retention or to incontinence, or to
a kind of mixture of both conditions.  AThen the lateral enlargements cause  the
urethra to  assume  a somewhat  tortuous
course, the  middle lobe,  if hypertrophied
by projecting against the entrance to  this
winding  channel, may readily occasion re-
tention.  Then  again, if the middle  lobe
continues small whilst the enlargement  of
the lateral lobes takes  a direction  up to-
wards  the bladder,  widening as they go,
the vesical neck may be  so dilated that in-
continence and a continuous  dribbling will
occur through a kind of fissure  that ex-
tends between the lateral lobes.
  The obstacle offered to the passage of the
urine by an enlarged prostate will usually
eventually give rise  to a chronically thick-
ened, fasciculated, and sacculated bladder,
the fundus  of which depends below  and
behind the enlarged gland, forming  a kind
of pouch that cannot empty  itself, and  in
which mucous and morbid concretions are
apt to collect.   The ureters  often become
dilated  and the  kidneys chronically  dis-
eased ; a series of changes well-illustrated
by the annexed cut (Fig. 252).
  The first symptoms of enlarged prostate
are usually the feeling  of a necessity  to
strain slightly before the urine will flow;
and then after the bladder has been  apparently emptied, the involuntary escape
of a small quantity of water.   The  patient also  finds  that he is much longer
than usual in emptying the bladder,  for though the stream flows freely enough
so soon as it has once begun  to escape, yet it cannot be  properly projected,  the
viscus having to a certain  extent, lost its tonicity.  About this time changes
begin to take place in the urine, which usually becomes somewhat fetid, though
it continues acid, and is intermixed with more  or  less viscid,  stringy mucus.
As  the  disease  advances and  the bladder becomes less  capable of  emptying
itself, the urine becomes  dark, mixed with adhesive, sticky mucus; and, at last,
if the mucous membrane  of the bladder falls into a chronic state of inflammation,
it assumes a milky appearance from an admixture of pus, and becomes horridly
offensive, blackening the silver catheter.
  The  exact  condition  of the  enlarged prostate can only  be ascertained  by
examination through the rectum and  urethra.   By rectal  exploration  with
the finger, the degree of  enlargement of the lateral lobes can best be ascertained,
though as in many cases the end of the finger cannot reach the further extremity
Fig. 252.
 
794
DISEASES  OF  THE  PROSTATE.
of the gland, it will be impossible to say to what  extent the hypertrophy has
gone.  The urethral exploration must be conducted  by means of a  silver  pros-
tatic catheter, and will afford information that the rectal exploration cannot give;
as by it is ascertained approximately the size of the middle lobe, and the condi-
tion of the urethra as to elongation and curve.
   Retention of urine constitutes the great danger in advanced cases of enlarged
prostate.  It commonly comes on  gradually, the patient having for some  time
before experienced considerable difficulty in passing his urine, and he will often
find that the more he strains in his efforts to do this the less readily will it come
away; whereas, when he remains  quiet, it will usually flow with more freedom.
The retention  from prostatic enlargement is of the  mixed  kind,  there being
always more or less incontinence conjoined  with  it.   AVhen the  bladder has
become tense, and the prostatic portion of the urethra put upon  the  stretch, the
escape of a certain quantity of urine will take place, until, by the relief of the
tension of the over-distended  bladder, the parts about  the  neck and enlarged
prostate become relaxed, so that they again fall together, and thus, the urethra
resuming its tortuous condition, the outlet is occluded.  In these cases, error may
always be guarded against  by the  surgeon feeling the enlarged bladder rising up
above the pubes, and reaching perhaps as high as the umbilicus.  This condition
is an extremely dangerous  one,  not so much from any risk of the bladder or
urethra giving  way in consequence of over-distension, which very rarely happens
in retention from enlarged  prostate, as from  the probability of the early setting
in of chronic inflammation of the  mucous membrane of the bladder, which is
specially apt to occur.   The bladder has usually not  emptied itself completely
for a considerable length of time before the retention is complete, and a quantity
of ropy mucus having collected in the fundus behind  the  prostate, whence it
cannot be expelled, becomes putrid, and thus disposes to the occurrence of that
form of chronic inflammation of the vesical mucous membrane, which, occurring
in a depressed state of the system, is  especially apt  to give rise  to a  brown
tongue with quick  pulse, and typhoid  symptoms.   Indeed, when  death occurs
from prostatic disease, it usually takes place in this way.
   In the treatment of enlarged prostate little can  be done  by medical means,
though the patient's condition maybe somewhat ameliorated by treatment calcu-
lated to lessen irritation about the urinary organs.  With this view the alkalies,
with henbane, and small doses of  copaiba, will  generally be found to be of ser-
vice.   Any  morbid condition of the  urine  should also be counteracted by the
                        means that will be  mentioned when speaking of stone
                        in the bladder.  Counter-irritation, the application of
                        iodine, and  other  measures calculated  to  promote ab-
                        sorption  of the enlarged gland, will be found of little
                        service, and are usually productive of serious annoyance
                        to the patient.
                          In the treatment of enlarged prostate, it is of great
                        importance to  use  the catheter  from time to time,
                        in order to  empty the pouch  that  forms  in the  bas-
                        fond of  the bladder behind the prostate;  and which
                        being  below the  level of the urethra,  tends to collect
                        an accumulation of viscid mucus and fetid urine which
                        cannot be expelled by the  patient's unaided efforts,
                        partly from their gravitating into this pouch, and partly
                        by the muscular power of the organ being impaired.
                        The removal of these matters is of great  importance,
                        as, independently of any retention, they may, by under-
                        going putrefaction, give rise to typhoid infection.   In
order to empty the bladder thoroughly in these cases, a prostatic catheter must
Fig. 253.
 
 TREATMENT  OF  RETENTION FROM  ENLARGED  PROSTATE.   795

be used.   This instrument should be made of silver, and be of large size, equal
to about No. 12.  In order to enter properly the bladder, which is carried away
from the surface by the elongated urethra, it should be about four inches longer
than an ordinary catheter; and as the neck of the viscus is usually pushed up high
behind the pubes by the projection upwards of the lateral lobes, the curve of the
instrument should be greater and longer than usual. I find the best-shaped pros-
tatic catheter to be one, the curve of which is exactly the third  of  the  circum-
ference of a circle five and a half inches in diameter.   The eyes should be large
and rounded, and I have found it of use to have the lower end of the stylet pro-
vided with a piston  plate, so that by withdrawing this the mucus  may be sucked
in through the eyes of the instrument.   In introducing the catheter, care should
be taken when the point enters  the  prostatic portion  of  the  urethra, to depress
the handle well between the thighs,  lest  the end hitch against the enlarged
middle lobe (Fig. 253), or do not sweep sufficiently round the pubes.
   When retention has occurred, relief can only  be afforded by the proper use of
the catheter, and this should never be delayed,  as typhoid symptoms in elderly
people rapidly set in.   Three questions present themselves  in  connexion with
the treatment of this form of retention.
   1st.  As to the  kind of catheter  that should  be used for its relief.   Sir B.
Brodie recommends a gum-elastic instrument, long, of large size, and kept  on a
well-curved iron stylet, so as to preserve its curve when that is withdrawn.  This
must be introduced either with  or without  the stylet;  if possible, without  it.
Other  surgeons  of great authority in  these matters  prefer the silver prostatic
catheter, and I certainly think that an instrument such as above described is
safer, and more easily managed than the gum-elastic one.  It might  be supposed
that a less chance of mischief would result from the gum-elastic than from the
metallic catheter, as being the softer and more yielding instrument; but this  is,
I think, erroneous,  if the stylet is allowed to remain in, as it is then as  rigid at
the point, as hard, and as likely to penetrate  soft structures as a silver one would
be.  If the stylet be withdrawn, it is a very unmanageable  instrument; it is
impossible to know how to  direct its point, and if the obstacle be a  difficult one
to surmount,  it is not easy to guide it over it.   With the metallic  instrument,
on the other hand, the surgeon can feel his way as it were, and will if he depress
the handle well, as soon as the point enters the  prostatic portion of the urethra,
find little  difficulty in guiding it into the bladder.  It is the first introduction of
the instrument that especially requires care and as much gentleness as possible;
after it has once been introduced, it will almost invariably readily find  its own
way-
   The next question in connexion with the relief of  retention in these cases is
whether the catheter should be  left in the bladder, or  be withdrawn after  the
viscus is emptied.   As a general rule, it is certainly far better not  to leave the
catheter in; its presence in the diseased bladder setting up a low form of inflam-
mation, or giving rise to the sloughing of the mucous membrane.   The instru-
ment should be introduced twice in the twenty-four hours, and care should be
taken if possible to empty the pouch behind  the prostate by depressing its point.
Should the mucus be very viscid and  offensive, the bladder  may be washed out
with tepid water through a double-current catheter.   After the bladder has been
emptied for the first  time, it will be found to refill in the course of a very few
hours,  usually in six or eight, the secretion  of the kidneys appearing to be set
free on the removal of the  pressure.   Should any great difficulty be  experienced
in introducing the catheter, it may be  thought desirable  to leave  it in for two or
three days, and then a gum-elastic one is perhaps to be preferred, as under these
circumstances it presents a  great  advantage over the silver catheter, becoming
soft, accommodating itself to the shape of the  parts after the  stylet has been 
796
DISEASES  OF  THE  PROSTATE.
Puncture above pubes
         c. Reflexions i
 taken out, and in not being so liable to irritate the mucous membrane with its
                                            point, which,  dipping  down  into
                                            the pouch behind the prostate, acts
                                            as a syphon, emptying this part of
                                            the bladder far better than a silver
                                            catheter could  do.
                                               The third question in connexion
                                            with the relief  of retention from en-
                                            larged prostate, is  as to the  course
                                            that should be pursued, if no in-
                                            strument can be  got into the blad-
                                            der in the ordinary way.  In these
                                            cases  which, however, very  rarely
                                            occur, two lines of practice may be
                                            adopted :  either the puncture of the
                                            bladder above the pubes, or forcible
                                            catheterism.   The  puncture  above
                                            the pubes can  very seldom be re-
                                            quired.   Since the Universitv Col-
                      b. Puncture through rectum  /   TT    ..  ,           ,   . J
                     i of peritoneum.            lege Hospital was opened, eighteen
                   .                         years  ago, only one  case has pre-
 sented itself in which  it was thought proper to adopt such a procedure.   The
 operation consists in making an incision, about an inch and a half in length, in
 the  mesial^ line, immediately above the pubes, and  then passing a long curved
 trochar,  with its concavity downwards, into the bladder behind that bone, and
 consequently underneath the reflexion of the peritoneum (Fig. 254, a).  The
 canula must be left in for the escape of the  urine, whilst the continuity of the
 natural passage is being restored.   AVhen the bladder is pushed up by enlarge-
 ment of the prostate, the peritoneal  reflexion is carried up with it, and a con-
 siderable portion of the anterior wall of the organ  uncovered by peritoneum is
 left  above the pubes.  In a  case which  was lately under my care, it was found
 that nearly an inch  and a half intervened between the pubes  and the serous
 membrane.
   A far safer procedure than  this, and one that is recommended by Sir  B.
 Brodie, Mr. Liston, and most surgeons of authority in these matters, is forcible
 catheterism.  As the retention is generally owing to an enlargement of the mid-
 dle lobe  of the prostate, relief may be afforded by pushing the point of a silver
 catheter  through this obstacle into the bladder.  A false passage is thus formed,
 in which the instrument should be left for about forty-eight  hours, when it will
 generally enter it with sufficient  readiness on being introduced again.
   The existence of malignant disease of the prostate is of very rare occurrence,
and may commonly be ascertained by exploration through the  rectum and ure-
thra.   The passage, also, of bloody urine, or of clear urine  followed by a dis-
charge of blood, mixed, perhaps,  with the debris of a cancerous growth, will like-
wise tend to establish the nature  of the affection, which is necessarily fatal.  The
consideration of prostatic calculi  will be deferred till we come  to speak of urinary
concretions generally. 
URETHRITIS.
797
                           CHAPTER  LVI.


                    DISEASES OF THE URETHRA.


                               URETHRITIS.

  Simple inflammation  of the  urethra  is especially apt to occur in strumous,
 rheumatic, or gouty individuals, from slight causes of irritation, either direct or
 sympathetic, that would not excite it in more healthy constitutions.   In stru-
 mous children, it may arise from worms in the intestines, or from  gastric irrita-
 tion ; and in gouty or rheumatic subjects, it appears often to occur in connexion
 with an acid or loaded  state of  the urine.  In other cases, again, the irritation
 of a stricture, the passage of instruments, or ordinary sexual intercourse, may
 occasion the disease, without there being anything of a specific or venereal charac-
 ter  about it.   Women who are out of health, pregnant, or suffering from leucor-
 rhcea^ may, and often do, give rise to local irritation of this kind.  Urethritis,
 especially when arising from sexual intercourse, is frequently mistaken for gonor-
 rhoea, but from this it may be distinguished by the less intense degree of inflam-
 mation, and by the absence of those secondary consequences  that so frequently
 follow true gonorrhoea;  but yet, in many instances, the diagnosis is extremely
 difficult, especially from the subacute forms of gonorrhoea that are so common in
 London.
  The symptoms of urethritis consist of heat, pricking, tension about the urethra
 for  a day or two, followed by muco-purulent discharge, often rather profuse, and
 accompanied by  some ardor urinaa.  The symptoms altogether are  not severe,
 and the disease usually subsides at the end of a week or ten days, but sometimes
 it becomes chronic, especially if conjoined with stricture, and then constitutes an
 extremely troublesome affection, more particularly in gouty individuals.
  The treatment of urethritis is  of a mild, antiphlogistic character.   The bowels
 should be kept open, and salines freely administered ; in many cases small doses
 of colchicum^ in  combination with alkalies, will be found  of especial service in
 cutting the disease short.   The use of emollient, or slightly astringent injections,
 such as opiate lotions, or a very weak  solution of acetate of lead," will be found
 serviceable as the disease is on the decline, but not until then; and when the
 affection has got into a  chronic stage, small doses of copaiba may be advan-
 tageously administered.    The diet, in all cases, should be of the blandest charac-
 ter,  stimulants of all kinds being interdicted.
 _ If the disease  be conjoined with slight stricture, it may not unfrequently give
 rise to  temporary retention of urine.   This may, however, most  commonly be
 readily relieved by antiphlogistic treatment, cupping, or leeches to the perineum,
 the  warm hip-bath and salines, with, perhaps, opiate suppositories, and plenty of
 demulcent drinks.  The catheter should  not be used in these  cases, if it is pos-
 sible to give relief without it.
  _ Urethral abscess occasionally  forms as the result of urethritis, a soft fluctu-
 ating point being perceived in the neighborhood of the canal.   So soon as this
 is detected, it should be opened, when  the aperture that results will readily close.
 If left, it will probably burst into the  urethra instead  of externally, the tissues
 •n that direction  being less resistant; and then, if it should be opened externally
 as well, a troublesome urinary fistula will result.
  Perineal abscess occasionally  forms as the result of urethritis, in whatever
way  excited, the  patient complaining  of a sensation of weight, with pain and
throbbing, deep in the  perineum.   On  examination, a hard,  tense swelling will 
798
DISEASES  OF  THE  URETHRA.
be found, situated a little anterior to the anus, and extending along the side of
the urethra.   It presents no sign of fluctuation until it comes forwards into the
scrotum.   The  treatment consists in the application of leeches,  followed by
fomentation, and an early incision through the perineum  into the swelling.  In
some cases, the abscess is situated altogether  external to the urethra,  and then
the aperture closes readily enough, like that  of any other ordinary abscess.  In
other cases, again, it communicates with the canal, and then fistulous  openings
are left through which  a certain quantity of urine escapes.   These  apertures
Gradually tenof to close if they be not  complicated with stricture or other ure-
thral disease;  should they be so, they will require special treatment, of a  kind
that will be mentioned at a later period.
                               GONORRHOEA.
   Gonorrhoea  is a specific disease accompanied by inflammation, and an  abundant
muco-purulent discharge, affecting the  urethra most commonly,  but also the
other mucous  membranes of the genital organs, as of the prepuce and  the glans
in the  male, and of the vulva and vagina in the female.
   The urethra is the  usual seat  of gonorrhoea in  the male, and the disease may
be looked on as  a sj ecific urethritis, which is usually fixed with greatest intensity
in the  fossa navicukris; but it may  extend itself over a much wider surface,
affecting the entire length of the canal, and  extending over the whole mucous
lining  of the  bladder.   In the  female it commonly spreads oyer the extensive
mucous surface of the internal organs of generation, and sometimes even invades
the uterus.
   Gonorrhoea  is a truly specific  and a  highly contagious affection, arising  in all
cases from the  application  of a peculiar animal poison, generated by impure or
indiscriminate sexual intercourse, to the parts which it attacks, and must not be
confounded with the  various non-specific inflammatory diseases that may affect
the parts commonly the  seat of  gonorrhoea, and which  are  all characterized by
muco-purulent discharges.
   The poison  of gonorrhoea differs entirely from that of syphilis, as has been fully
proved by the unerring test of inoculation;  these  diseases  not being capable of
reproducing one  another under any circumstances.
   Gonorrhoea is  usually looked  upon  as a purely local affection of the genital
organs.   Some surgeons, however, amongst whom may be  especially mentioned
Air. Travers, seem to consider it as occasionally assuming a  constitutional charac-
ter ; in this opinion  I entirely  agree.  Although the gonorrhoea  in  the early
stages is doubtless a  strictly local affection, yet  there is  a particular train of
phenomena occasionally following it  of a very characteristic nature, that pan
scarcely be looked upon in any other light than as being  the result  of constitu-
tional  infection, the  more so as they are very apt to occur in some individuals
who never have gonorrhoea without the disease being followed by these sequences,
whilst others  are"altogether exempt from them.   The parts that are principally
affected are the fibrous  tissues,  the mucous and  the  cutaneous surfaces.  The
affections of the fibrous tissues give rise to rheumatism, and to peculiar forms of
inflammation  of the  testicle and of the sclerotic.  The  affection of the mucous
membrane displays itself in specific inflammations of the  throat, and of the eyes;
and the  skin becomes the seat  of  certain  eruptions.  The  occurrence of these
various affections, assuming as they do a specific type so distinctly marked that
they can at once be characterized as gonorrhceal, certainly tends to show that the
disease impresses the constitution in  some peculiar manner, something analogous
to, though in  a far minor degree, and with much less certainty, than syphilis.
   The symptoms of gonorrhoea  in the male may be divided into three  stages:
1st. The incubative  stage,  or  the period of irritation;  2dly.  The acute;  and,
3dly.  The chronic inflammatory stage. 
NATURE  AND  SYMPTOMS OF GONORRHOEA.          799
  The first stage, that of irritation, usually comes on from three to five days after
connexion, when the patient begins to experience some degree of heat, itching,
and general irritation about the penis.  The lips of  the urethra  are  somewhat
red and swollen, its orifice gaping, and on squeezing  it some muco-pus  exudes.
This stage usually commences about the time mentioned, but sometimes  sets in
immediately after connexion; and in other instances  does not occur for eight or
ten days;  after lasting for twenty-four or forty-eight hours it terminates  in  the
second stage, which is one of active inflammation.  The discharge now becomes
abundant, thick, and of a greenish-yellow color;  there is great pain in making
water, with considerable heat and smarting, and the urine flows in a diminished
stream, but is passed with increased frequency.   The urethra is swollen, tender
to the  touch,  firm and  cord-like; the whole penis, indeed, looks generally red
and turgescent.   As the disease advances, and the bulbous portion of the urethra
becomes affected, tension in the perineum will be complained of.  If the prostatic
portion is the  seat of disease, there will be  heat and weight about the anus.
During the whole of this period there is generally a good  deal of constitutional
disturbance, restlessness, and fever.
   One of the most troublesome symptoms in this stage of the complaint is  the
occurrence of chordee, which consists in painful erections at night, with a twist
in the body of the penis, which is usually curved down towards the scrotum.
   These symptoms usually continue for about a fortnight, when the third  stage,
that of subacute  or chronic inflammation, sets in;  during this  period of the
affection the inflammatory symptoms gradually subside, but a thin muco-purulent
discharge keeps up, with some degree of heat and irritation about the urethra,
and occasional smarting  in making water; under proper treatment this usually
subsides in the course of another fortnight or three weeks;  but if neglected, or
in certain constitutions, it  may last  for  many months, or  even years, then
degenerating into a gleet.  In  proportion to the continuance of the affection  the
inflammatory symptoms subside, though the specific and contagious character
does not disappear, and the infection may continue so long as the discharge keeps
up.  Hunter mentions the case  of a girl who  had been  two years in the Mag-
dalen Hospital, and who infected a person with whom  she  had connexion  im-
mediately after she left that Institution.  The persistence  of the contagion of
gleet is, it is true, more marked in women than  in men.   So long, however, as
any discharge continues from the male urethra the patient must be looked upon
as infectious.
   The severity and the continuance of a gonorrhoea are  often opposed  to  one
another.   Thus the disease is  most severe in young and plethoric persons, and in
first attacks ;  but it is most difficult of cure in strumous and phlegmatic constitu-
tions, more especially if there be a gouty or rheumatic tendency co-existing,  and
is very troublesome to remove after repeated attacks.  I have observed repeatedly
that it is very apt to degenerate into a gleet  in those people who  are subject to
chronic diseases of the skin.
   The length of time that the infection of gleet will  continue in both sexes, but
especially in the female, makes it somewhat  difficult  to  say whether the poison
of gonorrhoea can be generated de novo, as it  is not improbable that many in-
dividuals communicate the disease, believing themselves to be perfectly cured,
though still suffering from slight gleet.
   The treatment of gonorrhoea must be conducted with reference to the stage to
which the  disease has attained, but  especially with regard to  the amount of
inflammatory action accompanying  it.   It is  of two kinds, rational, and specific
or empirical.  Both plans are useful, and, indeed, usually necessary for a proper
cure, but they cannot be adopted indiscriminately.   Thus, if specific means are
employed during the acute inflammatory stage of the complaint, much mischief 
800
DISEASES  OF  THE  URETHRA.
may ensue; whilst if antiphlogistic treatment is persevered in for too long a time,
the disease may be kept up indefinitely.                         #
  It has been proposed to adopt what has been termed the abortive or revulsive
treatment, during the earliest stages of gonorrhoea; during, indeed, the incuba-
tive period.  This method consists either in the injection of a very strong solution
of the nitrate of silver into the urethra, or the application to the inflamed mucous
membrane of a strong ointment of that salt by means of a  bougie smeared with
it;  other surgeons, again, have recommended  the administration of  very large
doses of  copaiba at this period.  These various plans  have, however, I  think,
deservedly fallen into disrepute.  I have on several occasions seen most intense
inflammation excited by these modes of treatment, and  never, in  any case, any
good result.   Independently of this, it is impossible to know whether the case,
in  the  earliest  stage,  will prove to  be one of  simple  urethritis or  a specific
gonorrhoea.
  In the acute  inflammatory  stage, attended by  heat,  swelling of the organ,
great ardor urinaa, and abundant muco-purulent  discharge,  the treatment must
be  entirely antiphlogistic, the activity of the measures being proportioned  to the
intensity of the inflammation.   If this be of a very severe character, leeches may-
be  applied to the perineum, or to any very tender  point  along the urethra.   If
not so intense, warm hip-baths, poppy fomentations,  or  the envelopment of the
penis in warm-water dressing, will  be of essential service.   At the same time
the urine must be diluted, and its acidity lessened, by the patient drinking large
quantities of alkaline diluents,—barley-water or linseed tea containing a little
nitre or carbonate of potass in solution, or soda-water; and  the skin and  bowels
may be kept in action  by the administration, every fourth or sixth  hour, of a
powder composed of 3j of sulphate of magnesia, 5 grains  of  nitre, and ^th of
a grain of tartar emetic, dissolved  in a wine-glass of  water.  All  stimulants
must be avoided, the diet being restricted to light slops, and perfect rest enjoined.
By such means as these,  the activity of the inflammation will  be  gradually les-
sened,  the discharge becoming thinner, the smarting in making water not  so
severe,  and the erections  less painful.   The patient should also be desired to pass
his water frequently, so that it may not be  too concentrated.
   AVhen this the second  stage of the disease has been reached, specific treatment
may be employed with great advantage, which, if it were had recourse to at  an
earlier  period, would certainly have increased the inflammatory action and given
the patient much distress.  At the same time  the specific remedies, such as co-
paiba and cubebs, must  be  cautiously given,  even  in  this stage; the surgeon
feeling  his way with them, and being prepared to discontinue them and to return
to  strictly antiphlogistic  measures, if he finds that  they increase the irritation.
Should the disease, however, from the commencement, have assumed  a subacute
character, the specific treatment may with  safety  be adopted at a much  earlier
period.
   Copaiba and  cubebs are the remedies that are  almost  universally had recourse
to  in this stage of gonorrhoea.   Of these, copaiba is  the least irritating and con-
sequently most generally to be preferred.   It may be administered in a variety
of  ways,  in capsule, pill,  draught, or extract.  In capsule  it is generally to  be
preferred, on account of the nauseous taste being thus  more readily disguised;
but in  many cases it acts with more certainty, and with better effect,  if given in
either of the other forms.  AVhen the capsules are given, the  patient may take
from six to eight or ten in the day,  and should at the same time have  an alkaline
mixture, which  increases materially the effect of the  drug.  A very excellent
mode of  administering copaiba is to rub it  down into a mass with burnt magnesia,
and to  let the patient take about 5J of this paste three times in a day, in a bolus
wrapped in wafer-paper.   Or, if the taste is not much objected to, he may take
 it  most advantageously in mucilage, with liquor potassae and tincture of henbane. 
TREATMENT  OF  GONORRHOEA.
801
  In  some  relaxed  constitutions,  and  more  frequently  after frequent  claps,
cubebs will be found  to cure the patient more readily than copaiba, or rather
most successfully, if given in combination with it.  An excellent plan is to put
about half an ounce of the powdered cubebs into a mortar, and to rub it up with
as much copaiba as will form a stiff paste, of which the patient should take 3j
as a bolus thrice daily.  The effects of this electuary are often most  striking,
but it can only be used in the constitutions indicated, and after the  more active
inflammatory symptoms have subsided.
  It is during the second stage of gonorrhoea that injections may advantageously
be given.   Much and very unfounded prejudice  exists against their use in the
minds of many; but surely it is as safe to apply  proper local applications  to an
inflamed  urethra as it is to an inflamed conjunctiva; and the bad consequences,
such  as stricture and  inflamed testicle,  which  have  sometimes been referred
to their use, have been rather  due, either to  the long continuance and to the
severity of the disease itself, than to  the remedies  employed, or to their  appli-
cation at  too early a stage, or of too  great a  strength.   It  is in long-standing
cases  of gonorrhoea,  in which the  discharge continues for months or years, that
stricture results, not in cases of ordinary duration; and in these it is the result
of the chronic  inflammatory thickening  of the mucous membrane,  and has no
more  to do with  the injections than with the copaiba or salines the patient may
have taken.   As the ardor urinae subsides, emollient and slightly astringent in-
jections may be used.  The best are perhaps the acetate of lead in tepid water of the
strength of two grains to the ounce.   If this  induce irritation, a few grains of
the watery extract of opium may advantageously  be added.   As the disease sub-
sides, a stronger astringent is required, and then  one or two grains of the acetate
of zinc may be added to each ounce of the injection; or a very weak solution of
the sulphate or chloride of zinc may be employed, gr.  ij. of  the first, and  gr.  _
of the second to each ounce of water; or an injection of gr. i of the nitrate of
silver to the ounce may be used.   During the whole of this  stage  the  diet and
habits of life must be carefully regulated, and all stimulants interdicted.   The
injections should be discontinued as soon as the discharge has ceased  ; unless this
be done they may re-induce it.
  The mode  of injection is of importance.  A glass syringe should always be
used,  with a smooth, rounded nozzle.  The patient, sitting  on the edge of the
chair  and holding up the penis, should  carefully insert the  end of the syringe
between the lips of  the urethra, and then slowly throw in  the injection  as  far as
it will go. Although the inflammation is usually confined to  the anterior portion
of the urethra, yet it may extend to the bulb, and the injection should be applied
to the whole^ length of the inflamed mucous membrane.   If  any enter the blad-
der it cannot signify, as  it will immediately  be decomposed by the salts and
mucus of the urine.
  In  the  third stage of gonorrhoea, that of gleet, much difficulty will  often be.
experienced in curing the patient of his discharge.  Here  much depends not
only on the administration of proper  remedies, but  in care  being  taken atten-
tively to regulate his habits of life.   It will constantly be found that after the
disease has apparently been cured,  excesses at table, and more especially drinking
beer, effervescing or acid wines,  will bring back  the discharge.  So also it will
return after connexion, though it had  previously ceased entirely.  This is  espe-
cially  the case in those constitutions that are either strumous,  gouty or rheumatic,
and in which all urethral  inflammations are with  difficulty removed.  In  these
cases,  then, abstinence from all stimulants, dietetic as well as alcoholic, and im-
provement of the tone of the system by change of air, sea-bathing, &c, will  often
be of  essential service.  At the same  time, the electuary of cubebs and copaiba,
or one composed of cubebs and the sesquioxide of iron,  may be administered with
advantage.  In other cases again, especially in relaxed  constitutions, the tincture of 
802
DISEASES  OF  THE  URETHRA.
the sesquichloride of iron, alone or conjoined with a few drops of spirits of turpen-
tine or tincture of lytta, will be found productive of much advantage.
   In chronic gleets, local applications will be found to  be necessary for the cure
of the disease.  Amongst these I have found none  more useful than one com-
posed of ten grains of the chloride of zinc and one scruple of gallic acid  to eight
ounces of water.   In some cases the nitrate of silver injections, of the strength
of half a grain, or the bichloride of mercury, in the proportion of a quarter of
a grain  to the ounce,  will be serviceable.  And  indeed in most instances  it is
beneficial to vary the injections, the mucous membrane appearing to get accus-
tomed to the same stimulus after a time, and thus not being impressed  by it in
a proper manner.
   After the gleet has continued for some  months, more benefit will often be
derived from  the  introduction of a full-sized metallic bougie every  second  or
third day than by any other local means, even where no stricture  exists.   The
instrument should be left in for about ten minutes, and should be of the largest
size that the urethra will admit.

                     COMPLICATIONS  OF GONORRHEA.
   Gonorrhoea when acute or virulent seldom runs its course without local com-
plications of some kind, the  result of the propagation of the inflammation  to
neighboring parts, often of considerable severity, and occasionally even hazardous
to life;—such as  chordee,  phimosis,  sympathetic  bubo,  abscess  in perineo,
irritability of the bladder, retention of urine, hemorrhage from the urethra, &c.
Many of these complications present no special features, but require to be treated
on general principles, without reference to their specific cause   Others, again,
demand more special management, and these we may briefly consider here.
   The chordee, or painful erection of the penis, with twist of the organ,  coming
on at night, is often a most distressing and troublesome symptom.   It is usually
best  relieved  by the application of  cold to the part, but more  especially by the
administration at bed-time of a pill composed of gr. j of opium to gr. v of camphor,
the camphor  acting as a direct sedative to the generative  organs.   Ricord re-
commends a suppository of camphor and opium, gr. x of camphor, and gr. j of the
watery extract of opium, to be introduced into the rectum an  hour before  bed-
time, as the best means to remove the tendency to chordee.
   The irritability of the bladder with spasm of the neck and dysuria may  be of
two kinds, either inflammatory,—coming on in the earlier stages of the disease with
pain in  the perineum, and all the symptoms of the active inflammation about the
part strongly marked; or atonic,—supervening  at a more advanced  period,
without any special  signs  of inflammation.   In the  first case  leeches to the
perineum, hot poppy fomentations, the warm bidet, with full  doses of  Dover's
powder, or of henbane and carbonate of potass or nitre, will probably afford much
relief.   When the disease is atonic,  the administration of  the tincture of the
sesquichloride of iron, conjoined with local soothing remedies, as the poppy
fomentations or bidet, and an opiate suppository will be  beneficial.
   In retention of urine from gonorrhoea the  obstruction  is usually dependent on
a congested and inflammatory condition of the mucous membrane of the urethra.
In these  cases, leeches to the perineum, the warm hip-bath,  and opiate supposi-
tories will probably afford relief.   It is always desirable to  avoid using the
catheter, as it is apt to lacerate the swollen and softened mucous membrane, and
thus to occasion troublesome bleeding;  and will always be productive of much
pain, and of increased irritation of the  canal.  Should, however, the retention
have continued 24 hours, or longer, it may most probably not give way by the
means above  indicated, and  then it  will be  necessary to use the  instrument,
when a full-sized silver one should be very carefully introduced; a large instru-
ment entering the bladder as  easily and with less risk of injury to  the tender
walls of the canal, than a smaller one. 
SEQUENCES  OF  GONORRHOEA.
803
  AVhen once the catheter has been introduced, it is  often a somewhat difficult
matter to determine whether it should be left in or taken out.  If it is left in,
inflammatory action is increased.   If it is taken out, it majr not be got in again.
The  solution to this question is  to  be found in the  facility with which the in-
strument is passed.   If it has been introduced without much difficulty, it is bet-
ter to withdraw it after the bladder has been emptied, and to continue the anti-
phlogistic treatment, when a second introduction may not be  required.   If, on
the other hand, the catheter has been passed with  great difficulty, and is firmly
grasped either by spasm or stricture it should be left in ; but very active treat-
ment must be employed to prevent it exciting  too much inflammation.
  It  must, however, be remembered that the retention may be due to  more
serious conditions than  this.   To prostatitis, to abscess in that gland, or in the
perineum,  or to  inflammatory exudation in the tissues about the  neck of the
bladder.  Under these  circumstances, more active antiphlogistic measures will
be required, with the use of the catheter twice in the 24 hours, and probably
free  incisions into the perineum, if there be pus or urine extravasated into that
region.
   In many cases also of gonorrhoeal retention, there is an old stricture as well as
the clap.   Here the employment of energetic antiphlogistic measures, with the
use of the catheter are indicated, but as the stricture is the chief  cause of ob-
struction the treatment must be directed to it.
   Hemorrhage from the urethra may occur either as the result of  chordee, and
 consequent rupture of some bloodvessels  of the mucous membrane,  as the conse-
 quence of attempts at passing the catheter, or as a kind of exudation from the
 mucous membrane.   Most commonly it may  be arrested by  the application of
 cold, and the employment of moderate local antiphlogistic treatment.   Should it
 be abundant, pressure by means of a bandage to the penis or  perineum,  and the
 introduction of a large gum-elastic catheter will arrest it.

                       SEQUENCES OF GONORRHEA.
   The sequences, or more remote complications of gonorrhoea, are partly local and
 partly constitutional.  Amongst the local we find more particularly warts  about
 the  prepuce  and glans or within the urethral orifice,  which require to be treated
 by excision or caustics ; and stricture, the management of which is fully described
 elsewhere.   In some cases also, in consequence of  extravasation of blood, or the
 effusion of plastic matter into the corpus spongiosum or the  corpora cavernosa,
 limited and localized induration and thickening of the penis may result, attended
 by chordee, painful erections, and a permanent twist in the organ.  In such con-
 ditions as these absorption of the effused mass may be attempted by the adminis-
 tration of small doses of the bichloride  of mercury;  with  the inunction of the
 iodide of lead ointment.
   After the cure of a clap that has been  of long continuance, the generative
 organs arc often left  in a weak  and irritable state; the  penis, scrotum and
 spermatic  cords being  lax and  elongated, with an apparent want of  power, and
 often painful and dragging sensations about the cords and groins.   In some of
 these cases the patient loses the power of erection, emission taking place before
 erection, and thus preventing proper connexion.  In other instances  again, erec-
 tion of the penis takes  place, but  is immediately  followed by emission; and  in
 some cases, although erection occur, the expulsive  power seems to be lost, and
 the  semen, though escaping through the ejacuktory ducts, is not properly ejected,
 but  either flows  back into the bladder,  or slowly escapes after  the erection has
 gone down.   Besides these various morbid states, nocturnal  emissions are com-
 mon, especially after slight derangement of  the  digestive organs and of the
 nervous system; and viscid prostatic fluid is not uncommonly squeezed out after
 the  escape of the urine, or during defecation.   These various morbid conditions 
804
DISEASES  OF  THE  URETHRA.
are commonly confounded with spermatorrhoea, which they closely resemble, and
constitute  different forms of impotence.   They  require  careful consideration
on the part of the surgeon, as their existence is  a  source of the greatest mental
depression and distress to the sufferer; certainly  one  cause of conjugal infidelity,
and  occasionally, I believe, of suicide.   These affections, which are of extreme
frequency amongst all classes of the community, have scarcely as yet  received
that attention on  the  part  of the  profession  generally  that their  importance
deserves, and the  unfortunate sufferers from them are too often driven into the
hands of those  pestilent quacks that flourish in  the  metropolis, and  now infest
almost every town in the  country, and by whom they are not unfrequently ruined
in health as well as in purse.
  These various forms of  impotence, of spermatorrhoea, of debility of the genera-
tive organs, or by whatever other name the condition may go by, are frequently
difficult  of cure, on account of the ready way in which  they are influenced by
moral causes ;  and the hypochondriacal state into which a patient laboring under
them usually falls, makes it of much importance  to speak cheerfully, to  hold out
hopes of a speedy recovery, and  to  endeavor to divert the  patient's mind from
dwelling constantly on his infirmity.   He should also  be cautioned not to attempt
to have  connexion during  the treatment, lest the occurrence of failure should
dispirit and depress him still more.
  The curative  treatment of these cases should consist in  giving tone to, and in
lessening  the irritability  of the  genito-urinary  organs.  The first object is ob-
tained by the administration  of the tincture of the sesquichloride of iron,  but
more especially by the habitual daily use of the cold hip-bath.   This the patient
should use  every  night and morning, remaining in it, at  first, for about three
minutes,  but gradually increasing the time of immersion to ten or  fifteen.  In
some cases,  the cold shower-bath appears to give more tone, and then should be
preferred.   These means, useful  as  adjuncts, will not however cure the patient.
For this purpose, the local irritability must be removed, by the application of the
nitrate of silver to the prostatic and bulbous portions of the urethra.   It will
always be found that there is a good deal  of tenderness  in these situations,  felt
by pressing upon  the  perineum, or  by passing  an instrument into the  urethra,
when, as the  point enters the bulb, the patient will usually suffer much pain.
The  continuance  of this irritation certainly keeps up the nocturnal emissions,
and thus maintains the debility of the genital organs, and the nervous irritability
that is so characteristic of these cases.   It may most effectually be remedied by
the application  of the nitrate of silver, as originally recommended by Lallemand;
and if this is done in a proper manner, a cure will usually be accomplished.   Of
late years I  have employed, with much advantage in such cases, the instrument
here figured (Fig. 255).  It consists of a silver catheter, having about  a dozen
minute apertures near the end.   In the interior is contained a slender  piece of

                                   Fig. 255.
sponge, about two  inches long, fixed to the expanded end of a firm stylet that
moves within the  catheter.   The instrument is charged  by filling the sponge
with some solution  of the nitrate of silver by withdrawing the stylet.   It may
then  be well oiled, and  being  passed down to  the  spot  to  be cauterized, the
solution is forced out of the apertures, by pushing down the rod, which com-
presses the sponge.   I have found this instrument far safer and more manageable 
GONORRHEAL  CONJUNCTIVITIS.
805
than Lallemand's or any other  porte-caustics that act by protruding a spoon or
sponge, which is apt to be grasped by the spasmodic action of the muscles of the
part, often being returned with difficulty into the shaft, and  not without risk of
lacerating the mucous membrane.  I generally use a solution of the strength of
5j of the nitrate to an ounce of water, though sometimes  only a half, or a third
of this strength can be borne.   The application  usually occasions a good deal of
irritation for a time, sometimes even a muco-purulent discharge, and can only be
repeated at  intervals of from  ten days to a fortnight.  Any  undue amount of
irritation must be subdued by ordinary antiphlogistic treatment.
   Besides these  strictly local  complications of  gonorrhoea, a certain set  of
sequences to  which some constitutions are especially liable, occasionally occurs
as the result of  this disease, viz., inflammation of the testes and of the eyes,
rheumatism, cutaneous eruptions, and sore throat.   Some of  these, as  the  affec-
tions of the eyes and testes, may either be local or constitutional; the others are
clearly constitutional.
   Gonorrhceal inflammation of the testis is certainly the most common of  these
sequences.  It  almost invariably affects  only one  testis, and commences in  the
epididymis, whence it extends to  the  body of the organ.  It  usually occurs in
those individuals who have a lax and  long scrotum, with very pendulous testes.
It seldom sets in before  the third week after the occurrence of the gonorrhoea,
but may occur at any period during the continuance of  the discharge, though
it is  more  frequent between the fifth and sixth weeks than at any other time.
In cases of  gleet, also, it not uncommonly occurs at a later period.   In  many
instances it  is  referred to some slight  injury—a blow, or squeeze,  received
during the continuance of the  gonorrhoea; but, in other cases, it would appear
to arise from  extension of the inflammation along the ejacuktory duct; and in
others, again, to a kind of metastasis  of the morbid action  from the urethra to
the testis.  The fact of the disease  commencing  in the epididymis may be ad-
vanced in support of the first opinion; whilst the fact that the  discharge usually
ceases when the inflammation of the testicle comes on, and returns as, it subsides,
may be adduced  in support of the doctrine  of its metastatic origin.  As  the
symptoms and treatment of gonorrhceal inflammation of the testicle present nothing
peculiar, I shall  reserve  their consideration  until we come to  speak of diseases
of this organ.
   Gonorrhceal inflammation of the eyes is fortunately not of very common occur-
rence.  It may affect either the conjunctiva or  the sclerotic.
   Gonorrhceal conjunctivitis is one of the most destructive forms of ophthalmia,
giving rise, not unfrequently in the  course of forty-eight  hours, to  the  most
intense  chemosis, with opacity  and softening of the cornea, followed by staphy-
loma and a discharge of the humors.   In the majority of  instances only one eye
is affected, but in some both are involved to an equal extent.   The disease com-
mences with the ordinary symptoms of conjunctival inflammation; itching and
swelling  of the eyelids, velvety redness  of the  conjunctiva,  muco-purulent dis-
charge, with  much  lachrymation.   The  chemosis  sets in early, and is of a very
severe character, and unless treatment affords speedy relief, the consequences are
most disastrous to vision.  Lawrence states, that of 14 cases  that fell under his
observation, 9 had only one eye  affected, and  5 both.  Of the 9 in whom one
eye only was diseased, the organ was lost in 6 cases;  of the  5  in whom both
eyes were affected, both organs were destroyed in one case;  in two one eye only
was lost; one patient recovered imperfectly, and in only one  did  complete  reco-
very ensue.
  It has been a question with  surgeons  whether gonorrhceal ophthalmia is  the
result of the  direct  application  of the  specific pus to  the  conjunctiva,  or occurs
as a constitutional  disorder.  There can be little doubt that the application of
the pus to the surface of the conjunctiva might occasion the disease, but at  the 
806
DISEASES  OF  THE  URETHRA.
same  time it is perfectly certain that in many instances there is no evidence of
contact; the inflammation occurring in both eyes without the patient bavin-
apparently communicated it; and though it is necessarily difficult to adduce posi-
tive proof on this point, it is but reasonable to presume that such cases may be
constitutional.                                                 .     ,
  The  treatment of this  dangerous affection must be of an active character;
blood should be taken freely from the temples by cupping, or if the  patient is
sufficiently robust, from the arm,  as strongly recommended by Lawrence, who
places great reliance on it; he must of  course be kept in a dark room and on a
strict antiphlogistic regimen.  The disease must, however, be met, and  the  eye
can alone be saved by active local treatment.   The most active topical agent that
we possess is the nitrate  of silver.   The use of this astringent, originally intro-
duced by Littell, has been much insisted on by Guthrie, AValker, and others, and
is generally adopted at the present day, being certainly the most useful agent
that we possess.  Surgeons differ somewhat in opinion as to the strength of  the
application; some, the Germans especially, advise that the solid stick should be
used, whilst others employ it in solution, of the strength of a drachm to the ounce
of distilled water; Mr. AVharton Jones  employs a weaker solution, one of four
or five  grains to the  ounce, and I have  seen  cases very  successfully treated by
this plan; so much so indeed  that I should be disposed in future  to adopt it in
preference to the stronger solution.   A few drops must be  introduced about
twice in the twenty-four hours, into the inner  canthus of the eye.  The lids
between times being kept covered by compresses dipped  in a weak alum lotion,
and the purulent discharge carefully washed away  as it accumulates, by the em-
ployment of tepid alum injections.  In  doing  this,  great care must be taken that
none of the discharges come in contact with  the eyes of the surgeon or nurses,
as it is  of a highly contagious character, and will almost to a certainty reproduce
the same disease; and instances are recorded in which, in this way, the atten-
dant's vision has been destroyed.   If the chemosis be considerable,  it must be
incised, and as the inflammation subsides, belladonna  lotions  may be employed
with advantage, and the  use of the nitrate of  silver gradually discontinued.
   Gonorrhceal sclerotitis  is by no means of such frequent occurrence as  the con-
junctival inflammation;  when it happens it will commonly be found to be asso-
ciated with gonorrheal rheumatism, and not unfrequently with inflammation of
the testicle, occurring apparently in those individuals in whom there is a tendency
to affection of the  fibrous tissues.  This  disease  is evidently of constitutional
origin,  as it cannot  possibly arise  from local contagion; it is attended by the
ordinary signs of sclerotic  inflammation, and is usually accompanied  by some
degree  of iritis.  In the treatment there is  nothing very peculiar, cupping or
leeches to the  temples, with belladonna fomentations, are the  principal local
means, and calomel and  opium, continued until  the gums are affected, constitute
the  chief elements of the practice to  be pursued, and must  be persevered in
until the anterior chamber clears, and  any effused  lymph is absorbed.  As  the
disease declines, and especially if  the patient is somewhat debilitated, soda, rhu-
barb and bark in powder may be given internally,  and blisters kept open on the
temples.
   Gonorrhceal rheumatism principally occurs in young,  florid, and otherwise
healthy men.   It is  of two kinds; in  one, the  most  common, and indeed the
typical variety, the fibrous and  muscular structures are  affected; in the other,
the  joints are  implicated.  The fibrous or  muscular form of rheumatism  is not
unfrequently associated with  inflammation of the testicle  or  the sclerotic.  It
 commonly affects the fleshy parts of the body, as the hips, the shoulders, and the
thighs, and  not unfrequently occurs in the soles of the feet.  It is always painful
at night, but is not commonly attended by  any very severe constitutional distur-
bance.   The synovial form presents the ordinary characters of rheumatism of the 
GONORRHEA  IN  WOMEN — DIAGNOSIS  FROM LEUCORRHEA.   807

joints, the knees and ankles being those chiefly involved.   In the  treatment of
these affections, venesection, followed by calomel and opium, or Dover's powder,
must constitute the most important elements until the acute stage is passed, when
the iodide of potassium may be advantageously given.
   Cutaneous eruptions chiefly consisting of roseola, with  slight pityriasis, and
perhaps a few patches of psoriasis with very flimsy scales, occasionally occur in
rather  severe  cases of gonorrhoea, usually appearing from  six weeks to three
months after the commencement of the attack.   They are chiefly diffused about
the chest  and belly, and present  no sign of coppery redness.  At the time of
their occurrence, the fauces commonly become  similarly involved, presenting, as
was first pointed out by Travers, a diffused superficial redness on the velum palati
and  pillars, with perhaps superficial ulceration on these, the tonsils  or the uvula.
The occurrence of these affections is usually preceded by slight febrile action,
which, however, subsides on their  full evolution.  These roseolar eruptions, oc-
curring during gonorrhoea, have  occasionally  been attributed to some peculiar
influence exercised by the copaiba, but I think  not on sufficient evidence.   I am
not aware that copaiba,  when administered for other diseases than gonorrhoea,
ever produces  such eruptions, and  they will  occur, as I  have seen in several
instances, when  no copaiba is being  given.  The treatment of these  affections
should  consist in the administration of salines, followed by the iodide of potas-
sium in small doses.   Mercurials are  never required.
   Gonorrhoea in the female  differs from the same affection in the male  in not
being so  severe, though it is  usually more  extensive, and of longer duration.
The severity is less on account of the shortness of the female urethra preventing
the  occurrence of retention of urine  as in the  male, and also from the absence
of such parts as the prostate, testes, &c, the  implication of which constitutes the
principal source of difficulty in men.   Gonorrhoea in the female  may  affect  the
parts to very various  degrees; thus the vulva alone  may be  implicated, or, as
most commonly happens, the inflammation may spread to the whole of the mu-
cous membrane of the vagina.   The urethra is  less commonly the seat of disease,
though  occasionally implicated with  other  parts; and, lastly, the interior of the
uterus may become affected by this specific inflammation.  In some cases even,
it will spread along the Fallopian tubes to the ovaries, and I have known one or
two  cases in which rather acute attacks of peritonitis, probably induced in this
way, have complicated this disease.
   The symptoms of gonorrhoea in women are sufficiently well marked in the early
stages,  where there is an abundant muco-purulent  discharge from  the  parts
affected, with  a good deal of inflammatory irritation  about them  accompanied
with pain in micturition, and a frequent desire  to pass water.  As the  disease
becomes chronic, however, it is more difficult to determine its true  character; it
being apt to be confounded with some of those accidental and leucorrhoeal discharges
to which females of all ages are subject.
  In the majority of cases, gonorrhoea may be distinguished from  all other muco-
purulent discharges of the female  organs by the presence of inflammation about
the external parts, the mucous membrane of the vagina and urethra.   In these
cases it will be  found, on introducing a speculum, which,  however, occasions
considerable pain, and is firmly grasped by the contraction of the  vagina,  that
the discharge  comes from  the wall of this canal, and  that the uterine orifice is
free  or nearly so from it.  Whereas, in leucorrhoea the discharge proceeds in a
great measure  from the interior of the uterus, the os and cervix of  which would
probably also present  signs of diseased action.   It must, however, be borne in
mind that the discharge in gonorrhoea may occasionally be in a great degree uterine,
and that of leucorrhoea may be an exudation from the mucous membrane of the
vagina.   Under such  circumstances, when the  disease is chronic, it is almost
impossible  to  arrive at a correct  conclusion as to  the nature of the  case from 
808
DISEASES OF  THE  URETHRA.
simple  inspection; and in these cases of doubt the surgeon had better give a
very guarded  opinion, lest he be led into the  error of inculpating an  innocent
woman.   The  difficulty is increased, and a good deal of obscurity thrown  over
the case by the fact that leucorrhceal discharges will occasionally give rise to ure-
thritis in the male, which closely simulates gonorrhoea.   Children  also  are occa-
sionally subject to an acute inflammation of the vagina and nymphae as the result
of simple irritation, of constitutional  disturbance, or of teething; these  cases
require to be recognised, as they have frequently been  the cause of unfounded
accusations.
  The treatment of gonorrhoea in the female must vary according as the disease
is acute or chronic.   In the acute stage, general and local antiphlogistic means
must be had recourse to—salines, low diet, rest in bed, and emollient  sedative
fomentations.  As the disease subsides into a chronic condition, astringent injec-
tions must be employed; a weak solution of the acetate of lead, or  the liquor
aluminis comp. largely diluted  with  tepid  water, being especially useful.   In
other cases again, a weak solution of the nitrate  of silver may be used with much
advantage.  These injections should be employed three or four times a  day, and
in large quantity.  After they have been thrown up, a piece of lint well soaked
in the lotion should be introduced between the  opposed mucous surfaces, so as to
prevent their coming into apposition, the discharge being in a great measure kept
up by their friction against one another. In order that the injections be properly
given, the woman should lie flat upon her back, and pump in the fluid by means
of one of Kennedy's elastic bottles.  In the treatment of gonorrhoea  in women,
specifics are of no use unless the urethra be affected, when copaiba may be given,
as in the male.   The disease is apt to degenerate into a chronic, gleety condition,
leaving a thin, muco-puriform discharge, which will continue to be infectious for
a great length of time.                                     '

                      STRICTURE OF THE URETHRA.

  Much discrepancy of opinion has for a long time existed as to the structure of
the urethra, some surgeons admitting,  others denying its muscularity.   Though
the presence of muscular  fibres  in  the urethra had been suspected by many in
consequence of the phenomena presented by some forms of stricture being solely
explicable in this way, it is only very recently that  their existence has  been de-
monstrated ; Kblliker  and Hancock having shown that the tube  is surrounded
through its entire length with an organic  muscular coat.  Hancock has demon-
strated the  course of these  fibres.   He has  pointed out that the fibres of the
inner layer of the muscular coat of the bladder pass forwards  underneath the
mucous membrane of the prostatic portion of  the urethra, and  those from the
outer layer of the muscular coat of the bladder outside the prostate.  These two
layers join at the membranous portion of  the urethra, forming the muscular co-
vering of  this portion of the canal.   At the bulb these two layers divide again,
the inner lying underneath the  mucous membrane, separated from it merely by
cellular tissue ; the external lying outside the corpus spongiosum, between it and
its fibrous investment.  At the anterior extremity of the urethra they unite again
and form its lips.  Thus the urethra is surrounded  through its whole length by
muscular fibres, a double  layer of which invests it at the membranous portion,
and  again at the external meatus.   The prostate and corpus spongiosum are in-
cluded between the planes of these fibres.   The vesicles  and ducts of the  pros-
tate  glands are  surrounded by layers of organic fibre;  those of the ejacuktory
ducts coming from the organic layer of the vas  deferens. These fibres are totally
distinct from the common muscular apparatus of the perineum, and  their exis-
tence proves the urethra to be, what had often been suspected, a musculo-mem-
branous canal. 
   SYMPTOMS AND  TREATMENT OF SPASMODIC  STRICTURE.  809

   By stricture of the urethra is meant a narrowing of the canal at one or more
points.   This may proceed from three  distinct conditions; viz.—spasmodic action
of the layer of the organic muscular fibres situated outside the mucous membrane;
congestion of the mucous membrane  of the  canal,  or organic changes in  the
mucous and submucous tissues, consisting of thickening, induration, or the de-
posit of plastic matter within them.   According as the disease arises from one
or other of these causes it maybe termed  a spasmodic, a congestive or an organic
stricture.   These different forms of the disease, though having the one condition,
narrowing of the urethra, and its consequences in common, present so much va-
riety in their symptoms, in the treatment they  require, and in the constitutions
which they occur, as to require separate description.
   1st. Spasmodic Stricture.—The existence of  this form of the disease has been
much cavilled at,  surgeons disregarding the  evidences of their own senses and
being led away by an  imperfect anatomical examination of the urethra, denied
the possibility of spasm of this canal, not being able to demonstrate the existence
of any muscular fibres there in  sufficiently close proximity to the  mucous mem-
brane to influence it by their action.   The possession of muscular  contractility
by the urethra is, however, obvious from the fact that a bougie may occasionally
be introduced with sufficient ease, but that the  surgeon on attempting to withdraw
it, will find it tightly grasped : so also occasionally on introducing the instrument
he will feel it meet with an obstruction which on steady pressure will yield with
that species  of quivering that  is  peculiar to spasm of muscular fibre.   Then
again the fact that a patient would at one time pass his urine with the most per-
fect  freedom, whilst if it were  rendered acrid or acid by drinking spirits, effer-
vescent wines, or other similar beverages almost complete obstruction would ensue,
tends to prove the existence of an occasional spasmodic  constriction of the canal.
These facts, though sufficiently convincing to many surgeons, had failed to carry
proof of the existence of spasmodic stricture to others, until the recent researches
of Kolliker and Hancock, which have  above been referred to, set the question of
the muscularity of the  urethra finally at rest.
   In spasmodic stricture we find evidence  of narrowing of the urethra, and con-
sequent impediment to  the free flow  of  urine, rapidly supervening under the
influence of certain causes, and as  speedily subsiding.   A patient for instance  in
his ordinary health and passing  water freely, may, if he take such food or drink
as will give rise to a very acid condition of his  urine, if he be  exposed to cold,
or get out of health in any way,  suddenly find himself able only to pass his water
in a  small stream by drops with much straining,  or may  even be seized with com-
plete retention.  Under appropriate treatment these symptoms rapidly subside,
recurring, however, on the  application of any exciting cause.   At  the  time  of
the occurrence  of this spasm there is often a sensation of weight and uneasiness
in the perineum, with  evident irritation of the urethral mucous membrane,  as
shown by reddening of the lips of the orifice :  in fact a tendency to a combination
of the congestive with  the spasmodic form of stricture.  The causes of spasmodic
stricture are usually such conditions as occasion  a relaxed and  irritable state  of
system, as long residence in hot  climates, more  especially if conjoined with
habitual excesses in drinking, high living, and venereal indulgences.   The more
immediate causes are usually any  circumstances that occasion irritation of the
urethral mucous membrane which, being  propagated  to the organic  muscular
fibres beneath, calls them into activity  and thus gives rise to the spasmodic affec-
tion.   The most usual  of these are those conditions of the  system in which the
lithates are largely eliminated, as exposure to cold and wet, by which the  action
of the skin is suspended, too free an indulgence in spirituous and acid liquors,
—such as red or effervescent wines, beer, or punch,—which  are well known to
give rise to an attack in many constitutions.
  Treatment of Spasmodic Stricture.—If the patient is suffering from great and 
810
DISEASES  OF  THE  URETHRA.
spasmodic difficulty in making water, a suppository, consisting of a drachm  of
laudanum in a little starch, should be thrown up the rectum the warm hip-bath
used, and a full dose of Dover's powder administered.  As the opium begins to
take effect, the urine will usually be passed without much difficulty.   Ihe bowels
should then be got to act, when the  patient will  usually be relieved.   If the
spasm continue, as it often does, for some days  or  weeks after this  a full-sized
wax bougie  should be introduced every second or third day, in order to lessen the
irritability of the urethra.  In some cases this is more effectually done by the use
of a pewter bougie, well warmed and oiled.   If the use of the instrument causes
irritation and increase of spasm, it  is better to omit it entirely, and to trust  to
constitutional treatment.  But the surgeon must not be discouraged if the first
few introductions  of the bougie appear to increase the irritation ;  as the urethra
becomes accustomed to the use  of  the instrument, relaxation of  the spasm will
take place.  At the same time the patient's general health should  be carefully
attended to ; the  bowels must be kept open, and  the diet  regulated ; all acids,
stimulants,  and sweets, being carefully avoided.   During the time that the bougie
is being used he should take, three times a day, a draught, composed of  twenty
minims of liquor potassee, with the same quantity of tincture of henbane and sweet
spirits of nitre in  camphor julep.
   As a preventive treatment of these attacks,  a careful regulation ot the diet,
warm clothing with the use  of flannel, and keeping the skin in action by means
of horsehair gloves and tepid baths, will be  found serviceable.
   2d.  Congestive Stricture.—Many surgeons look  upon spasmodic strictures as
essentially dependent on congestion of the  mucous  membrane of  the urethra,
overlooking altogether the existence of spasm, or  considering it as the result of
irritation of the perineal muscles, and not of the true organic muscles of the canal.
That the two conditions of congestion and spasm are frequently associated in the
urethra, in the relation of cause and  effect, there can be  no doubt;  and this is
the most frequent condition  in  which spasmodic strictures are found.   Indeed
 congestion  plays an important part in all forms of stricture ; it may, as we have
just seen, be connected with the spasmodic variety, it may occur alone, or it may
be associated with organic stricture.  Some parts  of the  urethra appear to  be
 more subject  to  congestion  than  others.  Thus, for instance,  the  membranous
 and prostatic portions, especially the folds of mucous membrane constituting the
 verumontanum, are peculiarly liable to become congested.
    Congestive strictures frequently occur as the  result  of chronic and long-con-
 tinued inflammation of the   urethra, or  of the  passage of urine that has been
 rendered irritating by being too concentrated, or by an admixture of an undue
 proportion of lithates.   It is especially in gouty or rheumatic subjects who suffer
 from irritability of the skin  and mucous  membranes that this  condition occurs.
 In these cases, there  is no  true  or  permanent obstruction, but the disease is
 transitory and solely due to a swollen state of the membrane of the part.
    In congestive  stricture we not only find the common symptoms occasioned by an
 impediment to the free passage of the urine ; but some swelling of the lips of
 the urethra with reddening  and eversion of them.  There is also  slight gleety
 exudation, and not  unfrequently  an abundant puriform discharge, in fact  ure-
 thritis of a marked kind, with a sense of weight or fulness in the perineum, pain
 in micturition, and  sometimes uneasiness in defecation.  This state of things
 constitutes a very troublesome affection, intimately connected  with the various
 forms  of urethritis, and exceedingly apt to  relapse  from  apparently very trivial
 circumstances, slight errors of diet, dyspeptic derangements, or any local sources
 of irritation.
    The treatment in these cases should consist  in careful regulation of the diet
 and habits of life, and especially in the administration of the alkaline and sedativ*
 mixture above indicated in  combination with small doses  of copaiba.  In many 
             CONGESTIVE AND  ORGANIC STRICTURES.          811

cases a course of Plummer's pill  in conjunction with the compound decoction  of
aloes will be found of essential service.   If there is  much tenderness or weight
about the perineum, the application of leeches to this part together with the use
of the warm hip-bath will be serviceable.
  Congestive strictures,  though more influenced by  constitutional than local
means in many cases,  yet require the introduction of bougies in order to prevent
the constriction becoming permanent.  In some instances a wax, in other a silver
or pewter instrument, will be found to answer  best.   Whichever is used,  care
should be taken to introduce it slowly and with every possible gentleness.  With
all care some hemorrhage usually follows the passage of the instrument, not from
laceration, but simply as the result of compression of the mucous membrane, and
the discharge of which appears rather to be beneficial than otherwise.
  3d.  Organic Stricture.—This form of stricture is the result of long-continued
inflammation of the urethra, or  of some injury to the canal from blows or kicks
in the perineum, by which a portion of it is destroyed or sloughs away.   Repeated
gonorrhoeas and long-continued gleets are the most  fertile causes of this disease.
In the urethra as elsewhere, plastic matter is deposited in and around the mucous
membrane, as the result  of inflammation ; consolidation of  this takes  place fol-
lowed by contraction of the canal.  The long continuance of inflammation is more
to be dreaded than its intensity in occasioning this mischief; hence it is of great
importance not to allow gleets  to run on indefinitely, as they will almost to a
certainty be followed by constriction  of some portion of the urethra.
  The seat of organic stricture  varies considerably, indeed  any portion  of the
urethra may be affected by it, except the prostatic.   It appears to be the common
belief amongst surgeons, that the membranous portion of the canal is the most
frequently affected by this disease.   This, however,  there can be little  doubt  is
an  erroneous opinion.   Mr. Henry Smith has examined ninety-eight specimens
of stricture  contained in the different London museums;  of  these he found
only twenty-one seated in the membranous portion of the urethra, whilst seventy-
seven were anterior to the triangular ligament; the majority of these being either
Fig. 256.                    Fig. 257.                     Fig. 258.
in  the bulbous portion of the urethra, or  a little in advance of this.   Not
unfrequently strictures are met with at the mouth of the  urethra, and occasion-
ally they are multiple, two very frequently occurring and sometimes as many as
four or five.  When there are several strictures one will always be found at the
bulb or in the membranous portion of the urethra. 
812
DISEASES  OF  THE  URETHRA.
   The characters of organic stricture vary greatly; in some cases it is  annular,
encircling the whole of the canal, and occasionally for some little distance.   These
elongated  annular strictures  usually arise from   consolidation  of  the corpus
spongiosum by plastic matter, compressing the urethra, as in  Fig. 257.   In other
cases again, annular strictures  may be narrow  and sharp-edged, and are then
called pack-thread or bridal strictures; consisting of bands  stretching across the
urethra (Fig. 256).  Sometimes there are several of these in close proximity
to one another, leaving merely narrow passages between  or under them.   These
bands  occasionally stretch directly across the canal, but  at other times and more
commonly they take a  somewhat oblique direction (Fig. 258).   It is not very
clear how these bridles or frena stretching across  the urethra are formed.   It
can scarcely be by the  effusion of plastic matter; it  is more probable that they
are occasioned by a valvular projection of the mucous membrane, which has been
perforated, perhaps, by the point of the catheter, and thus apertures produced in it.
These various kinds of organic stricture are hard and  elastic, sometimes when
old almost cartilaginous in their density, feeling gristly and  rough to the instru-
ment that passes over them.
   The amount of  constriction varies greatly in organic stricture, from  merely
slight narrowing of the channel to almost complete obstruction of it.  A ques-
tion has arisen whether  the canal of the urethra is  ever  rendered completely
impermeable by a  stricture.  In  answering this, it is  necessary  to  be agreed
upon the meaning of the term " impermeable."   If by it is  meant impenetrable
to the passage of a catheter, there  can  be no  doubt  that  such  strictures may
occasionally though very rarely occur, the channel being so narrow, oblique,  or
tortuous, that the instrument canno^ be passed through it.   Strictures, however,
of this description, may usually be ultimately made permeable  to instruments by
proper and careful treatment, at least I have never seen a  case in which this
could not be brought about.  If by impermeable  is meant generally impervious
to the passage of urine, there  can be, no doubt  that such a condition does not
exist.  It  would clearly be incompatible with  life, unless  a  fistulous opening
existed behind the stricture, through which the urine might pass out;  and, even
with such  an aperture existing, I have never heard of,  or seen a case in which
no urine whatever escaped by the  meatus; and it is clear  that  so  long as any
passes out in this way, a stricture cannot he looked upon as truly impermeable.
I cannot, therefore, but agree with Mr. Syme in doubting the  existence  of such
strictures.
   When an organic stricture is once formed, it will continue unless removed by
surgical means, and as it usually becomes  more  closely contracted, it will offer
an increasing obstacle to the free flow of the urine, and thus eventually tend  to
give rise to important structural changes in the  urinary apparatus.
   The urethra behind  it becomes increased in diameter, sometimes dilated into a
true pouch, in which sabulous masses, and even small calculous concretions occa-
sionally collect.  The bladder, subjected to increased pressure by the necessity of
overcoming the obstacle to the passage  of the urine,  becomes thickened and
fasciculated,  the ureters are often found dilated, from a  tendency to a reflux  of
the urine, or to compression of their vesical orifices, in consequence of the altered
structure of the bladder.   The kidneys become irritated, congested and at last
the seat  of some of those  various  structural changes that, by impairing their
functions, and interfering with the  proper depuration of the blood, may eventually
destroy the patient.
   Symptoms of  Organic Stricture.—It is surprising how  much constitutional
irritation is set up in some systems by a stricture, even though it be not very
tight.  The interference with the  free flow of the urine  causes irritation of the
bladder and kidneys, the secretion from which becomes less abundant than usual;
in consequence of this, the actions of the skin, and other depurative organs, are
deranged, and thus the system at large is influenced and suffers. 
            DIAGNOSIS  AND TREATMENT  OF  STRICTURE.        813

   The local signs of stricture are always well marked, and are very unequivocal.
 The disease usually commences with the retention of a few drops of urine after
 evacuation  of the  contents  of the bladder.   The patient  finds that he has to
 make water more frequently than  usual,  particularly at  night; there is  some
 straining, perhaps a slight gleety discharge, and a feeling of weakness about the
 genital organs.  The stream of urine has changes impressed upon  it during its
 passage through the stricture, by which its  shape and  direction are modified.
 Thus, it may become forked, scattered, twisted, fan-like, or be  discharged in a
 double current—one projecting directly forwards, the other dropping perpendicu-
 larly downwards.   As the disease advances, these symptoms necessarily become
 more marked, until they may terminate in complete retention.   In some cases of
 stricture, the  first circumstance that directs the attention of the patient to his
 complaint is the sudden occurrence of retention of urine.
   The existence  of stricture can, however,  only be determined with certainty
 by the introduction of an instrument down the urethra.   In exploring the canal
 in a suspected  case, two points have to be ascertained—the existence^ a stric-
 ture, and its degree of tightness.  The existence of a stricture is best determined
 by passing a plated steel sound, or a silver catheter of medium size, about No. 8,
 well oiled and warmed.  This will  readily pass so far as the constricted point'
 but then be arrested.  In this exploration, too small an instrument  must not  be
 used, lest it hitch  in the fossae of the urethra or against the verumontanum, and
 this accidental arrest be  mistaken for the obstruction produced by the stricture;
 or it might pass through the stricture,  and thus mislead  the surgeon.   The ex-
 istence of a stricture having been ascertained, the next point is to determine  its
 degree of tightness.   This is best done  by withdrawing the instrument previously
 used, and then introducing a smaller one, about the size of the stream of water
 that the patient makes.   If this fail to enter  the stricture, a  smaller  one still
 must be used, until  that  size is reached, which can be introduced with but a
 moderate degree of force.   In this way the  existence, the  seat and degree of
 tightness of the stricture, are ascertained.   The tact of an experienced surgeon
 will also lead him to judge to a certain extent  of the length, degree of indura-
 tion, &c, of the constriction.
   The employment of soft wax bougies has been recommended with the view of
 taking a mould of the size, shape, and direction of the stricture,  by pressing the
 end of the instrument into it.  The advantage of all this is, however, very ques-
 tionable.   I think that a surgeon accustomed to the use of metallic instruments
 can obtain all this information with more certainty by the finer touch afforded by
 them.
   The treatment of strictures  of the  urethra may be conducted by mechanical
 dilatation,  by the  application of caustics, and by the division of the contrac-
 tion.  AVhatever plan of treatment  be  adopted, the surgeon must bear in mind
 that his operations  have to be conducted upon a tender canal endowed with ex-
 quisite sensibility,  that sympathizes  closely with the  conditions  of the general
 system, and in which  improper violence  or  too active measures may set up a
 degree of irritation that readily extends  to  neighboring structures,  and thus
 jeopardizes  the  life of the patient.  But though it is necessary to recollect all
 this, he must not run into the opposite and equally dangerous extreme of adopt-
 ing inefficient measures  for the removal of the obstruction.   A bad stricture is
 one of the  most serious  diseases that the  human frame is liable to, and will
 almost inevitably, if left to itself, terminate  fatally by the  induction  of renal
 disease;  and we must not  therefore hesitate to adopt sufficiently energetic mea-
 sures for its removal; and if these are properly conducted, there is scarcely any
 affection in  which the surgeon can afford his patient greater relief than in this.
At the same time,  however, that local means are being used, constitutional treat-
ment should not  be neglected.  Organic stricture is often more or less associated 
814
DISEASES  OF  THE  URETHRA.
with spasmodic or congestive stricture,  and requires the same constitutional
treatment, modified according to circumstances, that are necessary in these affec-
tions—proper regulation of  diet, avoidance of all articles  of  food that generate
lithates, care not to allow the urine to become too concentrated, and attention
to the maintenance of the healthy  action of the liver and skin will tend much to
increase the patient's comfort, and to ward off the more serious consequences of
stricture.
  Mechanical dilatation is the usual and certainly the most successful mode of
treating ordinary strictures.   It has been objected to, on the ground that merely
stretching the stricture does not cure it;  but this is erroneous.   The means em-
ployed to produce dilatation in all  probability tend in many cases to promote the
absorption of plastic matters, effused in and underneath the mucous membrane,
and thus to  occasion a permanent  cure.
  The instruments that are  used for dilatation are either metallic, such as silver
catheters, steel  sounds, plated  or  pewter bougies;  or made of some soft and
yielding  material, as  guin-ekstic catheters, catgut,  wax, or  elastic bougies.
Though most surgeons will  prefer one kind of instrument to another, it is  well
not to  be too exclusive in the use of any one;  for it will be found in particular
strictures and certain  constitutions advantageous to  depart  from the ordinary
practice, and that the surgeon may modify with  great  benefit to his patient the
mechanical  means that he adopts.  As a general rule, I think that metallic in-
struments are decidedly preferable, more especially when  the stricture is tight,
cartilaginous, and of old  standing; nothing will pass such a stricture as this so
readily as a well-made steel  sound or silver catheter.
  The shape and curve of catheters and sounds is of much importance; the best
curve for these instruments, I think, consists of  the one-fourth  of the circumfe-
rence of a circle 4$ inches in diameter.   If sounds be used, they should be made
slightly conical, so that the thickest part corresponds to the bend of the instru-
ment, and  be well rounded at the point.   Sounds are particularly useful when
the stricture will admit a  moderate-sized  instrument.   The sound should have a
broad metallic handle, which transmits any sensation communicated to the point
more accurately than a wooden one.  If a catheter be used, and this instrument
is most applicable in small strictures, in which, if the difficulty of  introduction
be great, it  may advantageously be left, it should be  made very solid and stiff.
The rings should be large, so as to serve for a handle,  and the eyes well rounded
off  and somewhat depressed, so that they may not  scrape  the  urethra.   These
instruments should be  used  with every possible care and gentleness;  but though
no one more strongly recognises than I do the necessity of not employing unneces-
sary violence in their introduction, yet it  is useless to think of getting through a
tight hard  stricture  without the  employment  of  some degree of force.   The
catheter or sound will  not " find  its own way" here as it  may in a  healthy ure-
thra ; but it must be guided and directed by the hand of the surgeon, and there
is scarcely an operation in  surgery that requires more tact and delicacy of manipu-
lation than  that of passing an instrument through a tight, or, as it is termed, an
impermeable stricture.  Here  some degree of force must be used, but the skill
is shown in proportioning this to the amount of  resistance, and in using it  in a
proper direction.  The appearance of force is indeed  often greater than  the
reality; for though the point of the catheter have got through a tight stricture,
it may still  require considerable  pressure to push the rest  of the instrument
through it.
  Catheters and metallic sounds are best introduced by laying the patient flat
upon his back, with the  pelvis somewhat  raised, and the head and shoulders
low.   The surgeon, standing on his left side, inserts the instrument well warmed
and oiled into the urethra, with its concavity turned towards  the left groin, and
passes it down  the canal,  at the same time  drawing the penis upwards with his 
CATHETERS, SOUNDS,  BOUGIES.
815
left hand, so as  to put the mucous membrane  on the stretch, and lessen the
chance of its folds hitching against the instrument.  As this  approaches the
triangular ligament,  the handle is  carried to the mesial line, and at the same
time raised perpendicularly; and, as its point passes under the pubes, it should
be kept well against the upper surface  of the urethra, and made to enter the
bladder by depressing the handle towards and between the thighs.   The surest
guide to the bladder  is the upper surface of the urethra, which is more fixed than
the lower, and less liable to the existence of fistulous openings or false passages.
   If the stricture be not only very  tight, but twisted,  it may be somewhat diffi-
cult to get a metallic instrument through ; and then the plan recommended   «
by Sir B.  Brodie may be advantageously employed.  This consists in tak-   I
ing a fine  cat-gut bougie, and bending it in this shape,  about an inch from   H
the point, so as to follow the track of the stricture more  closely.   In this  1
way, strictures that are otherwise impassable may be got through with com- n
parative ease.  Under  the influence of chloroform, however, many stric- I
tures may be readily passed with metallic  instruments that  are  not  per- I
vious in any other way.   I have repeatedly succeeded by its use in passing 1
catheters through very tight  strictures  which had been  impermeable for 1
months or years without this agent.
   Gum-elastic bougies and catheters and wax bougies are not nearly so manage-
able as metallic instruments, usually bending back against tight  strictures.  In
fact, it is  only in those of a spasmodic and congestive kind, in  which  a large
instrument will readily pass, that they  are of much service.   They are usually
best introduced whilst  the patient is standing, and they generally glide most
readily into the bladder if they have been slightly curved before being passed.
When they are of wax, it is useful  to  smooth them down between the fingers
before introducing them.  In using the elastic catheter, a stylet is  usually re-
 quired ; but in some cases the instrument  appears to enter more easily without
 this.   In  others again, it may be passed with  the stylet down to the stricture,
 and then  partially withdrawing it,  the  point of the catheter will start up, and
 thus more readily slip in.
   The introduction  of an instrument  usually gives rise to a smarting, painful
 sensation  in the urethra, which is generally most  severe as its point approaches
 the neck of the bladder, and is then sometimes  attended by nausea and sudden
 faintness.  As a general  rule the  instrument  should  be passed every second or
 third day, and when  introduced it  should  be  left in for  about five minutes or
 until the spasm about the urethra induced by its introduction has subsided.  If,
 however,  the stricture is extremely tight, a very small  catheter only having been
 got in, the instrument may be left  for twenty-four or forty-eight hours, when it
 will be found that however tightly  grasped it originally had been, it has become
 loosened; a slight discharge being at the  same time  set up from  the urethra.
 It may then be readily withdrawn, and when the irritation has subsided at the
 end of a couple of days, a considerably larger one introduced.
   The augmentation of the size of the instrument  should be very gradual.  It
 is fully sufficient to increase it  by one number at each time  of introduction.
 Many urethrae even will not bear this, and it becomes necessary to pass the same
 instrument on two or three successive  occasions before  a larger size can be in-
 troduced   The size  of the instrument may be gradually increased until that is
 reached which  the  urethral  orifice readily admits; beyond  this,  the surgeon
 should not go; but so soon as the full  size, usually  No. 12 or 14, can be intro-
 duced with ease, it should not be passed so frequently as before ; once a week or
 ten days,  and gradually with less frequency.  But  for some length  of time to
 come it will be necessary to introduce it at least once a month or six  weeks, lest
 contraction take place again.                     .......       ,
   If the size of the instrument be increased too rapidly, irritation may be set up,
and inflammation of the testicles, and  abscess in the  perineum  or  prostate in- 
816
DISEASES  OF  THE  URETHRA.
 duced.  I have more than once had occasion to regret being in too much  haste
 to  increase the size of the instrument, and by augmenting it by two  or  three
 numbers at  one sitting, have seen the patient thrown  back for weeks by the
 supervention of some of the affections just mentioned.
   AVhen the stricture is situated solely at  the urethral orifice the best instru-
 ments for dilatation are nail-headed styles of graduated sizes.   These strictures
 are, however, very troublesome and have a great tendency to relapse.
   Besides the ordinary plan of dilatation which has just been described, Messrs.
 AVakley and Holt have invented instruments for the rapid  and forcible expan-
 sion of the stricture;  of the value  of this method  I can give  no opinion  from
 personal experience, but the inventors of it speak highly of its results.
   By dilatation, properly  carried out, most strictures  may  be considerably re-
 lieved in the course of a few weeks; and the  majority cured by continuing the
 treatment for a sufficient length of time.  Some, however, cannot be dilated in
 this way;  it would appear that the tissue of which they are composed is so con-
 tractile that although they may be expanded up  to a certain size—say up to
 number five or six—it is impossible to get beyond  this.   In other cases again
 there is a great tendency to relapse, and for  the constriction  to return; the stric-
 ture rapidly becoming tighter so soon as the introduction of instruments is dis-
 continued:  in these cases other measures that will be described must  be had
 recourse to.
   The introduction of instruments occasionally gives rise to  certain troublesome
 sequences.  Amongst these, syncope and rigors, hemorrhage, inflammatory irri-
 tation about the urethra or testes are the most common.  In  certain constitu-
 tions, usually of a  nervous and irritable character, there is a great tendency to
 the  occurrence of shivering  and faintness after the passage  of an instrument,
 more particularly as it approaches the neck of the bladder.  These effects usually
 go off after the withdrawal of the catheter, but in some cases they may continue
 for many hours, or even come on after the lapse of some time;  the rigors under
 these  circumstances being very distinct and intermitting, so  much so as to re-
 semble an ague fit.  In  such  cases as these a full dose of Dover's powder or of
 laudanum in some warm brandy and water  will usually  give  the  patient most
 relief.   This accident is seldom attended with any  danger, though in one case I
 have known death follow the introduction of a catheter apparently from syncope
 and nervous causes.
  Hemorrhage, which is sometimes rather profuse, may follow the introduction
 of a catheter, especially if the stricture is congestive and the instrument employed
 small.   It  generally ceases of itself, but if it be troublesome the application of
 cold will check it.
  The inflammation about  the urethra and in the testes that occasionally occurs
 during the treatment of stricture is best guarded against by not using too large
 catheters, and by directing the patient to abstain from much exercise during the
 time of their introduction.
  False passages  are occasioned by the  instrument passing  out of the  urethra
through its coats into the surrounding tissues.   They are especially apt to occur
in tight bridle-strictures, when a small instrument is being used, and more espe-
cially if the direction of the constriction is somewhat oblique, so that the point
of the sound is thrown against the  side of the canal.   The extent and situation
of a false passage necessarily vary according to the position of the stricture;  and
the danger is usually in proportion to its depth.   The false passage usually takes
a direction downwards and  to one  side of the urethra.   If the stricture be far
forwards, it may run into the corpus spongiosum, but if in the usual situation, it
may perforate the lateral lobe of the prostate, or run between this and the rectum,
being unable to extend upwards on account of the rigid nature of the structures
in this situation.   AVhen the false passage merely perforates the corpus spongio-
sum, running parallel to  the urethra, and opening again into the canal, or when 
         ACCIDENTS  OF CATHETERISM—FALSE PASSAGE.      817

perforating a portion of the prostate it enters the bladder, it  is not necessarily
attended  with much danger; but when it enters the cellular tissue between the
bladder and the rectum, breaking up this structure to a great extent, admitting
urine  into the recto-vesical space, and about the neck of the bladder, then the
most serious consequences, such as inflammation and abscess in this neighborhood,
are apt to ensue, which may not unlikely be followed by the death of the patient.
   At  the moment that a false passage is made,  during the introduction of an in-
strument, by the surgeon using too much force or pressing in the wrong direction,
he feels the point make a sudden slip, which the direction of the shaft indicates
to be to one side of the urethra.   The patient complains of severe pain, and is
often conscious of a laceration; there is  a grating or rough sensation communi-
cated  by the tissues amongst which the instrument has  passed, and though it has
entered deeply, it will be found not  to have  reached  the bladder.  On the sur-
geon  introducing his finger into the rectum, he probably feels the point of the
instrument in the cellular tissue between the gut and the bladder.   On withdraw-
ing it, it will be found covered with blood, and there will  be free hemorrhage
from the  urethra.
   The surgeon knows when he has entered  an old false passage by the change
that takes  place  in the  direction  of the instrument,  by its  not reaching the
bladder, and by the rough sensation communicated to it, very different from that
afforded by the smooth lining of the urethra.   The patient is often conscious  of
the existence and of the entry of the instrument into the false passage,  and will
warn the  surgeon of it.   If the surgeon is aware that he has made a false passage,
he, if possible, should at the time of the accident pass a larger catheter into the
bladder, and  leave it there for a few days until the laceration has healed.   If
there  be an old false passage, he must be careful by keeping the point of the in-
strument away from it, not to enter it, lest during the introduction of the cathe-
ter he raises with the point of the instrument the valvular angle that intervenes
between  it and the urethra; and every time that this  is opened  up it tends  to
lessen the chance of a closure of the aperture, whilst overlapping the urethra it
interferes with the onward  passage of the instrument into the bladder.   By with-
drawing the instrument, and changing its direction the false passage  may often
be avoided, and the bladder reached.  Should there have been much difficulty  in
getting it in, the better plan will be to retain it for two or three days, when the
canal  may possibly close.
   It has  already been stated that in certain forms of stricture dilatation  does not
succeed in effecting a  permanent cure.   In these cases two plans of treatment
have been  recommended,  the  destruction of the stricture by caustic, and  its,
division by the knife.
   The treatment of stricture by caustics, originally introduced by Mr. Whateley,.
has of late years been  especially advocated  by Mr. AVade.  By it two objects
are endeavored to be attained; the first,  is the destruction of the  stricture; the
second, the diminution of the  sensibility of the surrounding mucous membrane;
so that the irritability and  spasm of the canal may be  lessened.   The following
is the way in which the caustic is  applied.  A wax bougie, well oiled, is passed
down  to,  but not through the  stricture; the surgeon then with the thumb-nail,
makes a  notch on that  portion of the instrument opposite to the  meatus.  An-
other bougie of similar length and  size is then taken,  and  armed by a piece  of
potassa fusa, about the  size of a small pin's head, being placed in a depression  at
its end.   A mark is now made on it, at a point corresponding to the notch on the
first bougie, it is  then passed rapidly down until this mark comes opposite to the
meatus, and then pressed firmly for two or three minutes against the stricture,
upon which the caustic exercises its action.   This application, which is followed
by a gleety discharge, may  be repeated every second or  third day,  until a proper
sized bougie can be introduced; and then the  dilatation may be proceeded with 
818
DISEASES  OF  THE  URETHRA.
in the usual way.   Mr. Wade speaks highly of the utility of this mode of treat-
ment, not only in destroying the stricture, but also in lessening the irritability of
such as are spasmodic and very painful, and liable to bleed on the introduction
of instruments.   I have used this  method in a few cases, and  in two or three
certainly with marked benefit.   It  appears to offer most advantage in those
instances  in which there is a very narrow pack-thread or bridle-stricture, with
much congestion or irritability of the surrounding mucous membrane.  In very
elongated annular strictures, it is probable that less beneficial results would follow,
than in those indicated.
   The division of the  stricture may be practised either from within  the urethra
or from without, through the perineum.  The division from within may be per-
formed  in two ways, 1st. By passing a concealed steel stylet  down to the stric-
ture, and  then pushing forwards  the lancet-like  knife, attempting to perforate
the obstruction.  This plan, originally  introduced by Air.  Stafford, is only appli-
cable with safety to those strictures that are situated in the anterior part of the
urethra, where the canal is  straight.   In the deeper and more curved parts, any
attempt at perforation would  be fraught with danger;  for as it would of course
be impossible for the  surgeon to guide the stylet exactly in the direction of the
urethra, it would be  as likely to perforate the  walls  of this canal  as to pass
through the  stricture.  In hard and resisting  contractions, however, in  the
straight portion of the canal anterior to the scrotum, this instrument may occa-
sionally be used with  advantage.  The most convenient form of cutting stylet,
is I think the one figured here, which has  a probe  end, that is introduced through
the stricture, and serves as  a  guide  to the blade, which is projected and caused
to retract into its cylinder by the action of a spring (Fig. 260).
   Another mode of dividing strictures  from within the urethra, is to pass a
catheter containing a stylet through the stricture, and then projecting the stylet
            as the instrument is withdrawn, notching the obstruction. . As the
  Fig. 260.    stricture, however, must be of considerable size to admit of such an
            instrument as this, it is usually sufficiently amenable to other modes
            of treatment, and will therefore render such a procedure unnecessary.
               [An instrument has lately been devised by Dr. Pancoast of this
            city, by means of which, even strictures situated  at the curved por-
            tions of the urethra, can  be  divided with  comparative impunity.
            This  apparatus consists of a  curved canula, enclosing  a cutting
            stylet, grooved upon the back, which  can be protruded when desired,
            and by which  the incision of the stricture is effected.
               In order to use this instrument, the surgeon endeavors to carry a
            long, fine, catgut string through the stricture into the bladder; should
             he succeed in  so doing, he passes the external projecting end of the
             string along the groove of the stylet, and thus, of course, through
             the  canula.   The canula with its  enclosed stylet must now  be
             passed down the urethra until the opposing point is reached; the
             blade is then  protruded along the guiding string, and the stricture
             thus divided.
               Should, however, all  the  attempts of the  surgeon to pass the
             primary bougie prove abortive, the  stricture  may still be overcome
   |j         on the same  principle, although by a somewhat different process.
             The  string should be placed in the  groove of the stylet, and both
             blade and bougie being retracted within the canula the instrument
             is carried down to the stricture.  By a careful and continued mani-
             pulation, the catgut string can always be made to enter the stricture
             for a short distance; the blade is then protruded on the guide, and
             thus a portion of the length of the  stricture divided; the canula is
             then carried on and the manoeuvre repeated.
               In this manner the surgeon may.cut his way, as it were, through
 
      DIVISION  OF  THE  STRICTURE--PERINEAL SECTION.    819

strictures  impermeable  by  the  ordinary processes.   The instrument  having
reached the bladder successfully, the  contents of the  canula  should be with-
drawn, and the sheath itself left as a catheter.
  This procedure has never as yet failed of success in those instances in which
it has been  employed by Dr. Pancoast, who considers it  applicable to most of
those  cases  in which Air. Syme  advises the performance of the perineal  sec-
tion—Ed.]
  The division of the stricture from without by incision through the perineum,
may be  performed by two distinct operations :  the one being only applicable to
those  strictures that are pervious to an instrument; the other to those which are
impermeable.   In the first  case, a grooved staff  is passed through the stricture
and the section made upon  this.   In the  second case the surgeon attempts to
cut into and  through the stricture, without any guidance except such as his
anatomical knowledge may afford him.
  The first of these operations introduced by Air.  Syme as urethrotomy, and
commonly called  the " perineal  section'' is a  comparatively simple procedure.
It is performed in the following way.   A staff,  grooved along its convexity, and
varying in size from a No. 2 to No. 6 catheter, is passed  through the  stricture.
The patient is then placed in the  position  for  lithotomy, and an incision about
an inch and a quarter in length is made  immediately above the  rectum, directly
in the line of  the raphe.  The dissection must be carried very carefully in  this
direction, until the staff is reached, when the point of the knife should, if possi-
ble, be entered into its groove behind the stricture, and carried forwards through
this.  If this cannot be done, owing to its depth, the  stricture must be divided
by entering  the knife anterior to it, and pushing  it downwards along the groove.
The staff is then to be withdrawn, a No. 6 or  8  catheter to be  introduced  and
left in for forty-eight hours.  It must then be taken out, and at  the end of eight
or ten days the urethra dilated  by the introduction of bougies  in the ordinary
way.   The wound in the perineum usually allows the escape of  a small quantity
of urine for a few days, when it generally heals by granuktion without any diffi-
culty.   In some cases it may even unite by the first  intention, without a drop of
urine  escaping, although the urethra is fairly laid open.   This happened in the
last case on  which I operated.  The performance of  the operation  itself requires
time and is rather a niggling procedure.   The surgeon should cut very cautiously,
or rather scrape through  the tissues with  the  point of his knife,  keeping most
carefully in the middle  line; where, as Air. Syme has observed, a kind  of septum
exists even in the deeper structures of the perineum, and where there  can be no
danger  whatever of dividing  any artery of magnitude, which might happen  if
any lateral deviation of the knife took place.   The only vessel indeed which  is
at all  endangered is the artery of the bulb, and  this may always be avoided by
carefully keeping in the raphe, as it lies towards the side of the incision.
  It has been observed that in some cases  a peculiar train of nervous symptoms
sets in about the  time that  the urine first  passes through the urethra after the
operation.
  It is  not  necessary to cut very deeply into the perineum in  performing  ure-
throtomy, as in the  majority of cases  the  stricture, as has already been stated,
will be  found  anterior to the deep fascia and probably in the bulb.  I  must con-
fess that unless there were reasons to believe that the stricture was situated ante-
rior to the triangular ligament, I should  hesitate  in performing urethrotomy, for
although all necessary incisions  might be  made  anterior to this structure with
perfect  safety, as  they would only involve the perineum, yet I cannot think that
the deep fascia can be  laid open with impunity, or at least without  imminent
risk of  deep pelvic infiltration and inflammation.
  I look upon this operation of urethrotomy as a very decided advance  in the
treatment of certain forms of stricture.   It is easy of performance and  successful 
820
DISEASES  OF  THE  URETHRA.
 in its immediate results.   In Air. Syme's hands scarcely any accidents  have oc-
 curred out of seventy-seven cases in which, up to the present  time, he states he
 has performed it.   As my experience is very limited in comparison to his, as up
 to the present time (May, 1853), I have only had occasion to do it five times, I
 can  speak with less  confidence; but so far as my observation goes, I have  met
 with  no difficulty or danger  in  the  division of the stricture.  Although fatal
 cases have occasionally been recorded, yet this is nothing more than we must
 expect  to happen from time to time in any operation  that is  performed on  the
 urinary organs whilst diseased, more particularly if there be a granular condition
 of the kidneys, a state of things in which I have  known the simple introduction
 of the catheter followed  by death  in six or seven  hours.  If  I understand  Mr.
 Syme right,  it is with the view of  preventing the ulterior inevitably fatal conse-
 quences of all intractable  strictures that he has  proposed this very simple  and
 effectual plan of relieving the obstruction, by dividing it from without,  in those
 cases in which ordinary methods notoriously fail, and in which there is no alter-
 native but to perform urethrotomy, or to leave the patient to his fate.   In order
 that this operation  should be successful  we must  not wait for the occurrence of
 those changes that are the result of the chronic obstruction, such as  disease of
 the bladder and kidneys,  and which must  inevitably increase the danger of  any
 operation; but we must divide the stricture with  a view of preventing them.
  The most important question in connexion with  this operation, is  in what
 class of cases it should be  practised.   That most strictures  may be cured by
 dilatation,  there can  be no doubt, and  it is somewhat  difficult for surgeons to
 agree as to the amount of benefit to be derived by persevering in dilating stric-
 tures into which an instrument can be passed;  many holding with Liston, that
 whenever a catheter can be  got through a stricture, its cure by dilatation is in
 the surgeon's hands.   Though this may be generally true, instances not  unfre-
 quently occur in which dilatation fails to effect a cure; the stricture, as I have
 already remarked, being highly contractile, and not admitting of expansion  be-
 yond a certain point, relapsing whenever the dilating  means  are removed.  In
 other cases also  the  patient  suffers  so much pain and irritation whenever an
 instrument is passed, that he cannot bear its repeated introduction, more  particu-
 larly if the stricture  be complicated with  fistulae in perineo or false passages,
 which  render its cure by  dilatation tedious and almost impracticable.   In such
 cases as these it appears  to me that the surgeon, being unable  to benefit  his
 patient  materially by dilatation, must  choose between the employment of ure-
throtomy and palliative means.
  Indeed, it appears to me, that there are four classes of cases  in which urethro-
tomy may be advantageously employed.
  1st.  In  very old  dense cartilaginous strictures, often  of traumatic   origin,
which admit an instrument with great difficulty, and cannot be dilated  beyond
a certain point, owing to the conversion of  the urethral structures into a kind of
 dense fibrous, almost cicatricial tissue, that neither admits of  expansion nor of
absorption by the pressure of instruments ;  and in which a considerable extent,
half an inch or more, of the urethra is involved.
  2d. The same kind of stricture complicated with fistula, in the perineum or
scrotum, with perhaps considerable plastic infiltration of these  parts.
  3d. Very tight strictures accompanied by excessive  sensibility of the urethra;
in which each introduction of the  instrument is  attended by intense suffering,
 spasmodic movements of the  limbs and rigors, so  that the  patient  cannot be
 induced to submit to a proper course of bougies.
  4th. Very  elastic,  though perhaps narrow strictures,  that can  be   dilated
readily enough, even  up to the admission of full-sized  instruments;  but which
when the treatment is discontinued immediately begin to contract again, so that
the patient is never out of the surgeon's hands and sees no prospect of cure. 
             THE  PERINEAL  SECTION  IN STRICTURES.          821

  The liability to relapse after urethrotomy has not as yet been fully determined.
It is doubtless possible that in some of those cases in which a stricture is formed
by a large mass of contractile and hardened tissue, that this may again coalesce
after division, and thus lead to a recurrence  of  the  constriction; but  this even
does not necessarily follow.  If the wound unite by the  second intention, the
progress of granulation may cause the deliquescence and removal of the effused
mass that constitutes the  stricture; and under any circumstances no other plan
of treatment with which  we are  acquainted has any permanent influence  upon
such a stricture as this.   In many of the cases that Mr. Syme has operated on,
and which  have been under his observation  for years, and in  two or three  of
mine,  which I have had  an opportunity of observing for  the  last year or two,
the urethra is quite patent, and no tendency to recurrence of the contraction has
occurred.
  In order to perform urethrotomy  it is, however,  necessary that  the stricture
should be pervious to a grooved staff, however small  this may be ; and this it may
be supposed would limit  materially the cases in which the operation can be per-
formed.   Impermeable strictures, though frequently spoken of, are, however, I
believe, very rarely met with.   Mr.  Syme, indeed,  denies their existence, and
states  with much truth that if urine  can escape through a stricture,  a bougie can
be got in.   I must admit that I have never seen a  truly impermeable stricture,
either during life or after  death.   I  know  that a  surgeon may occasionally be
foiled in his first attempts in getting an instrument through a very tight stricture;
but I  believe that with patience, by  attention to constitutional treatment,  so  as
to lessen urethral irritation, and especially by the administration of chloroform,
the surgeon may always at last succeed in getting an instrument of some  kind
through the stricture.  In the first case in which I performed the perineal section,
almost all the urine had for twelve years been discharged through fistulous  open-
ings in the perineum and scrotum; and the principal portion  escaped through a
large hole on the inside of the left thigh, a few drops merely occasionally passing
out by the  lips of the urethra.   No  instrument  had  been passed for four years,
though repeated attempts had been made by different surgeons.   Being foiled in
getting a catheter into the bladder the first time I  tried,  I kept the  patient  in
the Hospital for two or  three weeks, attending carefully  to  his constitutional
condition, but without making any  further effort.   He was  then placed under
chloroform, when I succeeded in  passing No. 1.   The urethra  was  then dilated
up to  No.  5, beyond which no instrument could  be got to pass, when the perineal
section was performed.   The patient made an excellent cure, the fistulous  open-
ings closing, and the urine being discharged by the natural channel.  In another
case which I lately attended with Mr.  Bryant,  persevering attempts  had  been
made  for five years to get an instrument into the bladder, but without success,
the stricture  not only being  excessively tight, but the  urethra acutely  sensi-
tive ;  under chloroform I succeeded in getting  No. _  silver catheter into the
bladder, and speedily cured the  patient.  In a case of extravasation of  urine
following stricture, consequent on injury of the perineum, sent to me by Air.
Corrie of Finchley, in which no catheter had been introduced for eight years, it
was found after  death that although the urethra had been converted into a mass
of cicatricial tissue at the part injured,  yet that it  was permeated by a narrow
tortuous passage, through which the urine had escaped.
  The influence of  anaesthetics in facilitating the passage of instruments through
apparently  impermeable strictures is very marked. Shortly after the introduction
of ether as an anaesthetic agent,  Mr. Liston was going to cut through a stricture
that had resisted all attempts  made  by his most dexterous hand at  getting an
instrument into the bladder; but no sooner was the  patient put on the table and
fairly  narcotised than the No. 8  silver  catheter,  which had been passed down  as
far as the stricture, and the point of which was to serve as a guide to  the knife,
slipped into the  bladder,  and thus rendered a dangerous operation unnecessary. 
822
DISEASES  OF  THE  URETHRA.
  In the event, however, of a case of stricture occurring in which no instrument
can be "-ot through the obstruction,  neither the cure by dilatation nor  urethro-
tomy can be performed, and it may  then be necessary  to  have recourse to inci-
sion of the stricture without a guide.  This is done by passing a large  catheter
down as far as it will go, tying up the patient as if for  lithotomy, and then, cut-
ting down upon the end of the instrument, endeavoring  to carry the knife on
through the stricture into the urethra beyond it, and after this has been opened,
passing the catheter  into the bladder.   This operation I have  no hesitation in
saying is perhaps  the  most troublesome in surgery.   When the  tissues of the
perineum are hard and gristly, altered by the effusion of plastic matter, and con-
densed by repeated  attacks of inflammation  and  the existence of fistulas,  it is
a most difficult matter to  dissect through such  an altered  mass and  hit the
urethra beyond it; and the difficulty is  still further obscured by the bleeding,
which is  often profuse.   I have more than once seen the  most skilful operators
foiled in  their endeavors to do  this,  and compelled to  relinquish  the operation
without concluding it, or only succeed after prolonged and most painful attempts.
Fortunately this operation is  now  scarcely ever necessary; with  patience and
under chloroform the surgeon  may almost  invariably get a staff, however small,
into the bladder;  he then  has a sure guide upon which to cut, and by following
which he must certainly be led through the stricture into the urethra  beyond it.
In all cases, therefore, urethrotomy should, if practicable, be substituted for the
division of the stricture without a guide.

                      COMPLICATIONS  OF  STRICTURE.
  1st.  Retention of Urine has  a tendency to occur in all  tight strictures by the
gradual and progressive contraction of  the  canal.   It most usually, however,
takes place in consequence of a congestive or spasmodic condition being superad-
ded to the organic constriction.   It  commonly happens that a  patient having a
moderately tight organic stricture commits an excess, or becomes exposed to cold
and wet, and thus gets such a congestive condition superadded  that the  urine
will not pass at all, or only in such  small  quantity by  drops,  and with so much
pain and straining,  that  the  bladder cannot be completely emptied.  In  these
cases the retention  always eventually becomes  complete;  the bladder speedily
fills, rises up above the pubes with much distress and constitutional disturbance;
and if relief be not afforded  the  distended  portion of the urethra behind the
stricture  will  ultimately give  way,  and  extravasation  of  urine  ensue.  Under
these circumstances  it becomes imperatively necessary to empty the patient's
bladder as speedily as possible.
  The treatment  to be  adopted varies with the  severity of the  symptoms and
irritability of  the  patient.   If the retention have not continued very long, and
if the patient be not very irritable, an endeavor may be made at once to  give re-
lief by passing a small catheter into the bladder.   In this the  surgeon  may often
succeed  more  readily than might have been expected, the stricture frequently
yielding  before an instrument, more easily when there is retention than  when
this condition does not exist.   Even if the catheter do  not enter the bladder, its
point or that of a catgut bougie merely being got well  into the stricture, it will
generally happen,  as  Sir B. Brodie  has  pointed  out, that on the withdrawal of
the instrument the urine will  follow in  a full stream.   If the  patient  be very
irritable  it  is better, before  attempting the introduction  of  the instrument, to
give him an opiate suppository, consisting of a drachm  of laudanum in about two
ounces of starch,  and put him into a warm hip-bath; the introduction of the
catheter  may now  be attempted, and will very generally succeed.   Should it still
fail, the  effect of  the inhalation of  chloroform should  be tried,  when it almost
invariably may be  got to pass without the employment of any  great or dangerous
degree of force.   After the instrument  has  been got into the bladder it should 
             RETENTION  OF  URINE  FROM  STRICTURE.          823

be left there, being tied in by means of tapes passing from its  rings under the
patient's thighs to a bandage that  is passed round his waist.   Antiphlogistic
remedies must then be employed in rather an active manner, a free purge, leeches
to the perineum if there be tenderness in this region, and salines with antimony.
The catheter will  be found to be loosened at the end of forty-eight hours, when
it should be withdrawn, and the cure by dilatation proceeded with in the usual
way.
   If, however,  the surgeon is unable to introduce a catheter in the  ordinary way
through the stricture, relief must be given to the over-distended bladder, in
some other way, lest it or the urethra burst, and extravasation  of  urine  occur.
The  bladder may be  emptied in  three ways, either by forcible catheterism, by
making an opening into the urethra  behind the stricture, or by puncturing the
viscus itself through the rectum.
   Forcible catheterism is, I  think,  a most objectionable procedure.   Nothing
can surely be more unsurgical than to take a  small, stiff, silver  catheter,  pass it
down to the stricture, and then, by main force, attempt to  drive it on into the
bladder.   In these cases the surgeon usually fails in his attempt at reaching the
viscus, pushing the point of the instrument into the tissues around the neck of
the bladder or the prostate, and thus inducing great, and perhaps even fatal,  mis-
chief in these regions.  AVhen he does, by some fortunate accident, get into the
bladder, it is not by any skilful, though forcible, expansion  of the  stricture, but
rather by perforating the urethra, and burrowing through  the corpus spongiosum
and prostate, until he again enter that canal, or in  some such way reach the neck
of the bladder.
   In the kind of retention of urine that we are now discussing, the safest modq,
I think, of affording relief after the failure of the catheter, is to make an incision
into the middle line of the perineum, and to open the urethra behind or through
the stricture.   In doing this  there is often much less difficulty in cases of reten-
tion than when the bladder is empty, in consequence of the urethra being dis-
tended by the accumulation of urine and by the  straining of the patient so as
sometimes  to attain a considerable magnitude; though, if this  be not the case,
the operation may prove a very serious and difficult one.   The  operation  is per-
formed by  passing a catheter down to the stricture, cutting upon the end of this,
and then passing  the instrument on into the bladder, or allowing  the  urine to
flow from  the aperture thus made in the perineum.  In doing this, care must be
taken to keep strictly in the direction of the mesial line, so as not to wound ves-
sels of importance.   One  advantage of this operation is, that the stricture  may
by it be cured at  the  same time that the  retention  is relieved;  and as the  inci-
sions do not extend into the bladder, but are limited to the urethra, there is less
danger to  the patient than when that viscus is opened.
   Another advantage of the perineal incision in these cases  is, that it not unfre-
quently happens that  urinary abscess has begun to form, or the extravasation of
a few drops of  urine has taken place sooner than the surgeon may have had any
idea of; and if so, the incision through the perineum will afford an exit for any
extravasated matters, at  the same time that it relieves the patient  from the dis-
tress  and  danger  of  the  retention.  Should  any  mischief of  this  kind have
taken place, it  is not  necessary to be so particular about opening the urethra
with the knife, for an aperture having already been established in it, the urine
will readily flow through  the artificial channel thus formed  by free incision into
the perineum.
   The relief of retention from stricture may also be obtained by puncturing the
bladder through the rectum.   This  plan has been especially advocated  of late
years by Air. Cock, who has seen occasion  to perform it in about forty instances,
and who speaks favorably of  its results.  The puncture through the rectum is  a
sufficiently simple operation.   After emptying the bowel by means of an enema, 
824
DISEASES  OF  THE  URETHRA.
the surgeon passes the left index finger well into the  gut, feeling for the poste-
rior margin of the prostate;  he then carries the trochar and canula, which are
long and somewhat curved, upon this as a guide, and when the extremity of the
instrument has reached the posterior edge of the prostate, pushes it upwards into
the bladder (Fig. 254  b).  In introducing  the  instrument into the rectum, the
surgeon should withdraw the point of the stylet into the canula so as to avoid
wounding the gut, and not push it forwards until he has the end of the canula
fixed against the spot  where he intends to make the perforation.   After with-
drawing the stylet and emptying  the  bladder, the canula should be tied in by
means of tapes,  and left for a few days until means can  be taken to restore the
passage through the stricture, when it must be withdrawn and the aperture left
to close.  In performing this operation the surgeon perforates the bladder in that
portion of its fundus which is uncovered by peritoneum, being bounded behind
by the reflexion of the serous membrane, anteriorly by the prostate, and on either
side by the vesiculae seminales.   In order to avoid wounding any of these struc-
tures, he should keep strictly in the mesial  line, and puncture immediately be-
hind the prostate.
  This operation has the advantage of being far easier of performance  than  the
last, and may doubtless be advantageously had recourse to in  some of those cases
of retention from stricture in which there is no sign of  abscess or extravasation
in the  perineum, in which  the urethra appears not to be  dilated behind  the
stricture, and in which the prostate is not enlarged.
  2dly. Extravasation of Urine.—In consequence of the  ulceration  or disor-
ganization  of the coats of the urethra, this canal may give way behind the stric-
ture and,the urine become infiltrated into the surrounding tissues.  The part of
the urethra that gives way is invariably the membranous portion of the canal,
just anterior to, or between the  layers of  the triangular  ligament, where  it is
weak, being least supported by surrounding structures, and usually most dilated
and attenuated by the  pressure to which it  has been subjected.   Were it possi-
ble for the urethra to  give way altogether behind  the deep  perineal fascia, the
urine would become effused into the cavity of the pelvis.  But as it is, the con-
nexion  of the triangular ligament with the rami of the  pubes and ischium pre-
vents the extension of the infiltrated urine  in that direction, and the manner in
which the  superficial  fascia of the perineum is connected with  the deep fascia
uniformly causes the fluid to take a course forwards into the  perineum, scrotum,
and upwards upon  the external  organs of generation,  the  groins, and the ante-
rior abdominal wall; ascending  contrary to  its gravity rather than soaking back
into the more dependent parts of the body, as it would  do,  were it not for the
particular connexion of the fasciae that has just been alluded to.
   The effects of the urine that has become acrid and concentrated by long re-
tention are most deleterious upon those tissues with which it comes in contact.
The vitality of whatever  portion of cellular tissue  it  infiltrates  is immediately
destroyed  by it, the  tissue becoming converted into a kind of putrid stringy
slough, intermixed with  and  soddened by a quantity of  fetid, dark-colored, acrid
pus and urine.  The ravages of extravasation of urine are often extensive;  the
urethra giving way suddenly behind the stricture, the  fluid is  driven with all
the  force of the vital  and physical contractility of the over-distended bladder
into the perineum, and thence rapidly finds its way through the scrotum  upwards.
In other cases again, the extravasation occurs more slowly;  a few drops  appear
first of all  to escape from the urethra through a small rent or ulcer in it; these
give rise to inflammation in  the surrounding structures, by  which the progress
■of the extravasation is for a time limited.  It is especially upon  the cellular
tissue of the scrotum that the effects of the  extravasation manifest themselves in
their full intensity, causing great distension  and rapid sloughing of it.   The skin
speedily participates in this action, becoming of a dusky red  or purple color, and 
PUNCTURE  THROUGH THE RECTUM.             825
then falling into a state of gangrene.  In this way the testes may become denuded,
and the cords exposed.   It is remarkable, however, if the patient survive these
destructive effects, with what rapidity the reparative action goes on in this region.
It is seldom that infiltration extends higher than the groins, or the anterior por-
tion  of the abdominal wall; but  it may run up as high as the costal cartilages
before proving fatal.
   AVhen the extravasation is deep, the urethra being opened between the layers
of the triangular ligament, the patient  experiences a  sensation as if something
had given way in the perineum, with much throbbing and pain ; there may be
but  little swelling for a day or two,  but then a doughy diffused intumescence
takes place,  with  rapid  extension  forwards.  When the  rupture is altogether
anterior to the deep perineal fascia, then rapid swelling and infiltration take place,
partly urinous, partly inflammatory, of the scrotum  and penis ; these parts become
enormously distended, cedematous, crackling, and emphysematous, with the local
signs that  have  already been mentioned.   The  constitutional  disturbance is
always considerable;  at first of  an  irritative type, but  speedily  followed by
asthenic  and typhoid symptoms, by which the patient is at last carried off.
   The treatment consists in making a free and ready outlet for the urine as early
as possible.   This should be done as  soon as the extravasation is known  to have
occurred, by  a deep incision into the  middle of the perineum.  So soon as any
pain  and throbbing, with diffused swelling, occur in the perineum, the surgeon
should introduce his left index finger into the rectum, so that the gut may not be
wounded, and then pushing a long sharp-bladed bistoury deeply in the raphe of
the perineum, cut upward to a sufficient extent into the extravasation, and in the
direction of the urethra.   In  this way an outlet will be afforded to matters
already effused, and the urine will commonly be found to escape after a time by
the aperture thus made.   Should  the case not be seen until extravasation has
occurred, a free  incision  should not  only be made into the perineum, but also
into  the scrotum on either side of the septum, into the penis, and wherever else
the swelling is observed.  The sole chance of safety for the patient lies in making
these free  incisions,  through which  the parts may to a  certain extent  empty
themselves.   However extensive the infiltration and serious  the mischief may
be, we need not despair of the patient  if a free outlet can be obtained for the
acrid and putrescent urine  and  effused matters, and in order to secure this, the
infiltration must be followed by incisions  as high as it extends.  The parts must,
at the same time, be covered with chlorinated and yeast poultices, and the con-
stitutional powers of the patient must be supported by good nourishment and a
sufficient supply of stimulants.
   If the patient survive the immediate impression upon the system produced by
the gangrene and the urinary infiltration, he must  be prepared to go through a
severe trial  to  his  constitutional powers, in the separation of the sloughs, the
profuse discharge, and other sources  of  irritation that are  set up.  During  this
period he will require abundant support; the brandy-and-egg mixture, ammonia
and bark, with any nourishment that  he  can  take; and much attention  should
be paid to the removal of the slough,  the giving a  ready outlet to the discharges,
and  to keeping the patient as  clean and as free from all  local irritation as pos-
sible.
   3d. Urinary Abscess.—Alay be considered in many cases as a limited effusion
of urine  mixed with pus, and circumscribed by plastic  matter that is deposited
in the tissues with which the urine comes in contact.   It is generally occasioned
by the irritation of the passage  of  instruments,  but  may arise simply as the
effect of stricture or from inflammation of some of the urethral follicles.   From
some cause of this kind a small abrasion  or aperture forms in the urethra, a drop
or two of urine escapes into  the subcutaneous  cellular  tissue, this becomes
bounded  or circumscribed by plastic deposit around it, so that extravasation does 
826
DISEASES  OF  THE  URETHRA.
not occur.   Such an abscess as this may form at any part  of the urethra, but it
is most frequently met with in the perineum, appearing to take its origin from
the bulb or membranous part: such an abscess is rarely dangerous, but is chiefly
of consequence by being commonly followed by urinary fistula.
  A urinary abscess is indicated by the formation of a small, somewhat circum-
scribed, hard, and painful  tumor, situated in the neighborhood of the  urethra.
It is usually unattended by much constitutional disturbance, unless it  attain any
considerable bulk, when some pyrexia may ensue.   It is principally in the peri-
neum  that it attains any degree of magnitude, then  constituting a  perineal
abscess, characterized by a deeply seated,  hard, tense tumor, brawny and without
fluctuation ; attended by considerable weight and throbbing in this region. It
does not readily point, owing to the manner in which it  is bound down by the
superficial fascia.
  In the treatment of these abscesses early incision is required; when occurring
in the  scrotum or  anterior to it, the  surgeon should wait for fluctuation; but
when they are seated in the perineum, he need not do so, making a free incision
into the hard, brawny mass, which  must then be well poulticed.
  [In  the treatment of the perineal, and especially of the penile urinary abscesses
above  described, a new procedure has  been adopted recently by Dr.  Pancoast.
He directs an early external incision  into, or, better still,  upon the side of the
abscess.  The tissues must then be freely separated  until  the pedicle, springing
from the urethra be reached.  By means of a curved needle a ligature is passed
around this pedicle, and  knotted;  and by the time this  shall have cut its way
through as in the case of a ligated artery, the fistulous orifice of the urethra will
be found to have been closed by the effusion of plasma, accompanying the sepa-
ration  of the  thread.—Ed.]
  4th.  Urinary fistulae  commonly form  in  the perineum and scrotum as the
result of abscess in these regions communicating with the  urethra; occasionally,
however, they are  met with  in other  situations, as in the groin, the anterior
abdominal wall, or the inside of  the thigh.  They usually communicate with the
bulb, or membranous portion of  the urethra, but occasionally occur anterior to
this.   In number they vary considerably; when occurring in the scrotal and
penile  portions of the urethra, they are usually single ; but when in the perineal,
they are  often pretty numerous; several  apertures being  occasionally met with
about the perineum, scrotum and  nates.   In one case Civiale found as many as
fifty-two.   Their size also differs  considerably, some only admitting  the finest
probe,  whilst others are large  cloacae.   In a case recently under  my care the
patient had a tunnel of this kind in the groin that would readily admit three
fingers.  They are usually tortuous,  elongated, and narrow, sometimes constricted
externally and more widely dilated behind.  The surrounding parts are greatly
condensed, the whole of the scrotum and penis enormously enlarged, indurated,
and almost cartilaginous in structure.  The urine  may escape almost  entirely
through  them, scarcely  any being discharged  through the  urethral  orifice; or
there may be but a slight exudation from the fistulous opening.
  The treatment of urinary fistula varies according as it is complicated with
stricture, and according as it is situated in the anterior or  posterior parts of the
canal.
  If there be  stricture we must look on this as the cause of the fistula, requir-
ing removal either by dilatation  or the perineal section.   If the stricture is not
very tight and hard, dilatation commonly succeeds;  the instrument being intro-
duced  every second or third day, until the urethra is dilated to its normal size,
when the fistulous tracks will in many cases close.  In some instances, however,
the frequent introduction and withdrawal of the catheter is a source of irritation,
and then it had better be left in.   When this practice is adopted a moderate
sized elastic catheter should be used.  If this be too small, the urine will flow 
URINARY  ABSCESS  AND  FISTULA.              827
between it and the sides of the urethra, and thus escape through the fistula?;  if
too large, it dilates the urethral orifice of the fistula injuriously.
   If the stricture be very tough and irritable, the better plan is to perform ure-
throtomy at once, as in this way we remove all obstruction  and give free exit to
the urine, which instead of escaping by tortuous and  sinuous passages, finds its
way out readily through the new aperture that has been made.
   The fistulae, especially if small and recent, will sometimes heal kindly enough
after the removal of the obliteration, but if extensive, old, and cartilaginous, they
are of course little disposed to  take on reparative action; and  although  the cause
that in  the first instance gave  rise to them may be removed,  yet they constitute
an independent affection which requires special treatment for its cure.
   The  special treatment for urinary fistula, must vary according to the size of
the  canal, but more particularly  with regard  to the  part of the urethra with
which it communicates ; whether it is a perineal, scrotal, or penile fistula.
   If the fistula is perineal,  and of small size, a probe coated with melted nitrate
of silver, or a wire made red-hot in the  ordinary way, or by the galvanic current,
and passed down  it occasionally, may cause its contraction.  If large, a gum-
catheter should be kept in the bladder, and the edges of the fistula freely rubbed
with the nitrate of silver, or deeply pared and brought together by sutures.
   When the fistula is scrotal it often requires to be laid open, and to be made to
granulate from the bottom, when it may be found to communicate with large
sloughy and ill-conditioned  cavities in this situation.
   When penile, the fistula is usually much more  troublesome to  heal, its edges
are thin, and the track is short and shallow.  In  these cases  the best plan is to
introduce a gum-catheter, and then paring the edges of the aperture to bring
them together by means of the twisted suture, or to close in  the opening by
bringing a plug of tissue  from the  neighboring  parts and fixing it around the
margins of the orifice.

                       URINARY VAGINAL FISTULA.
   Preternatural communications between the urinary passages  and the vagina
commonly arise from injurious pressure upon and consequent sloughing of the
anterior wall of this canal,  to a greater  or less extent during parturition.   They
may, however, occur from idiopathic  abscess, or from malignant disease involving
these parts.
   Urinary vaginal fistulae  are essentially of two kinds, according  as  the com-
munication is established between  the urethra or the fundus of  the  bladder and
the vagina.   Hence they may  be divided into urethral and vesical.
   The urethro-vaginal fistulae are, so far as my observation goes, of most com-
mon occurrence, and this is  readily explained by the fact that the urethra passes
along the anterior aspect of the vagina for some distance before it terminates in
the bladder, and occupies that  portion of the vaginal wall that is  most likely to
be compressed during labor, under  the arch of the pubes.  These fistulae  are
usually  of small size and linear.   The vesico-vaginal fistulae establish a com-
munication between the neck or fundus of the  bladder and the vagina.   They
are consequently situated further back than the other, and are usually larger and
more ragged.
   The existence of a urinary fistula in the vagina, is always a source of serious
discomfort and distress  to the patient.   The dribbling of urine through the pre-
ternatural aperture is generally continuous, although if this be situated far back
behind the orifices of the ureters it might be somewhat intermittent, a flow taking
place as the lower portion of the bladder fills.  The incontinence of urine thus
produced, gives rise to irritation and  excoriation about the external parts, and
occasions a strong ammoniacal  odor to hang about the patient.
   The precise seat and extent  of the fistulous opening, are  best ascertained by
examination with a bivalve  speculum, or with a conical one, having a slit made 
828
DISEASES OF  THE  URETHRA.
at its upper part, at the same time that the introduction of a bent probe, or of a
female catheter into the urethra, will guide the surgeon to the artificial  opening
in the  urinary passage.
   Treatment.—The cure of one of  these vaginal fistulae can only be effected by
causing a coalescence of its sides.  When small and urethral, this may sometimes
be effected by touching the walls of the aperture with the  electric  cautery or a
red-hot wire, introduced between the blades of an open speculum, and repeating
this application once a fortnight or three weeks, until a cure is effected.
  When the fistula is larger, and especially when  vesical, its cure can  only be
accomplished by paring the edges, and bringing them together with  sutures, and
thus attempting to procure union by the first intention.   In effecting this how-
ever two difficulties present themselves :—The sutures either  cutting their way
out too soon, or the trickling of urine between the freshly pared edges, interfering
with adhesion.   In order to  overcome  these  difficulties, a variety of ingenious
contrivances  have been introduced  by different surgeons.   The  most useful of
these are in my opinion Air. Brookes' bead sutures, and  the " clamp suture" of
Dr. Marion Sims.
  The treatment recently recommended by Dr.  Marion  Sims,*  leaves little to
be desired in the management  of these cases ; Dr. Sims uses a suture of fine
silver wire, well annealed,  which after  being introduced across the  lips of the
wound, is properly fixed to silver or leaden cross  bars, these  sutures are intro-
duced  by passing a  silk thread by means of a nevus or corkscrew needle, about
half an inch from the freshened edge of the fistula, and  bringing it out through
a corresponding point on the other side of the fissure, without  having transfixed
the mucous membrane of the bladder.  As many threads  as  necessary having
been passed in  this  way, a  piece of silver wire about eighteen  inches long  is
attached to the silk, which is then drawn out, leaving the wire to occupy its place,
so that its centre corresponds to the fissure, and both ends hang out of the vagina.
The uppermost free ends are then passed through holes made in a narrow silver
or leaden bar, and clamped by having split shot fixed upon them in the same way
as is done on a fishing line.  The undamped  wires are  now drawn  down until
the bar is pulled close to the upper  suture holes, and a second clamp is then fixed
to these ends after it  has  been  pushed against the  lower suture apertures.  In
this way the  edges of the fistula are brought and held together  by  a  clamp on
either  side, which may be allowed to remain in  for from seven to ten days.   They
may then be  removed by clipping off the flattened shots  from the anterior clamp,
which  is thus detached from  its bed.   The posterior one, with the wires attached,
may then be hooked up, pushed backwards, and lifted out of the vagina with forceps.
  In the after-treatment, especial attention is required ;  and here the great point
is to prevent the contact of the urine with  the  edges of  the fistula.   With this
view a catheter should be  introduced, and worn in the bladder, so that no urine
may collect in this organ.   For this purpose, Dr.  Sims has  invented a  very in-
genious catheter, represented in the annexed  cut  (Fig. 261),  which  may be
                                                 worn with more comfort, and
                     Fig, 261.                      with less chance of slipping
                                                 than  the ordinaryinstrument.
                                                 After the patient  has been
                                                 put to bed, and the catheter
                                                 introduced,   a   full   opiate
                                                 should  be  given, and  con-
                                                 tinued throughout the treat-
                                                 ment, with the view of pre-
                                                 venting the  action  of the
                                                 bowels,  a point on which Dr.
Sims lays much stress, and to which the  success of his  operations may be in a
        * American Journal of Medical Science, Jan. 1852.  Ranking's Retrospect, vol. 15.
 
           TREATMENT  OF  VESICO-VAOINAL FISTULA.        829

great measure attributed.  It is very seldom that they are required to be opened
for ten or fifteen days, provided the patient be kept on a rigid diet.   During this
treatment the catheter may be removed once or twice a day, in order to be cleansed
and to be kept free from phosphatic or mucous accumulations, and free ablutions
of the external genitals by sponge or syringe and warm water should be practised
during the  whole of the treatment.   After the removal of the sutures, Dr. Sims
advises that the catheter should be continued, and great  care  exercised  not  to
move  about too soon, lest the weak cicatrix be  strained.

                       TUMORS OF THE  URETHRA.
  Small polypoid tumors  are  not unfrequently met  with  inside  the  urethral
orifice.  These growths have been carefully studied by Air. Norman.   They have
occasionally a gonorrhoeal origin, though they commonly arise irrespective of such
disease.  They are always very vascular, and are most frequently met with in  or
around the female urethra, where they are of a bright red color, have a florid hue,
bleed freely when touched, and are composed of a spongy kind of erectile tissue ;
they are commonly conoidal or oval, encircling the urethral orifice  on one side,
or even forming a complete zone  around it.   They grow  slowly,  and seldom
attain a larger size than that of a raspberry.   They are not  unfrequently accom-
panied by a vast deal of sympathetic irritation, great pain in  micturition, attended
by  an admixture of mucus or pus  in the urine, uneasiness in the lower part
of the abdomen, and often aching in the loins.
   These vascular tumors  are far  less frequent in the male  than in the  female
urethra.   When  they occur in men they usually constitute a small granular florid
 mass  inside the orifice of the canal.
   When seated in the female  urethra, these tumors  not unfrequently give rise
 to very great and continuous irritation.  Aluch pain during and  after  making
 water ; and in fact many of the symptoms of stone.  So that patients laboring
 under this  affection are often sounded on the supposition of  their being calculous.
   The treatment consists in removing the tumor by excision or ligature; caustics
 being inadmissible  in these  cases.   There is no  difficulty in  snipping them  off
 from  the male urethra by means  of a sharp-pointed  pair of scissors.  If within
 the female urethra, it may be necessary to  dilate  this  canal before they can be
 removed.   AVhen situated outside and around its orifice,  they must be  dissected
 off, the canal being  encroached upon as little as  possible.  The hemorrhage is
 often abundant;  but may be  stopped by the application  of cold, or by the pres-
 sure of a sponge  tent or a pad of lint supported by a T bandage.   In some cases
 they  may very safely and  effectually be removed by the application of nitric acid
 or  the electric cautery.
                         CHAPTER  LVII.

                      STONE IN THE BLADDER.

  The urine is liable to the deposit of various  solid matters, which when amor-
phous and impalpable are termed  sediments.  AVhen crystalline they constitute
gravel and when concrete form calcidus or stone.   These deposits whatever form
they assume are always the result  of  constitutional causes;  and these constitu-
tional conditions giving rise to them are commonly called diatheses.   Of these,
surgeons  usually recognise three.   The lithic, the oxalic, and the phosphatic ; 
830
STONE  IN  THE  BLADDER.
besides these, however, others doubtless  exist, the precise characters  of which
have yet to be determined.                                      \  -u'i.  t> i. i
  The lithic  acid diathesis chiefly occurs in individuals of robust habit ot body
and florid-lookimr, who have lived high and suffer from irritable gastric dyspepsia.
It is often associated with a gouty or rheumatic tendency, or with  some^ of the
more chronic forms of skin  disease,  especially psoriasis.   It is  characterized by
scanty and acid high-colored urine,  which deposits on cooling two kinds of sedi-
ment, a yellow and' a  red.  According to  Lehmann, these  sediments consist of
urate'of  soda;  but Golding Bird, and, I  believe,  most of the  chemists  in  this
country,  regard  them as urates  or  lithates of ammonia.  The yellow sediment,
containing an admixture of the coloring matter of the urine, is usually dependent
on slight "disorder of the digestive organs and skin, coming and going under the
influence of very trivial causes.   The  red sediment owing its color, according to
Bird, to  an admixture of purpurine,  a  highly carbonaceous ingredient,  and in-
dicative  of imperfect assimilation, is met with in persons of full habit, who  live
too freely.   A variety or rather an admixture of these sediments constitutes the
lateritious deposit so common in gout  and rheumatism.   The red sand or gravel
is a crystallized variety of  the  lithic  acid sediment.   It may be compared, in
general appearance, to cayenne  pepper, and under the  microscope  presents the
characters seen in Fig. 263.   It is not unfrequently met with in children  of a
strumous habit, who are allowed more animal food than they can well assimilate.
Occasionally  crystals  of lithic  acid are found intermixed with these deposits,
presenting the characters figured in 262.
  The calculi that occur in this diathesis are of two kinds :  the lithic  acid, and
the lithate of ammonia.   The lithic acid calculus is usually of small  or moderate
size, varying  from a pin's head to a pigeon's egg;  it is oval, somewhat compressed
and flattened, smooth  on the surface, and of a fawn color.  On section it is seen
to be laminated and to present various  shades of a light brown  or fawn tint.
The lithate of  ammonia calculus is  of very rare occurrence; when  met with  it is
chiefly in children, and is composed  of  concentric rings, having  a fine  earthy
appearance and being  clay-colored.
   The treatment of  the lithic acid diathesis must be directed to the removal of
the prime causes of this condition,  viz.: mal-assimiktion, defective  oxygenation
of the blood, and the ingestion  of too large a quantity of stimulating food.  All
this may be remedied by attention to  ordinary hygienic measures; the patient
Lilhic Acid.                          Lithate of Ammonia.
must live sparely, should avoid fermented liquors, especially red and effervescent
wines, and abstain from sweets, pastry, &c.   He should take plenty of out-door
exercise, and keep the skin  in  healthy action by warm or vapor bathing, and 
LITHIC  ACID  DIATHESIS.
831
the use of horse-hair gloves.   The bowels  must also be carefully regulated by
means of saline and other aperients with occasional alterative doses of Plummer's
or blue pill;  to which, if the constitution be peculiarly rheumatic or gouty, some
colchicum may advantageously be added.   A very good aperient for general use
in these cases, is 5J of Rochelle salt in 3iss  of the compound decoction of aloes,
taken at night or early in the morning;   or a dessert-spoonful of the following
powder every morning ;  R Pulv. Bhei, ^ss., Potass, tartrat. ^j., Magnesiae ustae,
Jij., Pulv. Zingiberis, 3j.; f. pulvis.   The patient may also be directed to drink
some of the natural alkaline waters, as those of Vichy or Fachingen.  The Vichy
waters, containing as they do a large quantity of carbonate of  soda, with free
carbonic acid, are extremely  serviceable  in this diathesis.   If they cannot be
procured, a very good alkaline drink consists of a scruple of bicarbonate of potassa
and 5 grains of nitre dissolved  in a tumbler of  cold  or  tepid  water, to which
about 5 grains  of citric acid, or a table-spoonful  of lemon-juice  may be  added,
and taken early in the morning or in the middle of the day.
   When lithic acid calculus has actually formed, it is well not to give the alka-
line remedies too long or in too large  quantity, lest, as Brodie has pointed out,
the stone rapidly increase in size by becoming encrusted with phosphates.
   The  oxalic diathesis  is characterized by the  formation of oxalate of lime in
 the urine.   It generally occurs in individuals in whom there is defective assimi-
 lation, dependent upon exhausted nervous energy, arising from overwork, mental
 anxiety, or  venereal  excesses.   The patient is  usually  pale, hypochondriacal,
 suffers  from dyspepsia, acidity of stomach,  and disturbed sleep.   In these cases
 there is often loss of sexual power; a state  of debility of the generative organs,
 connected either with want of erectile vigor, or too speedy emissions.   The urine
 is usually very pale,  abundant,  and  acid, and there is heat and smarting during
 its passage along the urethra.  In  this  diathesis there is no sediment or gravel
 properly speaking, but the crystals float in the urine, subsiding however when
 it stands, but not occurring in sufficient quantity to constitute  a true sediment
 (Fig. 264).
Fig. 264.                                  Fig. 265.
 
832
STONE  IN  THE  BLADDER.
is, owing to its roughness, and the irritable state of the patient's nervous system,
usually a good deal of pain  experienced in the region of the bladder, requiring
the free administration of opiates.
  The phosphatic diathesis chiefly occurs in old  persons, or  in  those who are
prematurely aged, with a broken constitution and an  anemic condition of the
system.  In this  diathesis the sediment  and  calculi may occur in three  distinct
forms.
  1st.
  2d.
  3d.
  The
       Triple or ammonia co-ma gnesian phosphate.
       The Phosphate of Lime, and
       The mixed phosphates, consisting of a mixture of the preceding varieties.
       triple  phosphates (Fig. 265) usually occur in urine that is copious, pale
and barely acid, sickly to the smell, and  soon  decomposing  and becoming very
offensive.   In other cases it is dark, alkaline, and mucous.  This condition espe-
cially occurs in old  people, is associated with much debility, irritability of mind,
pallor, and anemia.
  The phosphate of lime sediment is not of such common occurrence; it usually
occurs in pale, and offensive, readily putrescent urine, mixed with much mucus,
and in some cases apparently produced by the mucous membrane of the bladder.
  The mixed phosphates commonly occur after injuries of the spine as the result
of general impairment of the health, or in advanced cases of prostatic disease.
They are occasionally met with  in  large quantity forming a kind of mortar-like
sediment in the bladder,
  The phosphatic calculi are very common, the most frequent is the  mixed, or
fusible calculus as it is  termed, on account of the ready way in which it melts
when exposed to heat.   This calculus is friable, laminated, and  has a chalky, or
earthy look.   The calculus composed of phosphate of ammonia and magnesia is
not so common, it resembles the preceding pretty closely in its general characters,
but  is whiter and  has a more  chalky look; the phosphate  of  lime  calculus is
extremely rare—it is laminated and harder than the other varieties.
  The treatment of the phosphatic  diathesis consists principally in improving the
digestive powers, and restoring the general strength of the patient by the admi-
nistration of good food,  wine, or beer.  The  exhibition of tonics, especially of
nitric acid, should  be attended to and exercise in the open air enjoined.  As
there is usually much  pain and irritability of system in this  diathesis, opium
may advantageously be administered.
  Besides  the calculi mentioned, various other kinds of concretions form in the
                               urine; each  of which doubtless represents a
                               diathesis; the characters of which, however, are
                               not so  distinctly marked, or so well recognised
                               as those that have just been described.
                                  Cystine is  one of the rarer  forms of morbid
                               product  occasionally met with  in  the bladder.
                               It differs from all other ingredients, in contain-
                               ing a  large quantity—about 26  per cent.—of
                               sulphur.   It is very rarely seen as a  sediment
                               in the  urine, but when it occurs in this form it
                               presents  the microscopic characters seen in Fig.
                               266,  being  composed  of  hexagonal laminae.
                               Calculi containing  cystine have  occasionally
                               been met with.  Dr. Golding Bird states in his
                               work, that in  Guy's Hospital  Museum,  there
                               are eleven composed of this  peculiar animal
                               matter;  and  in the Museum of University Col-
lege we have some good  specimens.  Cystine in calculus has a peculiar yellowish
or greenish and waxy look, very different from any other ingredient met with in
urinary concretions.
Cystine. 
            STRUCTURE OF CALCULI—RENAL CALCULI.         833

  Xanthine, uric, or xanthic oxide, was first  noticed by Dr.  Marcet, and has
since been observed  by Laugier,  Langenbeck, and others.   It is of extremely
rare occurrence, and  has only been found in  a few recorded instances in the
form of calculous concretions.  These have generally been of small size, with
the exception of the  one removed by Langenbeck, which weighed 388 grains.
For the chemical characters and  constituents of this substance I must refer to
Dr. Bird's work.
  Carbonate of lime has occasionally been met with as an amorphous powder in
alkaline or very faintly acid urine.   I  am not aware of any calculus of this com-
position having ever been found, but Dr. Bird  states that he has detected carbonate
of lime as forming a distinct stratum in some phosphatic  calculi.
   Structure of Calcidi.—Calculi, though sometimes composed throughout of the
same deposit, are not unfrequently made up of layers  or strata,  differing in
chemical  composition from one another, and then usually go  by the name of
alternating calculi.  Most frequently the nucleus consists of lithic acid or lithates;
next in order of frequency conies  the oxalate of lime; and then the phosphatic
nucleus.   It is very seldom that the nucleus is absent; but concretions have occa-
sionally been met with in which none  could be detected, or in which it was even
replaced by a cavity.  The nucleus is usually  as nearly as possible in the centre of
the calculus, and  is generally pretty regular in shape ; occasionally, however, it is
branched  or curiously radiated, and then the concretion  generally affects a cor-
responding outline.   Calculi containing two or three nuclei have sometimes been
found, consisting probably of an  equal number  of concretions agglomerated
together.
  The body of a  calculus having  the  uric acid nucleus  is usually  composed of
some of the lithates;  but  not  unfrequently these are incrusted by a deposit of
phosphates.  In  other  instances again the  body  may be wholly composed of
some of the earthy phosphates, which  more  rarely alternate with the oxalate of
lime or the triple phosphates.
  An oxalate of lime nucleus usually  has a  body of  the  same constitution;  but
in some cases it  is incrusted by phosphates or urates.   When the nucleus is
phosphatic,  the concretion is always of the same constitution.
  Vesical calculi  may be formed either in the kidneys or the bladder; those that
contain a nucleus of the urates or oxalates are probably renal  in their origin;
whilst those that have a phosphatic nucleus are usually vesical from the first;
renal nuclei being rarely met with of this composition.
  Renal Calculi.—AVhen  a stone forms in the pelvis of the kidney, it usually
gives rise  to a good deal of pain and irritation in the lumbar  region.  When of
small size  it may descend into the bladder  with but little suffering to  the  pa-
tient ; but, if large enough to irritate the ureter and to pass with some difficulty,
it then gives rise  to a  peculiar train of symptoms  that will immediately be de-
scribed.   In some  cases the calculus  attains a very large  size, occupying the
whole of the pelvis of the kidney extending into the calices and ureter, and being
moulded, as it were, to the shape of the parts amongst  which it lies;  it then
gives rise,  by its pressure, to absorption of the substance  of the kidney,  and oc-
casions, by  the magnitude  that it attains, excessive  pain and irritation in this
region, the patient usually eventually dying, worn out by  constant suffering, and
the  irritation of incurable kidney disease.  In some instances stone in this situa-
tion has been known to give rise to abscess  in and around the kidney, and has
even been  discharged through an aperture in the lumbar region.
  In those cases in which a renal calculus descends into the bladder, the patient
is seized with pain in the loin that has been the seat of previous irritation.  This
pain is usually of the most agonizing character, extending  into the cord and testis
and  down the thigh of the affected side.  There is retraction of the testicle, with
constipation and "vomiting; frequently accompanied  by the passage of scanty, 
834
STONE  IN  THE  BLADDER.
high-colored, and bloody urine, and great constitutional disturbance.  This pain
usually continues of a  somewhat remittent  character,  until the calculus enters
the bladder, when it gives rise to a peculiar train of symptoms, depending on its
presence in that organ.
  During the descent of a renal calculus, which always occupies many hours,
and perhaps some days, the patient should have full doses of opium administered,
be put into a warm hip-bath, and have mustard poultices  applied to the loin, or
be cupped in this situation, if necessary; the bowels should also be thoroughly
emptied by enemata.   It is well to bear in mind  that  a somewhat similar train
of symptoms to that induced by the descent of the calculus may be excited by
some forms of irritation of the coecum or  colon, which will require appropriate
treatment.
   Vesical Calculi.—Though vesical calculi  occasionally owe their origin to the
descent of a stone from the kidney, yet it not unfrequently happens that there
is no evidence of their coming from such a source, but every appearance of their
being deposited  in the bladder;  a nucleus being originally formed in this viscus
by the aggregation  of some sabulous matters, around  and upon which fresh de-
posits take place, until  a true calculus is formed.  In some instances vesical
calculi have been found deposited upon, and incrusting foreign bodies accidentally
introduced into  the bladder, such as a piece of straw, a pin,  a bit of bougie, &c.
  The number of calculi in the bladder varies considerably; most commonly
only one is encountered; but in about one-fifth or one-sixth of the cases operated
upon, several will be found: from two to six or eight  are by no means  uncom-
monly met with.  Occasionally several dozens have been detected, and there are
even instances on record in which some hundreds of distinct and separate calculi
have been  found in one bladder.  The most remarkable case of this kind with
which-1 am acquainted is one  in which  Dr. Physick  removed from a judge in
the United States upwards of a thousand calculi varying in size from a partridge-
shot to a bean, and each marked with a black spot.  Occasionally several calculi
             become matted  together into  one large  concretion,  as  in  the an-
   Fig. 267.    nexed representation of a calculus that I removed last year from a
             child  (Fig. 267), which is formed of  eleven  distinct  lithic acid
             calculi soldered together in this  way, besides  which three others
              were lodged in the bladder.
                AVhen there are several  calculi  in the bladder the attrition of
             one against the other  usually causes  the opposing  surfaces to be-
             come  smoothed, thus constituting facets.   In some  cases, how-
ever, although the  calculi are numerous, there are no signs of attrition.  In a
patient of mine  who had fifteen calculi in his bladder, all the stones were round,
about the size and shape of marbles, without any signs of rubbing.
   Calculi have  been occasionally known  to  undergo spontaneous rupture in the
bladder, by a kind of concussion against one another, or, as Civiale supposes, by
the contraction  of a hypertrophied bladder, by which  one stone may be  broken
into a number of fragments.  In some instances these have agglomerated together,
by the  deposit  of a quantity of phosphatic  matter upon and around them.  In
other instances the different fragments may each  form the nucleus of a fresh cal-
culus, so that the bladder may afterwards contain several concretions.
   The size of calculi varies from that of a hemp-seed or pin's head to a concretion
of immense magnitude.   One of the largest with which I am  acquainted is a
calculus removed by the high operation by  Dr. Uytterhoeven of Brussels, which
 I saw some time ago in his possession, and  of which he has been obliging enough
 to  give me a cast; it is of pyriform shape, and measures 16£ inches in its longest
 circumference,  and 12 £ inches in circumference at its broadest part, being
 6 J inches long, and about 4 wide.   In the celebrated case of Sir AV. Ogilvie, Cline
 attempted, but  failed, to extract a calculus  measuring 16  inches round  one axis
 
VARIETIES AND  CAUSES  OF  CALCULUS.           835
and 14 round the other.   It weighed 44 ounces, and must have been about the
size of Dr. Uytterhoeven's.  These enormous concretions are happily rarely met
with, the usual size of stones removed by operation being from about one to two
inches in the longest diameter, somewhat narrow, and perhaps flattened.
  The weight of calculi commonly varies from  a few grains  to several ounces ;
the commonest size is from  three drachms to about an ounce or two in weight,
occasionally from three to six;  from this they may range upwards until several
pounds  are  reached.   Thus,  in  Cline's case  the  stone weighed 44 ounces,
Deschamps saw one of 51 ounces, and  Morand  one  weighing 6 lbs.; none  of
these admitted of removal.  The largest  calculi are usually  composed of phos-
phates, in greater part if not in <whole.
  The hardness of calculi varies considerably; the oxalate of lime is the hardest.
The lithates  come  next  in  consistence, and  are often very hard, though brittle.
The phosphates are always comparatively soft and friable.  N
  The shape of calculi presents  great variety;  most commonly, however, they
have an ovoid figure.   Concretions of urate  of ammonia and uric acid are gene-
rally pretty regularly ovoidal, smooth, and disc-like.   Those composed of oxalate
of lime  are  usually somewhat  globular or square-shaped, and generally rough,
Fig- 268.                               Fig. 269.
nodulated,  or  spicukted  upon  the surface.   The phosphatic  calculi present
usually the most irregular outline;  most commonly, it is true, they are ovoid or
globular, but not unfrequently branched  as  if moulded  to  the  interior of the
kidney, constricted, or of an hour-glass shape.  The cystine calculi are  generally
tolerably oval and regular in outline.
  Alost frequently calculi lie loose in the bladder;  but occasionally they may be
fixed in this viscus, owing either to their being encysted, and then lying in one
of the sacculi that have already been described within the walls of the bladder
(Figs. 268  and 269),* or by being fixed in and embraced by one of the ureters,
and in other  cases  by being deposited upon, and partly included in, fungous
growths.
  The causes of calculi are somewhat obscure.   There  can be little doubt, it is
true, that the  different forms of concretion  are connected with  the varieties of
diathesis  that have already been described, and we  may look upon the formation
of a calculus as an indication of the existence, in a greater  degree of  intensity
than usual,  of  the same causes  that, under ordinary circumstances, give rise to
sediments or gravel; but why, in particular  cases,  the aggregation into a calcu-
lous mass takes place, it is impossible to say.   Age appears to exercise  consider-

 1 Fio. 268. Exterior of bladder, containing an encysted calculus, at a.  Fig. 269. Interior of the same
bladder, showing small orifice leading into cyst at a, ureter, b. 
836
STONE  IN THE BLADDER.
able influence upon the production of calculi; for though stone may occur  in
the bladder at all periods of life, and even, according to Stahl, be congenital, it
is certainly more frequent  amongst children a few years old, and  at advanced
periods of  life, than during middle age.   Mr. Coulson  has collected  2972 re-
corded cases of lithotomy from various  sources; of these,  1466 occurred under
the age of ten, 731 from eleven  to twenty, 205 from twenty-one to thirty, 264
from thirty-one to fifty, and 306 from fifty-one and upwards.
   It would appear that in some parts of the world calculus is a far more common
disease than in others.  It is generally more frequently met with  in  cold than in
warm climates;  indeed, in tropical countries I believe  the disease is scarcely
known.  The Negro race also is remarkably exempt from this affection.   It is a
singular fact that in some parts of the same country calculous  disorders are of
far more frequent occurrence than in others.  Thus, it is  well known that the in-
habitants of the east coast of England and Scotland are peculiarly liable to these
disorders, and that in Norfolk, stone occurs with especial frequency,  this district
furnishing, in all probability, as many cases as the half of  the rest of England.
In America, also, it would appear that the inhabitants of certain states are pecu-
liarly obnoxious to  this affection; and  I  understand that  in some districts of
Germany the disease may be said to be almost unknown, whilst in others it is of
sufficiently common occurrence.  To what these differences are owing it is impos-
sible to say.  Peculiarity of race, of consititution, and of diet, with exposure to
prevalent easterly winds, have all been assigned as reasons for them, but probably
not on  very sufficient grounds.   Sex  influences  materially the  occurrence of
stone, which is far more frequent in the male than in  the female.
   [" Children are more subject to this disease in certain districts than in others,
and the same is true in regard to adults. The greater proportion of calculous cases
in AVirtemberg, in  the mountains of Switzerland, the Neapolitan States, and in
some of the counties of England, especially Norfolk, occurs in young persons, from
causes hitherto unexplained.  In the United States, a larger number of children
are affected with this disorder, in  Kentucky, Ohio, Tennessee, and Alabama, than
in any other regions. Pennsylvania, Arirginia, Maryland, the two Carolinas, Geor-
gia, Florida, Louisiana, and Arkansas, also furnish a considerable number of cases.
The inhabitants of Missouri, Iowa, AVisconsin, Michigan, Indiana, New York,
and New Jersey are comparatively exempt; and  in the  New  England  States
generally a case of calculus of the  bladder  is so  rare as to excite the surprise
of the observer.  In Canada and the other British Provinces of North America
the disorder is also  very infrequent; at all events, none of the surgeons of these
regions have acquired much reputation  as lithotomists, and but few cases of stone
are brought from thence  into this country.  AVe  are justified, therefore, in be-
lieving  that the malady is uncommon there.  The same remarks  are applicable
to Texas, Mexico, and California, as I have assured myself by repeated inquiries
from respectable and intelligent practitioners in those territories.   The causes of
these differences have not  been ascertained; attempts have been made to trace
them to the effects of climate, and to the influence of the water, food, and habits
of the people, but without success.
   " Climate, doubtless, exercises no little influence in the  formation of urinary
concretions.   It has been already stated that, in the  United States,  this disease
is most common in  Ohio, Kentucky, Tennessee, and Alabama;  a circumstance
which,  so  far  as  is known,  does  not depend  upon any peculiarity  of  living,
and which may therefore be supposed to be owing to  some mysterious opera-
tion  of the climate.   In Holland calculous disorders  are very common,  and
the circumstance is the more remarkable, because of the great use that is made
of gin, which is  a powerful diuretic.   That this  liquor  is not the cause of this
occurrence is proved by the fact that the Dutch colonists of Batavia, in the Island
of Java, whose habits are not at all dissimilar from those of the people of the mother
country, are almost entirely exempt from this affection.  Soemmering informs us that 
SYMPTOMS  OF  CALCULUS.
837
the disease is altogether unknown in some situations bordering on the Rhine.*  Cal-
culous affections are, as was stated before, much more common in Norfolk than in
any other part of England, and yet the habits of the residents there are the same
as in  the  other counties.   In the  East Indies, stone is comparatively unusual
though not  so much so as was formerly imagined.   AVe have already seen  that
it is proverbially uncommon in New England.   It is hardly safe, however, to
indulge in any remarks concerning  a subject which is involved in so much ob-
scurity as the one under  consideration.   Much of what has  been advanced is
wholly conjectural, and, therefore, scarcely worthy of serious attention.   Patient
and multiplied observations  in different parts of the world are alone competent
to furnish us with any real and substantial light;  for these we must wait before
we are justified in coming to any positive conclusion.
   " Many respectable writers and practitioners are of opinion that the production
of  calculous diseases is promoted  by the use of hard, impure water, in conse-
quence of the changes which it is supposed to  induce in the renal secretion.
The opinion is  plausible, and may be true, but how far, or to what  extent,
nobody has attempted  to decide.   If it be true that in  Kentucky, Alabama,
Tennessee,  and  Ohio, most  calculous  cases occur  in limestone  regions, it is
equally true that many are  found  in the  freestone districts of  those  states."
(From Gross on the Urinary  Organs.)—Ed.]
   The symptoms of stone in  the bladder vary somewhat according as the calcu-
lus lies loose in the cavity of the viscus  or  is  encysted.   They also vary consi-
derably, according to the size  and shape of the stone, the condition of the bladder,
and the constitution of the patient.  Most commonly the  severity of the symp-
toms are in  proportion to  the magnitude of the calculus.   This, however, is not
always the case.    In a patient whom  I recently cut, the most intense suffering
and repeated attacks of cystitis had been occasioned by a small but sharp-pointed
calculus, not weighing more  than 3j ; and some years ago I saw a  patient in
whose bladder five  calculi were found  after  death, nearly as large as chestnuts,
though their presence had   never  been suspected during  life by the different
surgeons under whose care he had  been for stricture, so little distress had they
occasioned.   In  some cases  the symptoms of stone very suddenly declare them-
selves, and then the surgeon  finds on examination that  the patient has a largish
calculus, which must have been a long time forming without attracting attention.
Rough calculi usually give  rise to more  severe symptoms than smooth ones,
owing to  their inducing  a chronic  form of  cystitis; and, as  the constitution is
usually a good deal shattered and the nervous system very irritable in those  con-
ditions of the system in which the phosphates are deposited,  phosphatic calculi
are usually attended by more suffering and constitutional disturbance than other
forms of the disease.
  The symptoms induced  by  stone may be divided into the rational and physical.
The rational signs, consisting of pain, increased frequency in micturition, the
occasional stoppage of the urine, and  various morbid  conditions  of  that fluid.
The physical signs are those  by which alone the surgeon can positively determine
the presence of the calculus,  feeling it with the sound.
  The pain  in calculus is  usually the first symptom that attracts attention;  it is
not only experienced in the region of the bladder and the perineum, but radiates
widely in the course of the sacro-lumbar nerves.   The  patient usually complains
of a heavy and dragging sensation in the groins, extending down  the  outside or
back of the  thighs, and not  uncommonly experienced in the soles of the feet.
The penis likewise is the seat of a good deal of uneasiness, frequently of  a sharp
and cutting  pain.    This is especially noticed in  children, in whom attention is
often  attracted to the  complaint by their constantly squeezing and pulling the
a Coulson on the Bladder, p. 166. London, 1842. 
838
STONE  IN  THE  BLADDER.
 organ to relieve the distress they suffer in it.  The pain is much increased by
 any movement by which the  stone is  jolted about in the bladder, as in driving,
 riding, or jumping; and is especially severe  in  those cases in which cystitis
 occurs.  It is always most severe towards the termination of, or immediately after
 micturition,  as there is then a tendency for the calculus to roll forwards towards
 the neck of the bladder, where it comes in contact with and is grasped by the
 most sensitive part of that organ. Hence it is not unfrequent in  cases of calculus
 occurring in children  to find  that the  little patient instinctively lies upon its
 back or side  whilst making water, and thus escapes much  of the agony that it
 would otherwise suffer.  In adults  in  whom the prostate happens to  be enlarged
 the calculus usually lies in a depression  behind  this gland, and hence, being
 prevented coming in contact with the  neck of the bladder, occasions less suffering
 than in other cases.
   An occasional stoppage commonly occurs in the flow of urine before the bladder
 is emptied, owing to the stone  being impelled against its neck, and thus blocking
 up the urethra; but on the patient lying  on his back or on his side  the stream
 flows again, the situation of the  calculus being changed.
   In consequence  of the irritation set  up  in the bladder occasioning chronic
 inflammatory action  of the mucous membrane,  there is  an increased frequency of
 micturition.   The urine is passed in small quantities, and  usually contains some
 mucus or pus, and is occasionally tinged with blood.  If the kidneys are irritated,
 it is commonly albuminous.
   As a result of the straining  and general  irritation  about  the genito-urinary
 organs, prolapsus of the anus, accompanied by tenesmus, is by no means uncom-
 mon, and in  some cases there  is very troublesome priapism.
   When a stone is encysted, those symptoms that depend  upon  its  being loose
 and rolling about in the bladder, are  necessarily absent;  thus there is no stop-
 page in the water, the urine is  seldom bloody, and the pain is  not materially
 increased by jolts and rough movements, though  there  is weight  and  pain in the
 usual situations, and increased frequency  of  micturition from the pressure and
 irritation of the calculus.
   The existence of stone is finally determined by sounding the bladder.
   A sound is a solid steel instrument shaped  like a catheter, but shorter in the
 curve, so that it may explore more thoroughly  all parts of the bladder, especially
 those behind the prostate.   It should  also have rather  a wide and smooth steel
 handle.  The operation of sounding  should  be conducted  as   follows:  The
                                               patient should lie upon his
                    Fig. 270.                    back on  a  hard mattrass;  a
                                               full-sized  sound well oiled and
                                               warmed should then be passed
                                               into the bladder; which should,
                                               if the patient can retain it, be
                                               allowed to contain three or four
                                               ounces of urine.  The surgeon
                                               then  using his left hand, or
                                               crossing  over to the  patient's
                                               right side, whichever he finds
                                               most convenient, carefully di-
                                               rects the beak  of  the instru-
                                               ment towards the back of the
                                               bladder, turning it  from  right
                                               to left over  the whole of that
region (Fig.  270);  he next draws it forwards on  one side  as far as the neck,
tapping as it  were gently with its beak; he repeats the same  manoeuvre on the
 
SOUNDING FOR STONE.
839
other side, and lastly directs the end of the instrument by raising its handle into
the lower fundus, which he care-
fully explores.  Should  he  not                    Fig. 271.
detect the calculus in any of these
situations, he depresses the handle
between the thighs, and tilts up
the beak so as to examine  the
sub-pubic   portion  of  the  organ
(Fig. 271).. In the event of his
not meeting with a stone, he may
direct the patient to stand up, and
then explore the bladder, first upon
one side, then on the other. Should
the rational  signs of stone be well
marked, though  no  calculus be
struck, the surgeon must not give a decided  opinion in  the negative after  the
first exploration, but should  examine the patient again a  few days later, with the
bladder in different states as to its contents.  In making this second examination,
I have found it of great service to use a hollow steel sound, by which the  organ
                                  Fig. 272.
can be injected or emptied at pleasure (Fig. 272).   The  patient should on this
occasion have his bladder injected through such an instrument as this, with four
or six ounces of tepid water, so as to distend the organ slightly, and prevent the
folds of mucous membrane overlapping any concretion that may exist in it.  Its
interior is then carefully explored in the way already described, and if the stone
cannot then be detected, the contents of the bladder are gradually allowed to
escape through the sound, and the patient desired to stand up whilst the explora-
tion is being proceeded with.  In this way, by examining a patient in  different
positions  and in different conditions of the bladder  as to  capacity,  a calculus is
sure to be detected if one exist.    These examinations must not, however, be too
protracted; the time occupied should not exceed above five minutes, lest cystitis
be induced.   AVhen a stone is struck by the sound, there is not only a  charac-
teristic and  distinct  shock  communicated to the  instrument, but there is a
tolerably  loud  click  heard, which can be detected by the  bystanders, and fre-
quently by the  patient as well as by the surgeon.
  By conducting the sounding properly, the surgeon may usually  ascertain not
only the existence of a stone, but its size, and hardness;  whether it is single, if
it be encysted,  and the general state  of the bladder, all  of which it  is of im-
portance  that  he should  be acquainted  with before undertaking any operation.
A good deal of this information may be elicited by the ordinary sound, but some
of the points can only be  determined by sounding with the lithotrite.
  The hardness of the stone may usually be judged of by the more or less clear
ringing character of  the click;  a lithic acid or oxalate of  lime calculus giving a
sharper sound than a phosphatic concretion.
  A calculus may generally be known to be encysted if  the sound strikes it at
times, but not at  others (Fig. 273); if the stone always  appears to he fixed in
one situation * and if the beak of the instrument cannot  be made to pass round
it, so as to isolate it, but feels a  kind of tumor projecting through the walls of
the bladder around or on one side of the point where the calculus is struck.
  The fasciculated,  roughened, and  sacculated condition of the  bladder may 
840                    STONE IN THE BLADDER.

generally be detected by the way in which the beak of the instrument grates and
rubs over the organ.
   The size  of the calculus  is  best determined by a lithotrite.   It is true that
a surgeon may sometimes come to a decision as  to the bulk of a calculus by ob-
serving the extent of surface along which the sound is in contact with the stone
as the instrument is being withdrawn.   But a very rough  guess only can be
arrived  at in this way, and I have  frequently seen very experienced  surgeons
deceived  in their estimate of the size of a  calculus, mistaking perhaps several
small ones lying together for  one large one.   By introducing a lithotrite and
seizing the  calculus gently between the blades, a correct estimate of its size may
always be arrived at.
   In order  to determine that several calculi exist in the  bladder it  is sometimes
sufficient for the surgeon to feel that the beak of the sound comes in contact with
a stone on either side of the organ, or that it can be distinctly insinuated between
two concretions.   In some cases, however, these points  cannot clearly be  made
out; and  then the surgeon introducing  a lithotrite and seizing the first calculus
that he meets with should hold this between the blades of the instrument, and
whilst it is so fixed move  it and the lithotrite from side to side, when, if a click is
heard and felt, he may be sure of the existence of another calculus.
   Errors occasionally occur in sounding; the surgeon mistaking a hardened and
fasciculated bladder, having its ridges perhaps incrusted with sahulous matter, for
a calculus;  this is  especially apt to happen  in  children.  In  these cases, how-
ever, the  mistake may be usually guarded against by the absence of a distinct
click, though a rough  grating  sensation be experienced, and by the surgeon
being unable to  isolate a stone.   Yet the difficulty  in  some cases is great; and
Velpeau states that he  is acquainted with four  instances, and S.  Cooper with
seven, in  which patients  have been cut and no calculus found; and when we
reflect that  these accidents have happened to such men as  Cheselden, who on
three occasions cut a patient  and found no stone;  to Crosse, to Roux,  and to
Dupuytren, it is easy to understand that in some cases  the difficulty of coming
to a correct decision must be very great.
   In women the symptoms of stone closely resemble those met with in men, but
the detection of the calculus is usually far easier, owing to the shortness of the
canal and the facility with which the stone may be tilted up  by introducing the
fingers of the left hand into the vagina.  The sound used in  these cases should
be shorter and less curved than that employed  for the detection of calculus  in
the male bladder.
   After a stone  has  existed for some  time  in  the bladder it induces serious
pathological  changes  in  the whole of the  urinary  apparatus.  The urethra
usually becomes  slightly dilated, and the  prostate not unfrequently somewhat
enlarged and irritable,  in consequence of which a kind of pouch is formed behind 
PREPARATION  FOR  LITHOTOMY.
841
it, in which the calculus is apt to lodge.   The most important changes, however,
take place in the bladder and kidneys.   The bladder becomes extremely sensitive,
especially about its  neck, and is consequently unable  to contain as much  urine
as usual; hence it becomes contracted.  In some rare instances, however, as will
be more especially noticed when we come to  speak of lithotrity, it  falls into an
atonic condition, and then is  apt to become rather largely dilated.   The mucous
membrane is commonly a good deal inflamed and irritated by the presence of the
calculus, and the  muscular coat  becomes thickened and hypertrophied, so as  to
give it a very fasciculated or columnated  appearance.  Cysts  occasionally form
containing sabulous matter and fetid pus or urine, and in  some cases lodging a
concretion, which then constitutes an encysted calculus lying altogether outside
the cavity of the  bladder, with which it merely  communicates by a very narrow
aperture, as in Figs. 268 and 269, representing a case that was under  my care
last winter, and that is fully  described in the Journals for March, 1853.  The
kidneys are usually irritated,  often congested, frequently in a  state of  granular
degeneration, and ultimately become  the seat of such structural changes  as are
incompatible with  life.   When death  occurs  as the consequence of  stone,
the patient usually sinks, worn out by protracted suffering and kidney disease.

    OPERATIONS FOR THE  REMOVAL OF  STONE FROM  THE BLADDER.
   Calculus may be removed from the bladder  by two distinct operations.  By
lithotomy, or the cutting operation;  and lithotrity, or the crushing one.   AVe
shall first consider lithotomy,  as the more ancient, and perhaps even yet the more
common operation of the two.
   It is not my intention to enter into the general history of lithotomy, an opera-
tion that has been practised from the  earliest ages; and a sketch of the gradual
modifications of which, that have at various times been  introduced, from the
rude attempts of the Greek  and Roman surgeons to the barbarous and unscien-
tific procedures adopted by  the itinerant  operators after the revival of letters,
would occupy much space and be attended by but little advantage.   For all this
I would refer the reader to the classical works of  Deschamps and of John Bell.
The operation, as now generally practised  in this country, is essentially that in-
troduced by Cheselden, and-modified more  or less according to the peculiar views
of particular surgeons.   Hence there are a variety of ways in which it is per-
formed, though surgeons generally are agreed upon the great principles  involved
in it.   It is in carrying these out that they differ,—as in the direction and extent
of the incisions, and in the instruments employed, which have been much varied
to suit  the taste  of particular operators;  much of this detail, which would be
foreign to the  scope of this work, will be found  in Air. Coulson's recent Treatise
on Stone.  I shall  in  a great measure confine myself  to the description of that
particular modification of Cheselden's, or the lateral operation introduced by the
late Air. Liston, most skilfully practised by him, and now very generally adopted
by most of the best surgeons  of" the day in this country.
   Before subjecting a patient to operation,  his general health must be properly
attended to; and, indeed, if  we find the constitution much  broken  by prolonged
suffering, the bladder or kidneys seriously diseased, as indicated by the existence
of pus or albumen in his urine in large quantity, it will be wise to postpone the
operation for a time, or perhaps even to defer  it altogether.  Supposing, how-
ever, that the stone is of moderate size, that the patient's health is in a pretty good
state, that the urine is either tolerably healthy or  contains but  a moderate  quan-
tity of pus or albumen, and that there is no  visceral complication to prevent the
performance of the operation, it will only be necessary to subject him to proper
preparative treatment for a short time, so as  to allay or remove irritability of the
urinary organs before proceeding with it.   With this view he should be kept  as
quiet as possible for about a week or ten days preceding the operation; his diet 
842
STONE  IN  THE BLADDER.
should be properly regulated, but not be of too low a kind; pain lessened by the
administration of opiates or henbane, and the bowels properly relieved.  On the
day preceding the  operation a dose of castor-oil or some other aperient should be
administered; and on the morning of the operation the rectum must be emptied
by means of an enema.

                  LATERAL  OPERATION OF LITHOTOMY.
  The surgeon must see that the  table is firm and of a convenient height, so
that when he sits on  rather a low stool the patient's nates will be on a level with
his breast; a few blankets doubled  should be  laid upon the  table covered by a
piece of tarpaulin hanging over the end, and a tray of sand placed under it on
the floor.   The instruments necessary are  the following :—a pair of lithotomy
tapes, a sharp and  a  probe-pointed scalpel, a staff, forceps, and scoops of various
sizes, and a tube.   To  these  may be added a searcher, and a brass  injecting
syringe.
  The tapes should be of coarse flannel, about three yards long,  by three inches
broad.
  The scalpel for  the adult should be  of the size and  the  shape represented
(Fig. 274), for children  it may be made  proportionately small.   A probe-pointed
one should also be  at hand of the size and shape here represented (Fig. 275).

                                  Fig. 274.
  The staff should have a deep groove on its left side, occupying nearly one-third
of the instrument; it should be well curved, of as large  a size as the urethra
will admit, and have a roughened handle.
  The forceps must not be too heavy, but should be of a good  length in the
handles, and have the joint well set back; the inside  of the  blades,  as recom-
mended by Air. Liston,  should be lined with linen to prevent  the stone  slipping
(Fig.  276).  Air. Coxeter has lately made them with open  blades,  but lined
with linen as heretofore  (Fig. 278);  in this way as there is less metal, the weight
is diminished, and the diameter of the  instrument with a  stone in its  grasp is
materially lessened.   The ordinary forceps are  straight, but it is  advantageous
to be provided with some that  are curved  (Fig. 277).   The handles  should be
made with a loop on one side and a ring on the  other;  the ring for the reception
of the thumb should be  placed somewhat obliquely.   The scoops of different
sizes, and curved, can most conveniently be used when fixed in  a roughened
handle (Fig. 279).  The tube should be of gum-elastic, well rounded at the end,
and provided with silver rings.  The searcher is a nearly straight sound having
a bulbous extremity.  The syringe presents nothing peculiar.
  In describing the operation  of lithotomy, we shall first of all consider the dif-
ferent  steps seriatim of an operation that presents  no unusual complication or
difficulty; we shall then consider the difficulties that  may be met with during
the operation, the accidents that may occur, the principal sources of danger, and
the causes of death.
   Ordinary Operation.—After chloroform has been administered, the  surgeon
should introduce the staff, which he uses as a sound, in order to feel for the cal- 
OPERATION  OF  LITHOTOMY.
843
cuius.  If he detects it, he proceeds with the  operation ;  if he cannot  detect
it, he withdraws the staff and introduces a sound with which  he examines the
bladder, and  in the event of his still failing to discover its  presence, the opera-
tion  must be deferred, for  it is an  imperative  rule  in  surgery  that  lithotomy
should never be performed  unless the  stone  can be felt at the time  that the
patient is actually on the table.
   The patient should be desired to hold his water for two or three hours before
the operation, but if he has not done so and the bladder is empty it must be
injected with about six ounces of tepid water, in order  to  facilitate the seizure
and extraction of the stone.  A  full-sized staff should then be introduced, the
patient firmly tied  up  and  brought to the end of the table, so that  his  nates
project beyond it;  where he is to be securely held by an assistant on either side,
who grasps the foot in his hand, places the patient's knee under his arm, and
draws the limbs well aside so  that the  perineum may be fairly exposed.  It is
desirable that the perineum be thus  fully exposed to the surgeon.   In a patient,
however, on whom  I operated during  the past winter,  this could not be done,
owing to the left hip being  stiffened  by chronic rheumatic arthritis;  but I did
not experience any particular  difficulty in the operation, though somewhat incon-
venienced by the position of the limb.   The surgeon then seating himself before
the patient, shaves the perineum—if this have not already been done—and  intro-
duces his finger into the rectum to  see that the  gut is  empty.  He then gives
the staff in charge of a trusty assistant, who stands on the patient's left and who
raises and draws aside the scrotum with the left  hand whilst  he holds the staff
Fig. 276.              Fig. 277.             Fig. 278.         Fig. 279.
in the right (Fig. 280).   The  surgeon then sees that the  staff is held in the
way in which  he prefers  it.   There  are  two ways in which it may be held;  it 
844
STONE  IN  THE BLADDER.
may either be drawn well up into the arch of the  pubes, or, it may be pushed
somewhat down, and slightly turned towards the  left of the  perineum.  Liston
always employed the first method, which I certainly think is the best, as it tends
to increase the space between the urethra  and the rectum, and consequently
lessens the danger of wounding that  gut, which  more than counterbalances the
advantage of the other method,—that of approaching the  membranous  portion
of the urethra to the surface.
   The external incision is made by entering the  knife in the raphe of the peri-
neum one inch and a half above the anus,  and  carrying it  downwards and out-
wards to the extent of three  inches  and a half, until it reaches a point that is
opposite to the middle of the anus,  but about one-third nearer to the tuberosity
of the ischium than to the margin of the anal aperture (Fig.  280).   It is useless
to prolong the incision beyond this,  as any freer division of the structures in  the
scrotum and on the nates cannot facilitate the extraction of the  stone; but it
must occupy the extent indicated, otherwise considerable difficulty may be experi-
enced in  the  later steps of the operation.  The  depth to which this incision
should be carried must vary according to the obesity of the subject, usually from
about three-quarters of an inch  to an inch.   By this incision the skin, superficial
fascia, and subcutaneous fat are  divided.   After it  is completed, the knife is
introduced again towards the upper  part of the wound, and the blade run lightly

                                    Fig. 280.
downwards over any resisting  structures.   In this way the transversalis perinei
muscle is divided together with some cellular tissue and small vessels, and the
triangular space is opened  between  the  accelerator  urinae and  erector penis
muscles; the knife is then withdrawn, and the left index finger pushed deeply
into this space until the  edge of the nail is lodged in the  groove of the staff,
which can be  felt thinly covered  by the membranous portion of the  urethra.
The point of the knife is then pushed through  the urethra at its membranous 
OPERATION  OF  LITHOTOMY.
845
part  into the  groove of the  staff, above the  index finger which protects and
presses to the right, the rectum lying beneath it (Fig.  281).
  When the knife is felt to be well lodged in the  groove, its handle is slightly
depressed so that the point may be raised, at the same  time the blade should be
somewhat lateralized, so that  its side lies parallel to the ramus of the ischium.
If the edge is turned too directly  downwards towards the mesial line the rectum
may be wounded, and if directed  too much outwards the  internal pudic artery
will be endangered; hence the mid course is the proper one.
  The surgeon keeping the knife steadily in this position and pressing the point
firmly against the side of the groove of the staff, which he must never for a mo-
ment lose, pushes it forwards through the  deep perineal fascia,  a few fibres of
the levator ani, and the prostate, and thus  makes an entry into the bladder; he
then withdraws the knife by keeping its back against  the staff so as not to en-
large the extent of the incision in the prostate.   Through this,  and along the
staff, he then pushes his left  index finger until it reaches the  bladder, when he
endeavors to feel  the calculus with its tip.   Should his finger be short, the  peri-
neum deep, or the prostate enlarged, he may be unable to reach  the  bladder in
                                   Fig. 281.
 
846
STONE  IN THE BLADDER.
position should always be preserved, and  the  point  of the  knife firmly pressed
along the bottom  of the groove in the staff.  This I consider a point of special
importance, as unless it be attended to, the knife may be slipped into the recto-
vesical space, and thus the bladder be  missed.   Liston used to  drive his knife
with such force against the staff as usually to  break, and  always to  blunt its
point.   In withdrawing the knife no cutting should be done, but the wound in
the prostate merely dilated by the  pressure of the finger.    This part of the ope-
ration may very conveniently be done, as was  always practised by Liston, at the
moment that the surgeon is stooping down, engaged in selecting his forceps.
The internal incision, that extending through  the prostate towards and into the
neck of the bladder, should  be  very limited ; it  must  never under any circum-
stances extend through the  edge of the prostate into  the  loose cellular tissues
                                                around that gland (Fig. 282a).
                                                If it do,  the patient will pro-
                                                bably die  of infiltration of
                                                urine  into and diffuse inflam-
                                                mation of the pelvic fascia,
                                                which will be opened if the
                                                boundaries of that gland are
                                                passed.   The opening in the
                                                prostate  must afterwards be
                                                dilated (but never cut), to a
                                                sufficient size for the extrac-
                                                tion of  the  calculus in  the
                                                way already mentioned.  This
                                                rule in lithotomy I look upon
                                                as fully established by Scarpa,
                                                Brodie,  Liston, and  others,
                                                and as  in accordance  with
the practice of the best lithotomists of the present day.
   The next part of the operation consists in the  extraction of the stone.   A pair
of forceps of sufficient length and size, proportioned to that of the calculus, and
previously warmed by immersion in tepid water, must be slid along the index
finger that is kept in the wound, and by which  the neck of the bladder should
be drawn somewhat down so as to meet the instrument.   The forceps having
been introduced  closed, the finger is withdrawn, when a  gush  of urine  will
usually take place through the wound  ; if that fluid have not already escaped at
the time that the incision is made through the prostate.  By this  gush the cal-
culus may, as Air. Fergusson observes, sometimes be  carried into the  grasp of
the instrument; most commonly, however, the stone requires to be felt for with
the  closed forceps.  AVhen its position has been ascertained, usually at the in-
ferior fundus, the blades are opened, and by pushing one against the walls of the
bladder and giving it a shake the calculus generally drops between them, though
occasionally it is somewhat  troublesome to seize, and this indeed may constitute
the  most tedious  and annoying  part of the  operation.   The forceps  are then
closed and the stone drawn downwards through the wound.  If it be small, the
stone may be extracted at once without any difficulty; if of  moderate  size, the
finger should be introduced in order to feel whether it is in a proper position for
extraction.   If its long axis lie across the wound, this  must be changed and it
must then be withdrawn by a kind of to and fro movement in  the  direction of
the axis of the pelvis.   Should the stone be broken, or should there be several
small  calculi, they may generally be best removed by means of the scoop.  In
the  event of fracture occurring, it would be necessary to wash out the bladder
with tepid water, injected by means of a brass syringe through a tube introduced
by the wound.
 
         AFTER-TREATMENT — LITHOTOMY  IN  CHILDREN.      847

  After the calculus has been removed it must be examined for facets, or the
interior of the bladder explored by means of a searcher;  and if another stone be
found that must be dealt with in the same way as the first.
  The gum-elastic tube may then be  introduced, and secured with tapes to a
band round the patient's abdomen.  This  tube must be kept free from coagula
by the  introduction into it, from  time to time, of the  feather  of a pen.  By
means of this tube a ready outlet is given to the  urine, and the chances of infil-
tration lessened.
  The patient must then be removed to a  bed, which should be properly arranged
by having a large square of Mackintosh cloth put across it.  On this a folded
sheet should  be  laid, which must be rolled up on the further side so that as it
becomes wetted by the escape of urine, it may be drawn across  from under the
patient.  This must be changed frequently in order to keep him clean and dry.
A full dose of tincture of henbane  in barley water should then be given; a warm
flannel laid across the abdomen; plenty of barley or gum water allowed for drink,
and nothing but  rice-milk or light  pudding for diet during the first three or four
days.  After this some broth may  be allowed and the quality of  the food gradu-
ally increased.  Occasionally, however, in exceptional instances, it may be neces-
sary to depart from this rule.   In  an old  man, on whom I  recently operated at
the  Hospital, there  was so  great a  tendency  to depression,  that it became
necessary to administer the brandy-and-egg mixture from the first, and to this  I
believe he owed his life.
   At the end of thirty-six or forty-eight hours the tube may be removed, the
sides of the incision by that time having  become glazed over, and little danger of
infiltration existing.  The water continues to flow entirely  through the  wound
for the first four or five days.   About this time it frequently suddenly ceases to
do so, escaping by the urethra.  This is  owing to the prostate becoming turgid
by inflammatory action, and thus  blocking  up the aperture in it; but  as this
swelling goes down, in the course of a day or two, the urine usually escapes by
the wound again, and continues to do so  in gradually decreasing quantities until
the aperture is finally closed, which usually happens at about the end of fourteen
or eighteen days; though in patients who suffer from phosphatic calculus it some-
times takes a longer period owing to the broken state of  the  general health.
After the operation appropriate constitutional treatment should be continued for
some time in order to prevent a recurrence of the disease.
   Lithotomy in  children is  performed much in  the  same  way  as  in  the male
adult; though it is. worthy of note that the urethra will  commonly be  found
larger  than might be  expected from  the age of the child, readily admitting a
Xo.  8 or 9 staff.   The perineum also is usually proportionately more vascular in
consequence  of the irritation  and straining.  The most important point, how-
ever, is, that in the child the bladder lies high, being rather  in the abdomen
than in  the pelvis; hence  it  is of importance  to raise the pointvof  the knife
somewhat more than in the adult in making the deep incision, and  to be careful
that it does not  slip into  the  recto-vesical space, which may happen unless this
precaution is taken.   I have  known  it  occur in two instances, to  hospital sur-
geons; in both cases the forceps were passed into this space under the supposi-
tion of its being the bladder, and in both the patient died unrelieved.
   This accident is the more  likely to occur, because in children  the parts are
very yielding, and readily admit  of being pushed before  the knife or finger.
There is always danger after the internal incision has been  made, that in intro-
ducing the finger into the bladder that viscus may be pushed before it, and thus
the surgeon fail in reaching its cavity.
      DIFFICULTIES AND DANGERS DURING AND AFTER LITHOTOMY.
   The difficulties during  the  operation are twofold:—getting into  the bladder,
and extracting the calculus. 
848
STONE  IN  THE BLADDER.
   The difficulty of getting into the bladder is rarely experienced.   It may, how-
 ever, arise in consequence of the surgeon  neglecting to keep the point of the
 knife well lodged in the groove  of the  staff, and thus  letting it slip into the
 recto-vesical space, the tissue of which being broken up,  leaves a kind of cavity
 that he mistakes for the interior of the bladder.  If the perineum is very deep
 and the prostate enlarged, he may also experience some difficulty in reaching the
 bladder, but he can  scarcely fail  to do so if he push the knife well on in the
 groove of the staff, and dilate the incision in the prostate with a blunt gorget, if
 his finger fail to reach the cavity beyond  it.
   Difficulty in seizing  the stone not unfrequently occurs.  This is likely to hap-
 pen in  all those cases in which, whether from the depth at which the  bladder is
 from the surface, or the  peculiar position of  the calculus, the stone cannot be
 felt with  the finger after the  incisions have  been  made into  the neck of the
 bladder.  This is especially apt to happen if the patient is old and fat, and has
 a  deep perineum, with perhaps some enlargement  of  the  prostate.   In  such
 cases as these, long and curved forceps should be used.   So, also, if the stone is
 very round  it is usually more difficult to seize than when  flat or elongated.
   Difficulty in extracting the calculus is  far more frequently met with than in
 reaching the bladder.   This may be owing to a variety of causes.   The position
 of the stone may be such that it can scarcely be reached with the forceps.  Thus,
 when it is situated in the upper fundus  of  the  bladder  above the pubes, it is
 altogether out of  the axis of the  incision, and in such a case can only be ex-
 tracted with great difficulty.   Key recommends that  in such cases the abdomen
 should  be compressed,  and  thus the calculus pushed down  into reach.  This
 suggestion is a very useful one ; and it was only by employing this  manoeuvre
 and using a very curved scoop that  I could  remove a calculus lodged above the
 pubes, in  a patient whom I cut at the Hospital some years ago.
   The  calculus may be lodged in the lower fundus, behind an enlarged prostate.
 Here the best plan is to use a much-curved  pair of forceps, and to tilt the blad-
 der up  by introducing the finger into the  rectum, and thus bringing the stone
 within reach.
   Difficulty in extraction  may occur in  consequence of the stone being in some
 way fixed  to, or retained in the bladder.  Thus, a small calculus may be enveloped
 by the folds  of the mucous membrane, and in this way elude the grasp of the
 forceps.   Under these circumstances, there is nothing for the surgeon to do, but
 patiently to try  to disentangle  and  remove the calculus by means of the finger
 and scoop,  if it can  be so reached; if  not, by expanding  the forceps in the
 bladder, to try to push aside  the mucous membrane that surrounds it.
   In consequence of spasm of the bladder, it has occasionally happened that a
 calculus is so firmly fixed as not to admit  of  the  application of  the forceps, the
 blades  of which cannot be introduced between the walls of the viscus without
 using an improper degree of force, and giving rise to the danger of rupturing the
 neck of the bladder.  Under these  circumstances, I  think it would be safer for
 the surgeon to desist from the operation, and in the course of a few hours or the
 following day, when the spasm might possibly be relaxed, complete the extraction,
 and thus perform the operation "a deux temps," of Deschamps.
   The  stone may be  so fixed between  hypertrophied fasciculi in the  interior of
 the bladder, as to  be detached  with considerable difficulty.  In  such cases as
these the scoop will  be found to be the  most useful  instrument.  When the
 calculus is encysted,  its extraction  will probably be  impracticable, or attended
with the most dangerous consequences.   Hence, it is expedient not to operate
in cases of encysted calculus that are known to be such.  If, however, the surgeon
has been  unfortunate enough to cut into a bladder containing an encysted cal-
culus, he must be guided in the course he should adopt by the condition in which
he  finds the stone.   If the  aperture leading into the cyst be very small, as in 
DIFFICULTIES  IN  LITHOTOMY.
849
Fig. 268, the better plan will be to proceed no further with the operation, as it
would be clearly impossible  to  remove  the stone.   If, on the other hand, the
aperture into the cyst be large, he might feel disposed to make an effort to extract
the calculus.   AVith this view he might adopt the plan pursued by Sir B. Brodie
in such a  case, and endeavor to  enlarge the orifice of the cyst by means of a
probe-pointed  bistoury  cautiously  applied,  and then  finish the  extraction  by
means of a scoop.   Such  a proceeding, however,  is  in  the highest degree
hazardous, on account of the readiness with  which the section might extend into
the peritoneal  cavity; as well as difficult in  execution, from the depth at which
the parts are  lying.  I believe that a calculus may occasionally be encysted, or
rather encapsuled, in another way,—by  being covered in by  a  kind of false
membrane whilst lying on the floor of the bladder.   This condition I found in a
child  that I cut for stone last year.   After removing a calculus about the size of
a pea, I felt, with the end of the finger, a hard irregular body, covered apparently
by mucous  membrane, lying at the inferior  fundus of the bladder.  On scraping
through the membrane  covering this with the  point  of  the nail  and a curved
scoop, I exposed the calculus (Fig. 267), and removed  it, with a cyst attached
to it.  On  examining the structure of this cyst, which  was about the thickness
of ordinary writing-paper, of a reddish color, and resembling a piece of mucous
membrane, it  was found  to  be a false membrane, composed of organised fibro-
cellular tissue.  The patient made a good recovery, with the exception of a slight
attack of secondary hemorrhage which  occurred on the  eighth  day after the
operation.
   The principal difficulty in extracting  a calculus generally depends upon the
shape and size of the stone.   Very flat,  broad calculi, those that are round, egg-
 shaped, or  branched, are the most  difficult to remove, even though their size be
 not very great.  As a general rule, however, it may be stated that the larger the
 calculus, the more difficult is its extraction.  This arises not so much from the
 outlet of the  pelvis  being too narrow, but from the necessity of making the in-
 ternal incisions through the prostate to a very limited extent.   There will always
 be considerable  difficulty experienced in extracting calculi weighing six or eight
 ounces and upwards,  though cases  are recorded by Cheselden, Klein, and others,
 in which calculi from twelve to fifteen ounces in weight have been extracted by
 the lateral  operation.   Any calculus above  one inch and a quarter in its shortest
 diameter will present  considerable difficulties in being extracted through an
 incision in  the  prostate  of the ordinary size;  viz., about  eight lines in length,
 even though this be  considerably dilated by the pressure of the fingers; and, I
 think it may be safely said, that a calculus two inches and  upwards in diameter,
 cannot be removed by the ordinary lateral operation  with  any degree  of force
 that it is safe to employ.   In the facility with which the calculus is  extracted,
 however, much  will depend upon  the make of the forceps.   As  Liston most
 truly observes, " There can be no more fatal error that to attempt the extraction
 of a large stone  with short and shabby forceps."   In these cases, I think  the
 open-bladed forceps (Fig. 278) will be found useful, the absence of metal in the
 most convex part of the "blade lessening  materially their diameter when grasping
 a stone.                .
   In the event  of the calculus being too large to be extracted by the ordinary
 lateral operation, what  course should the surgeon pursue?   Three  are  open to
 him: 1st.  The  division of the right side of the prostate from the interior of the
 wound   2dly.  Crushing the calculus in the bladder, and then removing it; and
 3dly. The performance of the high or supra-pubic operation.  The incision of
 the right side of the prostate gives considerable additional space, and is sufficient
 for most ordinary purposes; very large calculi being fortunately very rarely met
 with  This section  may be made by introducing a probe-pointed  scalpel (_ig.
 275) into  the wound,  guided  by the  index finger, and cautiously dividing  the
    J                                54 
850
STONE  IN  THE BLADDER.
rio-ht side  of the prostate downwards  and outwards, in the same way that the
section of the left has been made.   This procedure must be carefully done, with
due  regard to  the  important parts  in the neighborhood of the gland.  In two
cases I°have seen Air. Liston do  this.   In one the patient  recovered, in the
other he died of diffuse cellular inflammation of the pelvis; and I had occasion
recently to practise  it on a patient whom I cut  at  the  Hospital, and  who  made
an excellent recovery.   The second plan, that  of  crushing the calculus in the
bladder through the wound in the  perineum, would certainly be a very hazardous
procedure.   The  irritation that would necessarily be set  up  by the large  litho-
trite that has been invented for this purpose, by the presence of the fragments
of stone, and by the necessary difficulty and delay of clearing them out of the
viscus, would probably be fatal to  the patient.   In the  event  of its being im-
possible to  extract the calculus through the perineum, I  think it would be  safer
to adopt  the third course, and to perform the high operation, which will presently
be described.
  The principal accidents that may occur during the performance of the lateral
operation of lithotomy are hemorrhage ;  wound of the rectum; cutting the  bulb,
or missing  the membranous portion of the urethra.
  Hemorrhage during lithotomy may occur from three sources :—1st. The super-
ficial arteries of the perineum ; 2dly, the deep arteries of this region ; and,  3dly,
the prostatic veins.  Hemorrhage from the division  of the  superficial or the
transverse artery of the perineum is  seldom of  a very serious  character, though
occasionally if these vessels  are of larger  size than  usual, they may  furnish a
serious quantity of blood; under such circumstances their  ligature would be re-
quired, and might be practised either before or after the extraction of the calcu-
lus.  It is  better, if possible, to wait until the completion of  the operation, lest
the ligature be pulled off during the removal of the stone.   The division of the
deep arteries of the perineum, that of the  bulb and  the internal pudic, will be
attended by far more serious  and perhaps even  fatal consequences ; as, from the
depth at which the  vessels are seated, it would  almost be impossible  to apply a
ligature to  them unless the patient be very thin, and the perineum proportionately
shallow.   In the event  of a ligature not  being applicable, the surgeon would
have to trust to plugging the wound around the tube, or to the pressure of an as-
sistant's fingers continued for a considerable time.   It is doubtless very rare for
these arteries to be  wounded when they follow  their usual course, though such
accidents have happened in the hands of some  of  the most skilful lithotoniists,
such as  Home, Bell, Roux, and Desault.   It  was the opinion  of the  late Air.
Key that the artery of the bulb was generally cut  during lithotomy, but in this I
believe he  was mistaken  so far as its trunk is concerned, though doubtless in
many cases the bulb itself may be  wounded and the mesh of twigs in which the
vessel terminates  divided ; but this would  not  yield an alarming  hemorrhage.
The trunk of the artery of the bulb would, however, be  endangered by opening
the urethra too high up,  and lateralizing the knife too early.
  The internal pudic artery,  bound down by a strong fascia and under cover of
the ramus of the  ischium, runs but little risk unless the knife  be lateralized too
much,  and the incision be carried  too far outwards.  It js in some of the anoma-
lous distributions of these vessels that the greatest  danger  would be occasioned.
The artery of the bulb, the inferior hemorrhoidal,  the  dorsal artery of the penis,
or the internal pudic may take such an  anomalous course that their division must
be inevitable ;  and as the surgeon has no possible means of knowing beforehand
whether the distribution of the arteries is regular or not, and as his incisions are
all planned on the supposition that they are, he is  not to blame in the event of a
vessel being accidentally divided when taking an abnormal direction, which it is
impossible  to be acquainted with until after the accident has occurred.
  [Should the pudic artery,  or its bulbar branch  be  severed in the operation, 
DIFFICULTIES  AND DANGERS IN LITHOTOMY.       851
they may be best ligated by Physick's forceps, armed with  a curved  needle and
thread, (Fig. 283.)   Of this instrument  Dr.  Gross writes,  "It is an admirable
instrument, and should find a place in every lithotomy case—
it is far superior to Deschamp's needle, and the clumsy  con-
trivance of Arerdier."   If it be desirable to attempt the tam-
ponnement of  the  wound, the  canula  of Dupuytren will be
found of most  value.   This  consists  of a large  sized canula,
provided with  a linen bag,  fastened near its beak, and ex-
tending completely around the circumference of the instrument.
The canula  is  introduced into the bladder,  and the bag  is
then filled with lint or charpie, so as to exert compression
upon the sides of the wound to any extent desired.—Ed.]
  Venous hemorrhage of an alarming  and even fatal extent
has been known to occur from division of the  prostatic plexus.
This is especially apt to happen in old people, in whom these
vessels not only become greatly enlarged, but do not  readily
contract on account of the rigidity of the neighboring parts.
  A wound  of the bulb is not of very uncommon occurrence in
lithotomy, and I believe is of no consequence beyond furnish-
ing a small additional  quantity of  blood.   Indeed, the bulb is
so situated, in many cases  overlapping the membranous portion
of the urethra, that  this can scarcely  be  opened without
wounding  it.  In other cases again, the surgeon may go  into
the opposite  extreme,  and open the urinary passages altogether
beyond the membranous portion of the canal.   I was present
some years ago at the  post-mortem examination of a fatal  case
of lithotomy, in which perhaps the most skilful operator of the
day had opened the bladder  beyond the  prostate, leaving the
urethra altogether untouched.
   Wound of the Rectum  may occasionally  occur  either  in
consequence of the  staff being too much depressed, the edge
of the knife turned too  directly  downwards, or the  rectum
being distended and overlapping the  sides of the prostate.   If
the aperture in the  gut is  small it will probably close as the
wound granulates and fills up.   If,  however, the incision be
more extensive there will be the risk of a recto-vesical fistula
being induced ; under such  circumstances, treatment such  as
recommended for that  disease  should be adopted ;  or, it has
been suggested, that the rectum should be laid open through
the sphincter into the wound.
          SOURCES OF DANGER AND  CAUSES OF DEATH AFTER
                               LITHOTOMY.
  Lithotomy even in healthy subjects is always a dangerous operation,  and though
the rate of mortality doubtless depends greatly  upon the  dexterity and skill  of
the operator, more is,  I believe, due to the constitution and age of the patient.
Sir B. Brodie most justly says, "Success in lithotomy most undoubtedly depends
in a great degree on the manual skill of  the surgeon, and on the mode in which
the operation is performed ; but it depends still more on the conditions  of the
patient with  respect to his general health, especially on  the  existence or non-
existence of  organic disease."   That  the mere cutting into  the bladder is not a.
very dangerous proceeding, provided  that viscus and the kidneys are  healthy, is
evident from the fact that" in those cases in which surgeons have had to extract
bullets, bits  of catheter, &c, from this  organ,  bad consequences have  rarely
occurred though the operations have  often been tedious; but in  lithotomy the
case is different, for here the bladder is not only usually in a state of chronic irri- 
852
STONE  IN  THE  BLADDER.
tation, but the  kidneys are frequently diseased, and these conditions influence
more materially the  result of these operations than  any other circumstances.
Hence an operator may have a run  of unsuccessful cases ;  or by a fortunate con-
currence of favorable cases it has occasionally happened that a surgeon  has  cut
20 or 30 patients in succession without losing a single one ; but several deaths
then occurring, though the operation was performed in the same way and with
the same care as before, his average falls to about the usual level.   The  late Air.
Lynn had cut 25 patients without losing one, and he said that he thought he had
at last discovered the secret of performing lithotomy with success ; but, he added,
the Almighty punished him for his presumption, for he lost the next 4 cases that
he cut.  Mr. Liston, during a period of six years in which he operated 24 times,
lost no patient from lithotomy at University College Hospital; but  out of  the
whole 37 cases  which he cut during the period of his connexion with that Insti-
tution  there were 5 deaths ; reducing the  average to 1 in 7 2.   This success was,
however, very great when it  is taken into consideration that most of these cases
occurred in adults,  and that many of them were of a very serious character.  I
find on reference to the Hospital Records, that only 7 of the patients were under
10 years of age, whilst 14 were above 50 ; of these,  two were 80 years of age, of
whom  one  died and the other recovered.   I believe  that Mr. Liston only lost one
patient under 60 years of age, and  that was a lad of 18,  in  whom he found it
necessary to divide  the right side of the prostate as well as the left, and who died
of infiltration of urine.   Thirty-eight patients, successively operated on at  the
Norwich Infirmary, recovered ; but the average rate of mortality in that Institu-
tion, calculated from 704 cases,  has been 1  in 7|.   Cheselden only lost one in
every 10f ; and according to Air. South at St. Thomas's, the mortality has  not
amounted to  more than 1 in 9f ; but a good many of these patients were probably
children.   According to Mr. Coulson the average mortality in England deduced
from 1743 cases of the lateral operation is 1 in 6-93 cases.  Whilst in France it
is 1 in 5-7 ;  and for Europe  generally 1 in 5-14.
  Age exercises a marked influence on the result of lithotomy; which may be
looked upon  as one of the most successful operations in surgery at early periods
of life, a hazardous one at middle  age, and an extremely dangerous one at  ad-
vanced age.  Mr. Coulson finds on analysing 2972  cases of lithotomy that  the
mortality at each successive decennial period is as follows.  Below 10 years it is
1 in 13, and thence gradually augments from 10 to 80 years  to 1 in 9, 1 in 6,
1 in 5, 1 in  4, 1 in 365, in 3-23,  1 in 2-71.
  The shock of the operation occasionally proves  fatal, though probably much
less frequently so since  the  introduction of chloroform,  than  was formerly the
case.   Yet, even now, patients occasionally die from this  cause,  induced  either
by a very much prolonged  operation,  or by  the  system  being  weakened, and
having lost its  resisting power in consequence of disease of the kidneys, perhaps
of a latent character.   The first patient,  a young man, that I cut at University
College Hospital, died  from the shock  of the operation;  and after death  the
kidneys were found extensively disorganized, though the  urine had contained
but a moderate quantity of albumen, and  there was no reason to suspect  so much
organic disease,  A prolonged operation, even under chloroform, is dangerous,
and although it is certainly not well to operate against time, yet it is undoubtedly
advantageous to finish the operation with as little delay as is consistent with the
safety  of the patient, even though  he be  anaesthetized.
   Hemorrhage does not often prove fatal, either  shortly after the operation, or
at a later period.   Secondary hemorrhage, of a dangerous or even fatal character,
may,  however, come on six, eight, or ten  days  after  the operation.   I have
known it as late as the fourteenth day.   It must be borne in mind, that when
hemorrhage takes place after the operation, the blood  may find its way into the bkd- 
                      DANGERS OF  LITHOTOMY.                   853

der rather than escape internally, distending the viscus with coagula,  but not
giving any external evidence of the mischief that has occurred.
  Diffuse  inflammation of the cellular tissue of the pelvis,  especially  of  those
layers around the neck of the bladder, between it and the rectum, and  that
extend  from thence under the peritoneum, is the most  frequent cause of death
after lithotomy.  This inflammation, which  is always of the diffuse or erysipe-
loid kind,  followed by rapid sloughing of the textures that it invades, may arise
from two causes.
  1st.  From the urine getting infiltrated into the cellular tissue, in consequence
of the incision extending beyond the limits of the prostate, into the loose layers
of tissues  that surround that gland.
  2d. In consequence of the bruising and laceration to which  the neck of the
bladder, the prostate and the textures between it and  the rectum are subjected,
in prolonged attempts to extract a  large calculus from the bladder.
  The  danger of  cutting beyond  the limits of the prostate has already been
adverted to.  In the extraction of the calculi  of ordinary  size there can be no
necessity to extend the internal incision; but when the calculus is of considerable
magnitude, the surgeon, wishing to get as much space as possible, may inadvert-
ently carry his knife beyond the prostate; or if he  make  a cut into the  right
side  of this gland, he may perhaps prolong it a little too far, and thus open the
loose cellular tissue or fascia that surrounds  it, and that is continuous with the
pelvic and sub-peritoneal planes of cellular membrane.   By dilating the incision
in the prostate downwards and outwards, either with the finger or with a blunt
gorget, the dense envelope surrounding the  gland  is not divided, and injury to
this  tissue is prevented.
  If the incision extends beyond  the prostate, the urine, as it escapes  through
the wound, sinks into the meshes of the loose cellular tissue over which it flows,
and  thus give rise  to infiltration, followed by rapidly extending inflammation and
sloughing, which speedily involve the whole of the neighboring textures.   This
mischief generally occurs within the first forty-eight hours, and is indicated by
the patient being seized with rigors, followed by dry heat of skin, a quick pulse,
which,  after a time, may become intermittent, and a dry and brown tongue. At
the same time  he will complain of some tenderness  about the lower part of the
abdomen,  and  in the groins; the  belly becomes tympanitic, the body covered
with a  profuse sweat; hiccup comes on, the pulse becomes  more weak and flut-
tering,  and death usually occurs about the fourth or fifth day after the operation.
In some cases there are more decided signs  of peritoneal inflammation,  but, as
Brodie very truly remarks, this is  not the primary disease, but is only induced
secondarily by the inflammation and sloughing of the cellular tissue  of the pelvis
spreading  to the contiguous serous  membrane.
  The  treatment of such cases must be conducted on the ordinary principles that
guide us in  the  management of diffuse  inflammations.   It is only by adminis-
tering  ammonia with  such a quantity of wine or  brandy  as the  state of the
system  may indicate, together with such nourishment  as the patient can take,
that  life can be preserved.  The  disease is a depressing  one, and requires  a
stimulating plan of treatment.  Brodie has  recommended that in these cases a
free incision should be made through the sloughy tissues  about the wound into the
rectum, in accordance with the general principles that guide us in the manage-
ment of similar  affections  elsewhere.  In  one case of the kind that  occurred
under his  care, he saved the patient by passing a curved probe-pointed  bistoury
into the wound to its furthest extremity, to the left side of the neck of the  blad-
der;  he then pushed it through the tunics of the rectum, and, drawing it down-
wards, divided the lower part of the gut together with the sphincter; thus laying
the wound and the rectum into one.   The relief was immediate, and the patient
recovered.    This plan of treatment certainly seems  rational and worthy of trial
in similar cases. 
854                    STONE  IN  THE  BLADDER.

  Diffuse inflammation  of the  cellular  tissue around the neck of the  bladder
and prostate arising from bruising and  over-distension of the  parts during the
extraction of a large calculus is, I believe a more freqent occurrence  than infil-
tration of urine, and fully as fatal.  This sequence of lithotomy is especially apt
to occur in those cases in which, in consequence of diseased kidneys, or the exis-
tence of other organic mischief, the patient is  more than  usually liable to the
supervention of diffuse or erysipeloid inflammation.  Indeed it is in this indirect
way that I believe diseased kidneys constitute such a  formidable obstacle to the
safe performance of lithotomy.
  In  the extraction of large calculi considerable traction is required and  force
must  be exerted, hence undue bruising and pressure are very apt to be inflicted
upon  the parts that constitute the line of incision; and it is in  this way that the
danger of lithotomy increases almost in proportion to  the  size  of the  calculus;
though  it must be borne in mind that the larger the stone  the  more probability
there is of the existence of disease of the bladder or kidneys, and an unfavorable
result from this cause.   Air. Crosse, of Norwich, has drawn  up a table that shows
the influence  of the weight, or in other  words, the  size of a calculus  on the
results of lithotomy.   He found that when the stone was one ounce and under
in weight, the  deaths were in the proportion of 1 in 11 25 cases.   When  from
1 to 2 ounces in weight there was 1 death in 6-61  cases.  AVhen from  _  to 3
ounces,  1 death in 2-18 cases.  When from 3 to 4 ounces, 1 death in 1-57 cases.
When from 4 to 5 ounces, 1 death in 166 cases.   This  table, which  has  been
constructed on  the  results of 703 cases,  illustrates very clearly the fact, that the
operation for the removal of a large calculus is far more dangerous than that for
the extraction of a small one;  and the cause of the increased ratio of  mortality
in proportion to the size of the  stone, is  doubtless the  injury inflicted  on the
parts  by severe and perhaps prolonged efforts at the extraction of a calculus
through an aperture of insufficient size.   For here the surgeon is placed between
the alternatives of cutting beyond the  prostate, and  thus occasioning urinary
infiltration, and bruising or lacerating the structures by limiting his incision to
the margin of this  gland.
  The symptoms of diffuse inflammation of the cellular tissue  arising from the
cause now under discussion, very closely resemble those from infiltration of urine,
and the treatment must be conducted on precisely similar principles.
  ["  Operation with  the  Gorget.—The gorget is  fast falling into desuetude.
Whether this is owing to any intrinsic defect  in the instrument itself, or  merely
to the manner  of using it, cannot be easily determined.  However this may be,
very few operators, either in this country or in  England, continue to employ it.
Dr. Dudley, of Lexington, has performed all his operations, upwards of two hun-
dred  in number, with it;  and I am told that he still uses the same  instrument
with which he commenced his brilliant career  as a lithotomist, forty years ago.
Dr. Gibson, of Philadelphia, also adheres to the gorget, and so do likewise a few
of the other  surgeons of that city.  Most American operators prefer the knife,
which is also the case  in England, France, and  other portions of continental Eu-
rope.   The gorget has undoubtedly  committed  many blunders, the  recital of
which would form one of the most sickening chapters in the history of surgical
wrongs.   Nevertheless, it has done, and still continues to do, good service in the
hands of some of our  most eminent  men, and  ought not,  therefore, perhaps, to
be spoken of too lightly or severely, for its faults are, perhaps, after all, rather
attributable to the surgeon than to the dumb  instrument with which he does his
bungling work.
  "The operation  with the gorget differs, in no wise, in its early stages, from
the operation with the knife.  The period  for using the instrument is immedi-
ately after the incision of the membranous portion of the urethra.  The surgeon
then exchanges the scalpel for the gorget, the  beak of which he places  in the 
HIGH OPERATION  FOR  STONE.
855
groove of the staff, guided by the point of the left index-finger.   After assuring
himself, by drawing the instrument slightly backwards and forwards, that it is in
no danger of slipping, he takes hold of the  handle of the staff, and by a simul-
taneous movement of his hands, he lowers the instrument and the gorget nearly
to a level with the abdomen; pushing at the same time the latter onward into
the bladder.  In executing this part of the operation, care  should be taken  not
only that the gorget do not slip out of its place, and thus pass  between the rec-
tum and  the bladder, but that  it is properly lateralized, otherwise there will be
great risk of injury to the rectum and the pudic artery.  The  annexed  engra-
ving  (Fig. 284), represents  the gorget,  as modified  and improved by Physick
and Gibson."  (From Gross on the Urinary Organs.)—Ed.]

                                  Fig. 284.
                    HIGH OR SUPRAPUBIC OPERATION.

   Although the  lateral  operation for lithotomy is certainly far safer than any
 other for the extraction of stones of small or moderate size, yet there can be no
 doubt that its results are extremely unfavorable, as has already been shown, when
 the calculus exceeds a certain magnitude; and under these circumstances it may
 be deemed expedient to  perform the high  operation in preference to it.  It is
 fortunate, however, that  large calculi are comparatively rarely met with.  Thus
 of the 703 Norwich cases, that form the basis of Air. Crosse's tables,  and indeed
 of our chief information on these points, 529 were under 1 ounce  in weight;
 119 weighed from 1 to 2 ounces;  35 from 2 to 3; 11 from 3 to 4; 5 from 4 to
 5; and only 4 were above this size.   Hence if we confine the high operation to
 those instances in which the calculus is above such a size as will readily admit of
 extraction through the perineum, we shall seldom^.have occasion to perform it;
 but yet instances occasionally occur in which no other mode of extracting the
 calculus presents  itself.   Thus M. Uytterhoeven succeeded in extracting a calcu-
 lus, by this method, which measured 16£ inches in  one circumference, and 12_
 in the other, which was perfectly moulded to the shape of the inside of the blad-
 der, and which  clearly could not have  been removed by  any incisions through
 the perineum, as the outlet would have been insufficient for its extraction.   The
 patient survived the operation  eight days.  But not only may the high operation
 be required on account of the  size of the calculus;  it may be  rendered neces-
 sary by the  existence of  such  rigidity about the hips in  consequence of rheu-
 matic disease, as would prevent "the  proper  exposure of the perineum;  or, that
rerion mio-ht be the seat of disease that would interfere with any operation being
 practised through it. 
856
STONE IN  THE BLADDER.
  The high  operation consists in making an  incision through  the abdominal
wall, above the pubes, and opening the anterior part of the bladder  underneath
the reflection of the peritoneum that passes upwards from its superior fundus.
  In  performing this  operation, it is necessary that  means  should  be taken to
raise up the fundus of the bladder, so that it may project above  the pubes, and
thus admit of being safely opened.  With this view various contrivances  have
been invented, such as catheters containing sliding  stylets, which can be pushed
through the  bladder when that is exposed.   These  instruments, though inge-
nious, are not necessary, for the end  of an ordinary catheter introduced through
the urethra,  and made to project above the  pubes,  would serve as a sufficient
guide.  In performing the  operation, an incision  about  four  inches  in length
should be carried from the pubes directly upwards in the mesial line.   The pyra-
midales are then to be cut across near  their origin, the linea alba exposed, cau-
tiously opened near the pubes, and divided upwards some little way.   The  peri-
               toneum must next be pushed  back and the dissection carefully
               carried through the  cellular tissue above the  bone, until the in-
               strument previously introduced can be felt through the bladder,
               when,  if it  contain  a  sliding and  pointed stylet, this may be
               pushed through the coats  of the  bladder; if not,  an incision
               must be made down upon  it, and the aperture in the organ en-
               larged  downwards  towards the neck of the bladder by means of
               a probe-pointed bistoury, so as to admit the fingers.   The forceps
               must then be introduced, and the calculus extracted.   After the
               operation there will  always be risk of urinary infiltration into
               the cellular tissue  around the  margins of the wound.  In order
               to prevent this, the  older surgeons made incisions through the
               perineum into the  membranous portion of the urethra or neck of
               the bladder, thus complicating seriously the operation ; but this
               accident may best be prevented  by introducing a gum elastic
               catheter into the urethra, and leaving it  there for  a  few  days
               until consolidation  has taken place  and the wound shows a dis-
               position to  close, pressure  being  at the same  time  kept up on
               the lips of the incision.   Another cause of danger  in this ope-
               ration is wounding the peritoneum, which may occur  in conse-
               quence of the contracted state of the  bladder, causing it to lie
               low in the pelvis, and thus  preventing the proper introduction of
               instruments to carry  it up above the pubes.
                 Mr.  Humphrey, of Cambridge,  has collected  104 cases  in
               which  this operation has been performed; of these 31 proved
               fatal, chiefly from  peritonitis  and urinary infiltration;  the  mor-
               tality amounted consequently to 1 in 3£;  and  M. Sonberbielle,
               one of the greatest modern advocates of this operation, lost one
               patient in three.   The general  result,  therefore, is by  no means
               satisfactory,  though, as  in many instances,  the operation  was
               performed in cases  in which  the lateral  method was not appli-
               cable, we cannot with justice compare the  two procedures.
                  [The bilateral operation found as a suggestion in  Celsus, was
               improved and  introduced  by Dupuytren.  The  object of this
               procedure is to effect  a double  lateral section of the prostate
               gland; thus  permitting the extraction of a larger calculus, and
               causing less laceration of the substance of the gland, than by the
               simple lateral operation.  At the  same time a greater degree of
               safety is afforded to the rectum, and to the seminal  ducts.   For
the performance of the  operation an ordinary knife is sufficient, although the
double  lithotome cache of Dupuytren (Fig.  285) will effect the division of the
 
URETHRAL  CALCULI.
857
parts with more neatness and  rapidity.   The staff should be introduced into the
bladder, and the patient placed in the same position as for the ordinary lateral
operation.   A convex semicircular incision is made, three-quarters of an inch in
front of the anus, and terminating on either side midway between the margin of
the anus and the tuberosity of the ischium.   The surgeon then introduces two
fingers of his left hand into the wound, and depresses the rectum, whilst  with
his knife he divides the parts down  to the membranous urethra.   This must
now be  opened on  the staff, and the  lithotome, with  its blades closed, passed
along the groove  into the bladder.   The staff is then to be withdrawn, and the
lithotome turned, so as to present its concavity towards  the rectum.   The blades
must next be sprung, and the instrument withdrawn through the external incision ;
making a double lateral section of the prostate  gland  in its outward progress.
The stone is then to be extracted in the usual manner.—Ed.]
Fig. 286.
                          URETHRAL CALCULUS.

  Calculi  are not unfrequently met with in the urethra, especially in  children,
passing  from the kidney perhaps into the  bladder,
and  from thence  into  the urinary canal,  through
which they occasionally escape, but in other instances
lodge, more especially at the bulb or in the navicular
fossa.  These calculi are commonly of the lithic acid,
lithate of ammonia, or oxalate of lime varieties; they
are frequently round, but not uncommonly elongated
or spindle-shaped.   There  is reason, however, to be-
lieve that  calculi may form in the urethra.   One of
the most remarkable instances of this kind  is repre-
sented in the annexed cut,  taken  from a drawing in
Sir R. Carswell's collection at University College. In
cases of tight stricture, sabulous or calculous concre-
tions may occasionally be found behind the constric-
tion.  The presence of a calculus in the urethra may
always be  determined by the difficulty that is occa-
sioned in micturition, by the possibility of feeling the
stone through the walls of  the  canal, or detecting it
by introducing a sound into the urethra.
   The removal of these calculi may be effected either by extraction or excision.
When situated towards  the anterior  part of the canal, a urethral calculus may
frequently be extracted by passing a long and very narrow-bladed pair of forceps
down to it, by which it is seized and  drawn forwards;  occasionally when it has
reached the navicular fossa, it cannot be got through the urethral orifice without
dilating this by incision with a  probe-pointed bistoury.  If the calculus is too
large to be extracted in this way, and appears to be firmly fixed, an incision may
be made down upon it,  through the urethra, by which it may be removed.  It is
a good rule not to make this incision in  any part  of the urethra anterior to the
scrotum, for, in consequence of the coverings of the penile  portion of the urethra
being very thin, the aperture will probably  not be closed, but a fistulous opening
left.   AVhen the  stone is situated in the  scrotal  portion of the urethra, there
would be some risk of abscess and of urinary infiltration if the incision were
made through the lax tissues of the scrotum.  Hence, it is better, if possible,  to
push the stone back towards the  membranous portion of the canal, to cut down
upon, and extract it here.   This operation may readily be done by passing a staff,
grooved, along its convexity, or an ordinary director as far as the  calculus, and
making an incision upon the end of this, so as to lay open  the urethra; the sta_
is then  removed, and the calculus extracted by means  of  a  slender pair ot tor-
 
858
PROSTATIC  CALCULI — LITHOTRITY.
ceps.  A catheter should next be passed into, and retained in the bladder for a
few days, in order to lessen the tendency to the formation  of urinary fistula.   It
may happen that the calculus, which  is impacted in the urethra, is only one of
several that are lodged in the  bladder.  In  order to ascertain this, the surgeon
should, after removing the calculus for which the operation has been performed,
pass a sound into the bladder, so as to ascertain whether  any other concretions
exist in that organ; and, if so, they should  at once be removed by extending
the incision made into the membranous portion  of the urethra into the bladder,
by the lateral operation of lithotomy.  In  this way  I once  saw  Air.  Liston
extract two vesical  calculi after having removed one that had blocked up the
urethra.

                           PROSTATIC CALCULI.

   Prostatic calculi  differ from  all other urinary concretions in situation  and com-
position, being formed in the ducts of the  prostate gland,  and composed princi-
              pally of  phosphate  of  lime and some  animal matter;  usually
              about 85 per cent,  of the  phosphate, to 15 of the  organic in-
              gredient.   They generally occur  in old people, though they may
              sometimes be met with in young subjects.   From a  lad of nine-
              teen, whom I cut for vesical  calculus, I extracted two of these
              prostatic concretions.
   They are usually of a  gray or ashy color, somewhat triangular in shape, smooth
and polished  (Fig. 287); having  facets,  being very hard, and  seldom much
larger than a cherry or  plum-stone; though  they may occasionally attain  a con-
siderable bulk, having been met with  as large as a hen's egg, and then present-
ing a branched  or irregular appearance.  Though usually but one or two exist,
which are sometimes deposited in a kind of cyst in the gland, as many  as thirty
or forty have been met with, its whole tissue  being studded with them.
   Prostatic calculi give  rise  to  a  sense of  weight, pain,  and irritation in the
perineum,  and often occasion a tolerably free secretion  of mucus from  the
gland.  On introducing  a sound this passes over them, striking the calculus with
a distinct click  before its beak enters the bladder.   This is increased by the
finger in the rectum pushing the  gland up, and thus bringing the stone in more
direct contact with the sound.  In some cases the stone may be felt  through the
coats of the rectum.
   The treatment consists in introducing a  grooved staff  and cutting  down upon
the prostate, as in the lateral operation, until  the calculi are reached, when they
may be extracted with  the forceps or scoop.   When complicated with vesical
calculus the lateral  operation should  be performed, and the stones  removed as
they present themselves.

                                lithotrity;.*

   The operation of lithotrity, by which the stone is  crushed in the bladder and
the fragments expelled through the urethra,  is of modern, and, indeed, of very
recent invention; for,  notwithstanding that various  rude and  incomplete at-
tempts may at  different  times  have been made  with this  view, it was not until
about the years 1818 or  1820 that the subject began to attract serious attention.
About this time Civiale, followed  by Amussat, Leroy, and others,  began con-
structing instruments, which though very imperfect, yet were sufficient to break
down a calculus in the bladder.  From this period the system made rapid pro-
gress, and the successive improvements made by the surgeons whose names have
just been mentioned, together with the ingenious mechanical adaptations intro-
duced bf AVeiss, Heurteloup, Costello, and Charriere, enabled surgeons to attack
the stone with certainty  and effect.  It is,  perhaps, principally due to the labors
 * [The terra lithotrity is applied by the author to the proceeding described by most surgeons as Litho-
tripsy.—Ed.]
 
CASES  ADMITTING  OF  LITHOTRITY.
859
of Civiale and Amussat in France, and of Brodie and Liston in this country, that
the system has been reduced to its present state of perfection.
  Before  proceeding to the  operation  of lithotrity, it is necessary that the
patient's constitution should be carefully attended to, and especially that all local
irritability about the urinary organs should be'  subdued  by ordinary medical
treatment.  This  is  even of  much greater importance  in  lithotrity than  in
lithotomy.  In lithotrity we  must  always expect  that  any existing irritation  or
inflammation  of the bladder will be increased  by the necessary introduction  of
instruments and the presence of sharp fragments of calculus in the bladder, and
their passage  along the urethra; but in  lithotomy all  source of irritation is at
once  removed by the  extraction of the stone.   Before determining to perform
lithotrity  then, it is necessary  to  examine  very  carefully the condition  of the
urinary organs, and if these be diseased, it will probably be requisite to abandon
the operation.
   The conditions that the surgeon has principally to look to  before lithotrity is
determined on are the characters of the stone, and the state of the urinary organs.
In order that  lithotrity should be successful, it is necessary that the stone  should
not be above  a certain  size, that it be not too hard, and that  more calculi than
one do  not exist.  The urinary organs must also be in a healthy state and free
from irritation.
   With regard to the size  of the calculus,  it may be stated generally, that the
smaller it is, the  greater will be the success of the operation.   As a general rule,
it is not well  to attempt to crush a calculus above an inch or an inch and a half
in diameter.  It is not that a  large stone  cannot be broken; because in most
cases, this might readily enough be done ;  but because the quantity of fragments
resulting would be so great that the bladder would  in all probability not be able
to get rid of  them; or, the  necessary operations for their disintegration and re-
moval would  occasion  a dangerous amount  of  irritation.   The size of the cal-
culus may always be readily ascertained by seizing it in the lithotrite, and then
measuring it by the graduated scale upon  the handle of the instrument.
   If there are several  stones, lithotrity is not a very successful procedure;  for
although each calculus may be a  small one, yet the aggregate of the whole is
considerable;  and  besides this, the small calculi will  each require  a separate
operation, as  it were, and will each contain a hard and probably very resisting
nucleus.
   The  hardness  of the calculus influences materially the question of lithotrity.
If the concretion is very hard, especially if composed of oxalate of lime or lithic
acid, giving a very clear and ringing sound, the case will not be a  very favorable
one for crushing.   For not  only may the density of  the  calculus be such as to
cause it to resist  any force that it  may be safe to bring to bear upon it; but if
broken, it will splinter into sharp and angular fragments which cannot  readily
be ground down, but will  greatly irritate  the bladder,  and will probably escape
with difficulty through the  urethra.  The  most favorable calculi for  crushing
are  those that are soft and friable, as the different forms of  phosphatic  concre-
tions, though  in this diathesis the shattered state of system and irritable condition
of the urinary organs often counterbalance  the  advantage that would otherwise
have been derived from the character of the stone.
   The  conditions of the urinary organs that influence the propriety of perform-
ing  lithotrity have  reference to the state of the  urethra, of the prostate, the
bladder, and  the kidneys.                            ..,...,   .    , . ,
   If the urethra be the seat of stricture, or is  very irritable, lithotrity, which
may  require  the frequent  introduction of instruments  and will entail the  con-
tinued  passage of fragments  of calculus, cannot be performed.
   If the prostate be enlarged, more particularly if the  third lobe  is very promi-
nent a dependent  pouch will be found at  the lower fundus of the bladder, into 
860
STONE  IN  THE  BLADDER.
which  the fragments of the crushed stone are apt to fall, and from which they
cannot be expelled;  hence such a condition  of the gland as this is  a serious,
though perhaps not an  insuperable bar to  the performance of any crushing
operation.
  The state  of the bladder deserves especial attention ; the circumstances con-
nected with it  that  principally  militate against lithotrity  are  a very  irritable
condition of it; its being contracted, hypertrophied, or sacculated.  A very irri-
table and sensitive bladder not only will be the seat of severe suffering,  but may
readily become  dangerously inflamed in  consequence of the repeated introduction
of instruments, and  the presence of angular  fragments.   Hence, if the  ordinary
operation of  sounding occasion  much distress; if the patient  cannot hold his
water long, and passes it in small quantities,  he will scarcely be able to  bear the
procedures necessary for  the operation.   At  the same time  it must be borne in
mind that the bladder may be in an opposite condition  in cases  of stone, having
fallen into a state of  atony; and this, as Civiale has pointed out, may be  a source
of great  danger  after lithotrity, the organ  not possessing sufficient expulsive
power  to rid itself of the fragments with which it is encumbered.
  A sacculated condition of the bladder is  also a serious objection  to lithotrity,
as not only are the fragments  likely to lodge in the sacculi, but these cysts
become filled with an offensive puriform fluid, and thus  may  occasion low or
typhoid cystitis, followed perhaps by pyemia.
  Lastly, the condition of the kidneys merits special attention.   If these organs
be much irritated, as indicated by the presence  of a considerable quantity of
albumen in the urine,  or in any other way, the performance of a series of opera-
tions in the  bladder would  be likely to increase the mischief in them, and
consequently ought not to be undertaken.
  The age also of the patient must be  taken into account, though lithotrity can
doubtless be  performed  at all periods of life.   The  small size of the urethra
before  puberty is such as scarcely to admit of the ready introduction of the neces-
sary instruments, or of the escape of fragments of calculus;  and hence it is rarely
had  recourse to at this  period  of life.  So  also at advanced ages  the  irritable
state of the urinary organs, the tendency to the supervention  of low cystitis, and
the condition of the prostate, are usually such as to prevent the performance of
the operation.
  Supposing, however, that a case is  met with in which the calculus is of mo-
derate size, single and not too hard, the  urinary  organs  healthy, and  not over
sensitive, and  the patient an  adult but not  too aged, the surgeon may have re-
course to lithotrity  with  every prospect of readily and permanently freeing the
patient of his calculus.   In performing the  operation in  such a case, but little
preparatory treatment is needed, though it is well to keep the patient quiet for a
few days, and to regulate his bowels before anything is done.
  The instruments required for lithotrity are the following :—An ordinary sound
with a short beak to examine  the condition of the  bladder.   A  hollow  steel
sound, through which the bladder may, if necessary, be injected after or during

                                   Fig. 288.
sounding, without the necessity of changing the instrument (Fig. 272).  This
I have found of especial service in the later stages of the operation for detecting 
                     OPERATION  OF  LITHOTRITY.                  861

small fragments.   A brass syringe, fitted with rings, and having a large piston-
rod, so that it  may work easily;  this should admit of adaptation to the hollow
sound.   A full-sized silver catheter, with large round or oval eyes, and having
an elastic gum bougie fitted to its interior, instead of a stylet,  to clear it of frag-
ments.  This  should also admit of adaptation to the syringe.   The instruments
for crushing the stone and removing the fragments consist of Weiss's lithotrite,
as represented in the preceding cut (Fig. 288); or a similar instrument worked
by a rack and pinion  instead of the straight screw (Fig. 289).   The  lithotrite

                                  Fig. 289.
must be  made  of well-tempered  steel; and should  always  be tested by being
made to crush a piece of sandstone grit, about the size of a walnut.  It should
be of as full a size as the urethra will  readily  admit, must  have the male blade
well serrated, and the female or  under blade  open  at the  beak, with  an  oval
aperture  through which the  detritus of the crushed stone is forced, and  thus
any entanglement of it between the blades prevented.                  ,
  The lithotrite should  always be cut out of a bar of solid steel, and not,  as is
the case  with some foreign  and cheap instruments,  be made of a plate of this
metal, turned up at the edges; as such a one  possesses too little strength to be
used with safety.   The scoop may, however, be so constructed without danger.

                                   Fig. 290.
  The scoop, such as is represented (Fig. 290), and invented by Civiale, has a.
double action; enabling the surgeon to work it either by the hand or a screw; it
is furnished with a kind of spoon-shaped beak, which is somewhat flattened, and
admits of the extraction of a certain quantity of detritus.  Besides, these instru-
ments, a small  lithotrite  is  occasionally used for  crushing  fragments in the
urethra, and another instrument shaped like that represented (Fig. 118) for with-
drawing them from that canal.
  The operation may be performed with  the  patient either lying in bed upon  a
hard mattrass, on a couch,  or table;  or it may be done, and in some cases  most
conveniently, in the  sitting posture.   The surgeon standing on the right side of
the patient, carefully introduces the hollow sound or catheter  and  draws off the
urine • he  then  slowly and very cautiously injects the bladder by means of the
brass syringe,  with about six or eight ounces of tepid water.   The use of draw-
ing off the  water is to make sure of the  bladder holding the proper quantity of
fluid when  it is  afterwards injected, and the object in injecting it is to distend
it with fluid to such  an  extent as to prevent the mucous membrane being seized
in the grasp of the lithotrite, or injured  by the splintering of the stone.   The
instrument is then withdrawn  after the situation of the stone  has been detected 
862
STONE  IN  THE  BLADDER.
by it, and the lithotrite is introduced.   As this is  nearly  straight, some little
skill is required in passing it.   In doing so, the eye must be kept upon the short
curved beak of the instrument, the direction and position  of which must be con-
stantly observed, and especial care must be taken in  carrying it under the pubes,
not to injure the urethra by pushing the beak of the lithotrite forwards too sud-
denly, instead of winding  it as it were under the arch of that bone.  In doing
this, the shank and handle of the lithotrite should, at first, be well raised, and as
its curved end  slips under the pubes must be gradually depressed  between the
thighs.   The direction of the curve is the thing to  bear  in mind, and the posi-
tion of the handle must be varied in accordance with the  course  that this takes.
The lithotrite should be well greased with olive-oil, so that the branch and screw
may work smoothly.  Lard or  ointment should  not  be used for this purpose,'as
it is apt to clog and to entangle gritty bits of calculus.
  The next point is to search for the stone, which will generally be  found in the
situation where its presence was detected during the sounding of the bladder;
most frequently at  the inferior fundus.   Should it be situated in a sacculus or
depression in this region,  it may most readily be seized by introducing  a finger
into the rectum, and raising up the lower part of the bladder.  In seizing the
calculus, some little tact is required; this part of the operation may  generally be
best  done  by pushing the female blade of the lithotrite  against that portion of
the bladder which is next the stone, pressing gently down with it so as to make
a conical depression in the bladder, and then  inclining  the beak  towards the
stone, draw back the male blade with the thumb ; with a shake or jerk,  the sur-
geon then tries to get the calculus between the blades at the same time that the
male branch is being pushed forwards to seize it.  In this manoeuvre the female
blade should be moved as little as possible, but the stone must be seized by press-
ing the thumb upon the half  circle of steel fixed on the male branch.  In this
way the stone may  often be seized at the first  attempt, but in other cases it is
not grasped until after  several efforts have been  made  to fix it;  the calculus,
especially if round, slipping away from  between the blades of the  instrument,
and being merely scraped  by them.
   When the stone  has been seized it is gently raised in the grasp of the lithotrite,
so as to be placed about the middle of the bladder, and it  is  then crushed.   This
important part of the operation, like  all the others, requires  to  be  deliberately
and carefully done.  It should not be effected by suddenly and forcibly screwing
up the  instrument,  but the screw should be gradually worked by a series of short
and sharp turns, so as  to constitute almost percussive movements.   In this way,
the calculus is  generally made to  crumble down, rather than to fly asunder, and
as it yields, the screw  must be worked tightly home.  The  blades of the instru-
ment may then be opened again, a fragment of the broken calculus seized and
broken up in the same way as  before, and thus  the  disintegration of the stone is
in a great measure  effected and sometimes  completed at one sitting.   It  is of
great moment, however, that too much time be  not  consumed at any one sitting.
The long-continued contact of instruments with the interior of the bladder is apt
to produce  great irritability, or a kind of atonic condition of that organ, and the
shorter the sittings, the more likely will the case do well.   The first sitting should
not exceed ten minutes and the subsequent ones five.   In the repetition of the
sittings, the surgeon must be guided by the effect produced on the stone and on
the bkdder.   The calculus may be entirely destroyed in one sitting, but  most
commonly from three to  five  or six  are  required;  these should, if possible, be
 conducted at intervals of three or four days, though this must depend upon the
amount of  irritation induced by them.
   After  the stone has been  crushed  but  little  detritus will usually escape
 during the first twenty-four hours, but after  this  it begins to be  expelled; in
 some cases in considerable quantity each time the urine is  passed.   In  others it 
 IMPACTION  OF FRAGMENTS  IN  URETHRA — CYSTITIS, ETC.  863

does not escape so readily, and then the surgeon requires to introduce the scoop
(Fig. 290), by which he can seize the smaller fragments, crush them up, and
screwing the instrument home, extract the beak  filled with detritus.   In using
this instrument care must however be taken not to get hold of too large a frag-
ment, for in breaking this up, whether by the hand or screw, the  beak may be
clogged with the detritus in such a way that  it does not readily close,  and then
there might be considerable difficulty in withdrawing it.   Should  this accident
occur the scoop may be emptied by passing the beak back into the bladder, tap-
ping sharply upon the instrument, and moving the male branch to and fro.
  After each sitting the bladder should be washed out by injecting it with tepid
water through a  catheter with  large eyes;  or, what is better, a double-current
catheter.  In using the latter instrument, the point of which should be directed
towards the inferior fundus, a  considerable quantity  of water may sometimes
with advantage be pumped  through the bladder by adapting a flute-valve syringe
to it.
  AVhen the surgeon  believes that he has pretty well emptied the bkdder of the
detritus, he must carefully explore the organ by means of a short-beaked or hol-
low sound; and if he detect any fragment, however small,  that must be seized,
crushed, and removed with the scoop.
  During the whole  of  the treatment, it is  necessary to  adopt means to alky
irritation; with  this view the patient should be kept in  bed, or  on a couch;
a moderate diet only  should  be  allowed, plenty of  demulcent drinks given,
such as barley-water, soda-water, or  milk, and opiates or  henbane if necessary
exhibited.

                ACCIDENTS AND DANGERS  OF  LITHOTRITY.

  In considering the accidents of lithotrity, I put out of consideration those that
may arise from the surgeon acting  carelessly or with improper force,  and thus
occasioning laceration of the urethra, or injury to the coats of the bladder;  so
also accidents occurring from the  bending or breaking of the instruments will

                                   Fig. 291.
scarcely happen if these have been properly tested on a piece of sandstone-grit
before being employed in the bladder.
  The most dangerous  accident arises from the impaction of some of the angu-
lar fragments of stone in the urethra.  They are  especially apt to lodge about
the bulb, and there  give rise to a very great degree of irritation, and even of
fatal mischief, producing great  constitutional disturbance  of an irritative and
asthenic type.   When the fragments are impacted low down in the urethra, it is
absolutely necessary to remove them from the canal as  speedily as possible, lest
the constitutional  disturbance occasioned  by them prove fatal  to the  patient.
This may be done in various ways; it has been proposed to push them back into
the bladder with a soft bougie, or by injecting a stream of water into the urethra
through an open-ended catheter; but these devices are not very likely  to be
successful  and may  give rise to risk of laceration of the urethra.   It has
been proposed to crush them in the urethra with a small lithotrite (Fig. 291);
but this plan is somewhat hazardous, as it is very difficult to avoid pinching up
the  mucous membrane of the canal with the bit of stone.   The  safest practice
seems to be either to extract them through the urethral  orifice, or to  cut them 
864
STONE  IN  THE  BLADDER.
out through  the  perineum.   Extraction  through the  urethral orifice may be
effected by the forceps  (Fig. 292), or  by Civiale's  instrument (Fig.  118).
                  Should this means fail, or should the fragment be very deeply
                  seated, as in the membranous portion of the urethra, the bet-
                  ter plan would be to make an incision directly  down upon it,
                  and to remove it  through the perineum.   If such an opera-
                  tion as this be required, the  surgeon might possibly feel dis-
                  posed to extend the incision  a little, and empty the bladder
                  of any remaining detritus by means of a scoop.
                     The principal  dangers in lithotrity arise from the state of
                  the bladder and kidneys;—by the  induction of cystitis of a
                  low form,  atony of the  bladder, or  renal irritation, or by the
                  occurrence of pyemia, with much constitutional  disturbance
                  of a low type.
                     Cystitis may occur in consequence of the increased irrita-
                  tion to which  the bkdder  is subjected.  AVhen it sets in it
                  speedily assumes  a low form,  and  is  apt to  prove  fatal by the
                  induction  of typhoid symptoms;  even if it do not do so, its
                  occurrence is an insuperable obstacle to the further crushing
                  of the stone, and in such cases as these, the best course that
                  could be  pursued would be, after getting the patient into as
                  favorable  a state as possible, to remove  the fragments by
                  lithotomy.
                     Atony of the bladder is  one of the most dangerous condi-
                  tions that can occur in lithotrity.   This state of things  hap-
                  pens usually in elderly people, in whom the urinary organs
                  may appear to  be in a peculiarly quiet and favorable condi-
                  tion before the operation, the patient being able to hold his
                  water for  six or eight hours, and  to bear the injection of ten
                  or twelve ounces  of fluid.   Under these  circumstances  the
                  surgeon should be upon his  guard, for  the danger of this
                  condition  is, that the bladder does not possess sufficient con-
tractile power to  expel the fragments.  These  consequently  accumulate in the
lower fundus and irritate the mucous membrane, and thus the foundation  may
be laid for fatal cystitis, which in these cases always  assumes a typhoid type.
   The atony of the  bladder  appears to  arise partly from that natural want of
expulsive  power,  which is not unfrequent  in old people, and  partly from a kind
of paralysis of the organ, induced by  the contact of the instruments and the pres-
sure of the fragments; this happened in a patient whom I lithotrized at Univer-
sity College Hospital about  two  years ago, and who died with severe constitu-
tional depression, and with some pyemic symptoms.
   AA7hen atony of the bladder has come on, it is essential that the surgeon should
rid the patient of the fragments which he is  unable to expel.  This may some-
times be done by means of the scoop, assisted by washing out the bladder through
the double-current catheter, but the  safer  plan would probably be to get the pa-
tient into  as good a condition as possible and then cut him.  This I recently did
in an interesting  case  under  my care at the Hospital;  the patient, an old man,
had been  lithotrized  by a surgeon out of doors a few  weeks before admission, but
no fragments had passed; on sounding him, I found a moderate-sized calculus,
with what appeared to be a large mass of soft  concretion, of the nature of which
I was not aware until after its removal; the patient having concealed the fact of
his having been  lithotrized.  On cutting  him in the usual  way, I removed a
lithic acid calculus about as large as a pigeon's egg,  and a handful of fragments
of another calculus of the same  composition, which  had been crusted over and
matted together by phosphatic deposit.  The patient made a very good recovery.
 
            LITHOTOMY  AND  LITHOTRITY  COMPARED.         865

  Irritation of  the  kidneys, giving rise  to suppression of urine, occasionally
occurs.   In such cases, cupping the loins, and the warm hip-bath, would be the
proper treatment to pursue.
  Very considerable constitutional depression occasionally follows the operation
of lithotrity, the pulse becoming quick, feeble, and intermitting; the skin hot
and dry ; and the tongue  brown.   This  condition, which is apt to  prove fatal
either directly or by intercurrent visceral  mischief, appears to arise in some cases
from direct shock to the system; in others, from the formation of abscess in the
neighborhood of the prostate, or around the neck of the  bladdder ; and in other
instances, again, from the supervention of unhealthy suppuration in some  of the
sacculi that are occasionally met with in this organ ;—from whatever cause arising
this condition is usually eventually fatal by the supervention of pyemia.

           COMPARISON BETWEEN LITHOTOMY AND  LITHOTRITY.

  Lithotomy and Lithotrity differ so entirely from one  another in principle and
detail, that it is useless to attempt to establish a comparison between the different
steps of these two operations.   It is, however, a question of very considerable im-
portance and interest to  ascertain by which operation a patient can most safely
have  a calculus removed  from his  bladder.   In determining this point, it is
not only necessary to make a comparison between the general results of cases that
have  been subjected to the two procedures, but more  especially to  determine
those circumstances that influence the result  of either operation in particular
cases—to determine, in fact, in what cases lithotomy, and in what lithotrity, holds
out the best prospect to the patient.   It  is, I think, in  the  highest  degree un-
practical to enter into a discussion as to which should be the  general  method of
treatment in cases of stone.  Both operations have  been reduced to  great sim-
plicity and certainty; but neither should be  exclusively practised.  It is un-
doubtedly the duty of the surgeon to make himself familiar with the practice of
both,  and to adopt that one which promises best in the  particular  instance with
which he has to do.  If, however, I were called upon to say which  operation I
consider most generally applicable, then I should unquestionably answer lithotomy.
But yet there can be no doubt that there are many cases in which lithotrity is the
preferable method;  and in those in which lithotomy or lithotrity may be done
with an equal chance of success, the preference should,  I think, be given to the
crushing over the cutting operation.
  The statistics that are before the profession do not represent the true state of
the question, so far as a  general comparison between the operations is concerned.
For it  must be borne in  mind that those cases  that are lithotrized have been in-
variably picked cases ; whilst lithotomy has been performed on almost all patients
as they have presented themselves.  It has already been stated (page 859) that
for lithotrity to be successfully done, it is necessary that  the stone be of moderate
size, single, not too hard, and that the urinary organs be in  a healthy state and
free from irritation.   And this is the state in which most of the cases have been
in which crushing has been  done.   In lithotomy cases  on  the other hand, the
surgeon has had to contend with all the difficulties of large  or multiple calculi,
diseased bladders, and bad constitutions.   Hence on  comparing  the  statistics of
the results of lithotrity with those of lithotomy, we compare the statistics  of the
results of operations performed under the most  favorable  circumstances  on  a
series of picked cases, with those of cases taken indiscriminately and often pre-
senting most unfavorable circumstances.
  Another cause of uncertainty with regard to the statistics of lithotrity is, that
those  we possess are chiefly from a professed lithotritist,  31.  Civiale, the accuracy
of which has been denied in a very decided and  emphatic  manner by many of
the leading surgeons in Paris, who have inquired fully into  the matter; and the
                                    55 
866
STONE  IN  THE  BLADDER.
conclusions from which must necessarily be received with much hesitation in this
country, where it is difficult to arrive at the real truth of the statements advanced
on either side.
  If we compare Civiale's statistics of lithotrity with those of lithotomy as prac-
tised by the most skilful surgeons, Cheselden, Liston, and the Norwich operators,
we should at once decide in favor of the crushing method ; for Civiale states that
out of 591 operations he had but 14 deaths, or 1 in 42-2 ; whilst, as we have seen,
the  most skilful lithotomists in this  country, where the results  of the cutting
operation have been far more successful than elsewhere, can only boast of such a
rate  of mortality as 1 in  7 9, or at  most in 10.  But though the success is  thus
stated  to have been great in  the cases that occurred under  Civiale,  it has been
far different when we look to the practice of  other  French surgeons.  Thus of
162  cases operated upon by lithotrity by various surgeons in Paris, Civiale states
that death resulted in 38,  and a cure in 100 instances ; the results of the remain-
ing cases being unknown, or the cure incomplete.  In this country it is impossible
to say, even approximately, what the average mortality after lithotrity has been;
those surgeons who have had most experience in this operation not  having pub-
lished  any account of their cases;  but I believe there is  a pretty general feeling
that in the different London hospitals in which it has been performed, lithotrity
has not been a very  successful operation.   The same remark appears  to hold good
with regard to the Parisian  hospitals;  3Ialgaigne estimates the  mortality from
lithotrity in these Institutions at 1 in 4, while he calculates that of private cases
at 1  in 8.  This difference between the results of this operation in hospital and
private practice  can  easily be accounted for by the difference in the constitutions
of the  patients, and by their  applying for relief in private  in a less advanced form
of the  disease than in hospital practice.  We find the same hold good with regard
to the  results of lithotomy.   Thus  Mr.  Coulson states that Dr. Dudley lost only 1
in 36 of the private patients  that he cut; Dr. Nuttauer, 1 in 36\; Air. Alartineau,
1 in 42 ; and Dr. Alott, 1 in 50.   These results are fully as favorable as Civiale's
statistics of lithotrity, and  show the influence that the constitution of the patient,
and  a  proper  selection  of cases  may exercise  upon the  results of  the  cutting
operation.
  Lithotrity, as has  already been stated, cannot be applied to  all  cases of stone,
but  in many that are unsuited to  this operation, lithotomy may be done with
success.   In some cases, however,  no operation can be practised in  consequence
of serious disease of the genitals, bladder, or  kidneys, or of some visceral mis-
chief that would necessarily  interfere with the performance of any  capital  ope-
ration.  The necessity of selecting cases of lithotrity is well instanced by a state-
ment that Civiale has  given with reference to this point.   This dexterous litho-
tritist considered that of the 838 calculous patients that applied to him during a
series of twenty years, only 548 were fit cases  for lithotrity,  and 290, or more
than one-third, were not operated on by this method; of the last 332 cases in-
cluded in this list, 241 were lithotrized, 2 in 3-6 being considered unfit for  that
operation.   Of the 91 cases not crushed, 28 were cut, and in 8 others lithotrity
and  lithotomy were combined.   Of these, 36 cases  subjected to lithotomy,  AI.
Civiale lost  18,  or exactly one-half.  These figures  show that lithotrity cannot
be considered the general  operation for stone;  but must, even in the hands of
the most dexterous and successful  practitioners, be in many instances replaced
by the cutting operation.
  The circumstances that most chiefly determine the surgeon  in the selection of
the particular operation to be performed, are the age of the patient,  the size and
character of the  stone, and the conditions of the urinary organs.
  The age of the patient is an important element.   As a  general  rule it may be
stated, that it is at  the middle  and advanced periods of life that  lithotrity is
most successful, whilst at early ages lithotomy is the preferable operation.   The 
LITHOTOMY AND  LITHOTRITY  COMPARED.          867
 success of lithotrity at advanced periods of life is as good as in middle age, and
 has been  very great in the hands of some surgeons.  Thus, Segalas states, that
 ot 14 octogenarians whom he lithotrized he did not lose one; and of 27 septua-
 genarians but two.   Lithotomy, on  the other hand, is  extremely fatal in a^ed
 persons.  In children, under or about the age of puberty, lithotrity is a difficult
 operation  though it may be performed even at very early periods; but the small
 size of  the urethra and the restlessness of the child interfere materially with the
 success of this operation.   Lithotomy, on the other hand,  is  so  successful  an
 operation  in children, that  the surgeon would probably  gain nothing by substi-
 tuting lithotrity for it.   Thus, of 35 children under ten, operated on by Che-
 selden,  but one died ;  and of 58 cases of children  operated  on at  St. Thomas's
 but one proved fatal.   Hence, lithotomy, being equally safe and far speedier'
 should be preferred to lithotrity in all cases under about twenty years of age.
   The  size  and  character of the stone influence  in a  very important manner
 the choice of an operation.  Surgeons  generally recognise the fact that a small
 stone is more favorable  to lithotrity  than  a large  one,  and  that  the  operation
 should not be undertaken if the calculus exceeds one and a half inch in diameter.
 Below an inch all calculi  may  be crushed, provided other circumstances are
 favorable.   Aluch, however, will  depend  upon their composition.  Phosphatic
 calculi  of larger  size may even  readily  be  crushed, and thus be got rid  of.
 Lithic  acid concretions,  the fragments of which do not  disintegrate, but split
 up into sharp and angular spiculas and scales, do not, if large, admit of lithotrity.
 Oxalate of lime calculi, occurring as they do  chiefly in  young  people, compara-
 tively rarely require lithotrity, but, when crushed,  break up  very readily, and as
 there is usually  a co-existing  healthy state of the urinary organs,  the  cases
 have a favorable  issue.   Some of the  French lithotrizers  are in  the  habit of
 breaking  up friable phosphatic calculi  from fifteen to twenty lines or  more in
 diameter,  but stones of this size are, I think, usually and more prudently sub-
 jected to lithotomy in this country.   The existence of several calculi, even when
 small, though not a bar,- is yet  an  objection to lithotrity  for  reasons already
 stated.
   The condition of the urinary organs is perhaps of more importance  than the
 size and character of the stone.  As a  general rule it may  be stated, that the
 greater  the irritability and inflammatory tendency of these  parts,  the  less suc-
 cessful will  lithotrity be.   The repeated introduction of  instruments,  however
 carefully  and skilfully conducted, the presence of fragments  of  calculus, and
 their tendency to impaction or entanglement  in  the urethra, necessarily dispose
 to inflammation, even in the most favorable cases, and very  readily excite it, if
 there be any tendency to such action existing  in  the parts.  If,  however, the
 stone be of small or moderate size, friable, the bkdder  healthy, and  with good
 contractile power, the urethra capacious, and the  patient of sound constitution
 and quiet nervous temperament,  the stone may often  be broken up  and the
 fragments expelled with  remarkably little suffering.  In fact, under a combina-
 tion of favorable circumstances, such as these, lithotrity ought unquestionably to
 be preferred to lithotomy.
   If, however, the bladder be very irritable, or if the patient's constitution is an
 excitable one, so that he does not bear the introduction of instruments well, and
 more particularly if it be found that this local and constitutional  sensitiveness,
 instead of being blunted by the methodical introduction  of sounds  or bougies, is
 rather increased by them; and  especially  if the stone be of a medium or large
 size, so that several sittings would be required  before  the fragments could be
 expelled, lithotomy should  be had  recourse to.
  The existence of organic disease,  however, about  the  urinary organs consti-
tutes the greatest  obstacle to  lithotrity, and when  extensive must constitute a 
*6S
STONE  IN  THE  BLADDER.
complete bar to the performance of that operation.  It is  not easy, however, to
determine the amount of local disease that should be thus held to contraindicate
lithotrity.  On this point the opinions of surgeons differ much, and it is particu-
larly in the management of these cases that the advantage of that tact and dex-
terity in the use of the crushing instruments which habit can alone give, is so
well exemplified.
  Organic disease of the kidneys is a more serious obstacle to  lithotrity than to
lithotomy,  on account of the prolonged nature of the operation, and the greater
liability to  sympathetic or propagated irritation in  these organs,  giving  rise to
purulent nephritis.  It is not only by the operation increasing the renal mischief
that harm might result, but rather in  consequence  of the  tendency  to low
and diffuse inflammation, to pyemia,  &c,  that  always  co-exist  with kidney-
disease.
  A chronically inflamed state of the bladder, more particularly if the organ is
thickened and fasciculated, so that it will not bear the injection of a few ounces
of tepid water, seriously interferes with the success of lithotrity.   If the bladder
be sacculated, there will be a still  greater  risk of an  unfavorable result, these
sacculi not only retaining fragments of calculus, but also becoming the seats of
unhealthy  inflammation,  in  consequence of  which typhoid  cystitis of a  very
serious character, followed by pyemic symptoms  and metastatic abscesses, may
result.  In such cases as these, lithotomy offers the only chance to the patient.
The existence of a moderate amount  of vesical catarrh,  if the bladder  is other-
wise healthy, is no objection to lithotrity.
  Atony of the bladder is a serious inconvenience, and a great source of danger
in lithotrity.   It cannot well be positively ascertained, though it may be sus-
pected, if the patient can hold his water for  a great many hours, and can bear
without complaint the  injection of a large quantity—eight  or ten ounces—of
fluid,  the interior of the bladder feeling large and smooth to the sound.   This
condition chiefly occurs in old men  of feeble habit of body;  and, if ascertained,
should call for the performance of lithotomy.
  In encysted calculus, lithotrity is for obvious reasons inadmissible.
  Aloderate enlargement of the prostate, such as  habitually met with in elderly
people, does not necessarily prevent the  performance of lithotrity, though it un-
doubtedly complicates the  operation,  and increases its difficulties, the fragments
having a tendency to become lodged in the lower fundus behind  the  enlarged
gland.  This more especially happens if the middle lobe is enlarged, and under
these  circumstances, though the stone may undoubtedly be crushed, yet the frag-
ments would probably require to be removed by the scoop; the operation would
consequently be very tedious and prolonged,  and  lithotomy  would probably be
found to answer best.   Any inflammatory disease or abscess of the prostate, must
necessarily prevent the performance of lithotrity.
  Stricture of the urethra does not prevent the performance of lithotrity, but only
retards the operation until  the constriction  can be properly dilated.  Should this,
however, not be practicable to the full extent of the urethra, lithotomy on a small
staff must be practised.
  I have said nothing in this comparison between lithotrity and lithotomy of the
comparative  painfulness of the two operations; for as chloroform may  be admi-
nistered with equal advantage in both sets of cases, there is  little difference in
this respect, except that perhaps the  advantage lies on the side of lithotomy, as
being the shorter proceeding.
  From all that precedes,  then it would appear that useful as lithotrity unques-
tionably is, in many cases it cannot be looked upon as a general means of treating
stone  in the bladder;  being only applicable under very favorable  circumstances,
and that a large number of cases will always be left in which lithotomy offers
the sole means of relief. 
CALCULUS IN THE FEMALE.
869
   Recurrence of  calculus after operation  may take place from  two  distinct
causes—either in  consequence of a continuance of the constitutional condition
or diathesis, under the influence  of which the  calculus was originally formed,
or from a fragment of calculus having been  accidentally left behind after its
extraction.
   Relapse from the first  cause  is  probably not very common, but its occasional
occurrence shows the necessity of continuing constitutional treatment adapted to
the particuliar diathesis after the removal of the calculus from the bladder.   It
is relapse  from this cause  that probably occurs in cases of lithotomy, though even
in this operation, a fragment of  calculus may accidentally be broken off during
extraction, and left behind.  Vet  such an accident is  not very frequent;  for if
the calculus happens to be broken  during extraction, the fragments, if  not com-
pletely cleared out of the bladder, will  usually be washed away  through the
wound by the flow of urine.   The  registers of  the Norwich  Hospital  show
1 relapse in 58  cases; and those of Luneville, 1 in 116 cases  of lithotomy
(Coulson).
   In lithotrity, on the other hand,  relapse is far more common.   In the practice
of 31. Civiale it has occurred about once in every tenth case.   This must evi-
dently arise from some fragment of calculus having escaped detection and being
left behind, thus constituting a nucleus for  a  fresh formation.   The frequency
of the occurrence of secondary calculi after  lithotrity, even in  such practised
hands as 31.  Civiale's, certainly  constitutes an  objection to that operation, and
shows the necessity of the surgeon  most carefully examining the bladder before
he pronounces  the patient cured; and even then watching  him for some length
of time in order to meet the calculus at its first formation, and  to adopt means
for its early removal.
   In the event of a secondary calculus forming, whether after lithotomy or litho-
trity, most surgeons would feel  disposed to extract it  by the cutting operation.
If lithotomy have  previously been  performed, this must be done again in the
usual way, through the cicatrix  left by the former wound.

                       CALCULUS IN THE FEMALE.

   Stone  is of rare occurrence in women; in London, certainly,  I believe it  is
seldom met with.  Thus,  South states, that during a period of twenty-three years,
144 males were operated on for stone at St. Thomas's Hospital, and only 2 females.
At the University College Hospital, I only recollect  having seen  one case of
calculus in the female.  In some  districts, however, stone would appear to be
more common  in  women  than  this: thus, according to Mr. Crosse, at  the Nor-
wich  Hospital, the proportion  has been  about 1 woman to  19  men.   Civiale
states as the result of his  researches, that in the North of Italy, the proportion
is as 1 to 18; and in  France, as about 1 to 22.   Calculus in women is very fre-
quently deposited upon foreign bodies, accidentally or purposely introduced  into
the bladder, such as pins, pieces of pencil, &c.
   The symptoms of stone in  women so closely resemble those occurring in the
male, that I need not recapitulate them here.   Its  presence may always readily
be detected by the introduction of a short, nearly straight female  sound.
   The removal of  the calculus may be effected by extracting the stone  through
the urethra;—cutting it out through the vagina;—or, crushing it  in the bkdder.
   The operation of lithotomy in the female, is that by which  the calculus is
extracted through  an incision made from the anterior wall of the vagina into the
bladder.   This procedure, though  readily enough effected, is  scarcely ever  had
recourse to at  the  present day, on account of the liability to a vesico-vaginal
fistula resulting.  It should only be performed in those cases in which the calculus
is too large to be extracted through the urethra. 
870         DISEASES  OF  THE  PENIS  AND SCROTUM.

   The extraction through the urethra is  the plan that has commonly been had
recourse to.  In order to effect this, however, it is necessary that the canal should
be dilated to a sufficient extent for the introduction of the forceps, and the proper
removal of the stone.   This dilatation of the urethra may be accomplished either
with or without previous incision through the mucous membrane.  If an incision
is determined on, its proper direction has been a good deal canvassed.  Thus,
Brodie  makes it directly upwards; Liston notched the neck of the bkdder down-
wards and  outwards on either side.  I think it signifies  little in which direction
such an incision is carried, as it must not extend deeply; its sole object being to
divide the  mucous membrane and submucous cellular tissue, and thus to prevent
injurious stretching.  After the division, the  dilatation may most conveniently
be effected by one of  AVeiss's  three-bladed dilators, or  an instrument like that
figured (242, b), and  the canal rapidly expanded so as to  admit the fingers and
forceps; the stone is then extracted through the dilated canal without difficulty.
The great and indeed fatal objection to this operation, is that it is almost invari-
ably followed by incontinence  of urine, resulting from  the stretching to which
the urethra has been subjected.
   It is  in  consequence of the liability to incontinence of urine that is left after
the operation just described, that it has been proposed to extend lithotrity to the
female, and there can be no doubt that  this operation is peculiarly  adapted  to
calculus in women; the short, straight and capacious  urethra,  preventing any
difficulty either in the introduction of instruments or in the expulsion of frag-
ments.  The operation may be done without dilating the urethra, though if the
calculus be of very large size, it might be well to adopt this precaution to a mode-
rate extent.  The instrument with which stone is crushed  in the female, are the
same as those employed for the same purpose in the male, and the operation re-
quires  to be conducted in precisely a similar manner.  The only special diffi-
culty attending it, is the injection or rather retension of a sufficient quantity  of
fluid in the bladder;  but with a little management and  proper elevation of the
hips this may be effected.
                         CHAPTER  LVIII.


             DISEASES OF  THE  PENIS AND SCROTUM.

  The penis is liable  to certain malformations.   Thus it occasionally happens
that there is an arrest of union in the mesial line, so that a  slit or fissure is left
communicating with the urethra.  This gap commonly occurs on the under sur-
face of the organ, constituting hypospadias, and is confined to the glans and an-
terior part of the penis, though  it occasionally extends backwards to the root of
the organ, and then may be associated with some  of those kinds of malformation
that are erroneously considered as examples of hermaphroditism.   These condi-
tions are mostly incurable, though plastic proceedings have occasionally been de-
vised for their relief.
  The upper surface of the penis is  less frequently fissured, only, I believe, in
cases of extroversion of the bladder.  This  condition, termed epispadias, may be
looked upon as incurable.
  The prepuce is not  unfrequently the seat of malformation or disease.   That 
                      PHIMOSIS--CIRCUMCISION.                  871

condition of it in which it is so much elongated that it extends beyond and covers
in the glans, and at the same time so much contracted that it prevents the proper
exposure of this portion of the organ, is termed phimosis.   This may be either
congenital, or acquired, as the result of inflammation or disease.
  In the congenital phimosis  the  penis is usually somewhat atrophied, and the
development of the glans prevented by the pressure of the narrow prepuce.   In
the majority of cases  this condition is simply a source of inconvenience, but it
may become a source of disease from the retention of  the sebaceous secretion of
the part, setting up irritation and repeated attacks of inflammation.   Congenital
phymosis especially becomes a source of inconvenience if any gonorrheal or vene-
real disease is contracted, as it renders the exposure of the diseased part difficult
or impossible, and  interferes with the necessary treatment.
  Phimosis that is acquired has usually resulted from repeated      j-jg. 293.
attacks  of inflammation, or of specific  disease in  the  part,
giving rise to  solid oedema, or false hypertrophy of the  pre-
puce.
  The treatment of phimosis, when not congenital, must be
conducted in accordance with its cause.  Thus, if resulting from
inflammation, that must be subdued;  if from  venereal disease,
that must  be   remedied,  when perhaps  the contraction  and
elongation  will gradually subside.  If, however, the phimosis
be congenital, or if it be  acquired, but permanent, it must be
subjected to  operation, and indeed, I think, that all cases of
congenital  phimosis in children, should be operated upon with
the view of preserving the health and cleanliness of the parts in
after-life.
   Operations for phimosis may be conducted on two plans;  the elongated and
contracted  pressure may be slit up, or circumcision may be performed.   Slitting
up the prepuce, whether upon  its upper or under surface, is always, I think,  an
objectionable procedure, leaving the prepuce of its abnormal length, and more or
less fissured and knotted.   In all cases I prefer circumcision as the simplest and
speediest operation, and as leaving the most satisfactory result.
   [A new  method for the cure of phimosis has been devised and practised for
some years past by Dr. Pancoast.   It consists in the removal of a /\ shaped por-
tion of the upper semi-circumference of the prepuce,  the apex of the  /\ being
directed towards the root of  the penis.  The skin is  then to be  strongly drawn
backwards  by an assistant;  whilst the surgeon clips away with a pair of curved
scissors, the thickened and divided mucous membrane of the prepuce  until the
side of the frenuni is reached.  By this  means, merely a narrow hem is left at
that point,  at which the mucous membrane is  reflected over the glans. From this
mucous hem delicate stitches are passed obliquely upwards, through the margin
of the skin, in  such manner  as to effect a perfectly circular inversion of this
latter, which is now to form the new mucous  lining of the prepuce.
  In  detaching the f\ shaped portion of the prepuce Dr. Pancoast directs an
assistant strongly to retract the skin, whilst the surgeon inserts a tenaculum into
the mucous membrane posteriorly,  in order to avoid an excessive removal of the
covering of the penis.—Ed.]
   Circumcision may most conveniently  be performed  in the following way :—
The surgeon draws the elongated prepuce  slightly forwards, until that portion of
it which corresponds to the back of the  glans is brought just in front of that
structure.  He then seizes the projecting  prepuce with a  pair of narrow-bladed
polypus-forceps, which he gives to an assistant, who must hold them tightly.   He
then with one sweep of the bistoury cuts off all that portion of integument which
projects beyond the forceps, which are then taken away. It will now be found that 
872           DISEASES  OF THE  PENIS AND  SCROTUM.
he has only removed a circle of skin, but that  the  mucous membrane lining it,
                      still tightly embraces the glans.   He slits this up, by in-
        Fig. 291.        troducing the point of a pair of scissors at the preputial
                      orifice; and then  trimming off the angles of the flaps of
                      mucous membrane and  snipping across  the frenum, he
                      turns back the mucous  membrane,  and attaches it to the
                      edge of the cutaneous incision by four points of suture,
                      two on each side.   Before introducing these he will gene-
                      rally find it necessary to ligature a small  artery on either
                      side of the  penis, and  sometimes  one in  the  frenum.
                      Union readily takes place by simple dressing, and a very
                      narrow line  of cicatrix is left by which the patient is by
                      no means  inconvenienced.   In some cases I have found
                      adhesions  between the prepuce and the  glans which re-
                      quire to be dissected through, but no inconvenience results
                      from this slight addition to the operation.
  If sloughing of the prepuce have occurred allowing the glans to protrude as
in Fig. 294, circumcision must be practised.

                              PARAPHIMOSIS.

  In paraphimosis the prepuce has been forcibly drawn back behind the glans,
which  becomes strangled  by the  pressure exercised  by the preputial orifice, so
that the parts  cannot be replaced  in proper relation to one  another.   This acci-
dent principally occurs in boys, or in individuals who have naturally got a tight
prepuce, and who on uncovering the glans find  it difficult to get this part of the
organ  back again.   This  difficulty is speedily and greatly  increased by  the
swelling from congestion that is set up in the constricted glans.
  The treatment of this condition is sufficiently  simple.   The  surgeon should
first try to reduce the swollen organ.  He may often succeed  in doing this by
seizing the body of the  penis between the index and middle fingers of either
                                       hand, and then  endeavoring  to draw •
               Fig. 295.                  the prepuce forwards at the same time
                                       that he  compresses the glans  between
                                       the two thumbs  and pushes  it back.
                                       Should reduction  not be effected in this
                                       way, the constricted  and strangulating
                                       preputial orifice must be divided.  In
                                       doing this,  the  surgeon  will observe
                                       that  the glans is separated from  the
                                       body of the penis by a deep and narrow
                                       sulcus, which is  especially evident on
                                       the upper part of the organ (Fig. 295 a).
                                       This sulcus which is overlapped on one
side by the glans and on the other by a fold of integument, corresponds to the
inner margin of the preputial orifice, and it is  by the division of this, in which
the stricture is situated, that immediate relief will be given.   This operation
may readily be done by drawing the glans forwards, then passing the point of a
narrow-bladed scalpel into the sulcus on the dorsum of the penis, and making a
perpendicular  incision about one-third of an inch in length through the integu-
ments  at the bottom  of the groove directly across it.   In consequence of the
great stretching of the parts, the incision will  immediately gape widely, so that
instead of being longitudinal it will appear to be  transverse, and  then reduction
of the glans may readily be effected.
s
 
BALANITIS--CANCER OF THE PENIS.
873
                                 BALANITIS.

   Inflammation of the prepuce commonly occurs as the result of local irritatior,
 not unfrequently set up as the result of gonorrhoea.   AVhen confined to the pre-
 puce, and constituting balanitis, that structure is much swollen, infiltrated, and
 reddened, and whilst the  inflammation  lasts, continues in a state of phimosis.
 AVhen the mucous membrane of the glans is affected as well, constituting posthitis,
 there is  a good deal of irritation and  smarting, together with muco-purulent
 discharge.
   The disease requires to be treated on  ordinary antiphlogistic principles; the
 continued application of lead lotion, with the internal administration of salines,
 will generally remove it; but in  many instances the most effectual plan will be
 found to consist in rapidly sweeping the  inflamed surfaces with a stick of nitrate
 of silver  passed  down  between them on  one side of the frenum,  and carried
 round to the opposite side.
   Herpes of the glans and prepuce is chararacterized by the formation of small
 vesicles or excoriated points upon  the mucous membrane of this region, attended
 by much smarting and itching,  and chiefly occurring in persons of a gouty habit
 of body, with an irritable mucous  membrane.   This slight affection is often very
 rebellious to treatment.  In many instances, local means alone will not suffice;
 for though relief may  be obtained by  powdering the
 part with the oxide of zinc, by using slightly astrin-          Fis- 296.
 gent and cooling lotions,  yet no permanent benefit
 will be derived unless  constitutional irritation be re-
 moved by treatment of a cooling or alterative charac-
 ter,  modified according  to the circumstances of the
 case.
   Hypertrophy of the prepuce not unfrequently occurs
 as the result of chronic  irritation or disease; it  is
 usually of limited extent, and requires no special in-
 terference on the part of the surgeon; but in some
 instances  it may become so  extensive as to demand
 operative interference.   Thus Vidal has related  and
 figured  a case  that had attained such  an enormous
 size, that  the organ reached  to below the knees,  and
 was as large as a thigh.  This monstrous growth  was
 successfully excised.
   Warts on the penis have already been  described; they may attain a very  large
 size, as in Fig. 296, and are best treated by excision.

                          CANCER  OF  THE  PENIS.
   The penis is liable to cancerous  disease, which commonly assumes the scirrhous
 form, and usually springs from the sulcus behind the glans, and may thence in-
 vade the neighboring portion  of the organ or the prepuce.  It may assume the
 primary form either of a tubercle, of infiltrated cancer of the glans, or of a can-
 croid ulcer.   It has been supposed, and  with some show of reason, that conge-
 nital phimosis  predisposes to the affection, probably by  confining the secretions,
 and thus keeping up irritation of the part.   Thus Hey states, that of 12 patients
 with this disease  who came under his  observation,  9 had congenital phimosis;
 and Travers states that the Jews who are circumcised are seldom subject to this
 affection.  But as  they are a limited  community in this country, and  as the
 disease is rare, we cannotJdraw any conclusive inference  from this observation.
 The  affection, however, can occur in  individuals who have  not  suffered  from
phimosis; of  this  we have  had  several instances  at  the University College
Hospital.
 
874          DISEASES  OF THE  PENIS AND  SCROTUM.

  The progress of the disease is  usually somewhat slow; the organ  enlarging
and hardening, without any very great degree of pain.  If it form as a tubercle,
it mav, after a time, give rise to a  large irregular and  sprouting  mass, having a
granular fungous appearance, bleeding with much fetid discharge, enveloping
and at last implicating the glans, prepuce, &c.   In other cases it  may commence
as a hard scirrhous mass, of a pale reddish-white color, situated on the glans, or-
between  the prepuce and  the  glans.  This increases in size, at last cracks, and
allows a serous  fetid discharge to exude.  Ulceration  then  rapidly takes place.
Sometimes this schirrus appears  to be very distinctly localized; but after its
removal it will  always present the character of an infiltrated cancer.   It is, I
believe, always primarily situated at the anterior extremity of the penis, not oc-
curring in the body of the organ, except as a secondary deposit.
  Cancer of the penis requires to be diagnosed from warts of a fungoid character.
This may usually be done readily enough by comparing the indurated state of
the malignant,  with the  soft and  lax  condition of the non-malignant affection.
From chancrous induration, the history of the  case and the way in which it is
influenced by treatment,  will enable the surgeon to effect a diagnosis.  In indu-
rated plastic effusions into the corpus spongiosum, no pain  is experienced, and
the disease remains in a  stationary condition.
  The treatment of cancer of the penis must be conducted on the principles that
guide us in the malignant affections  wherever situated, viz.;  to extirpate or
remove  the  diseased organ; provided the affection is localized, the  glans not
implicated, and the constitution  not poisoned.   In  the  case of cancer of the
penis, this may readily be done by an  operation that is simple in its  execution
and devoid of danger.  In many  cases, doubtless, a return may  take place, and
that speedily, either in the part itself or in  the  neighboring lymphatic glands;
but yet,  even if this occur, it is clearly the duty  of the surgeon to  rid the  patient
of a loathsome disease, and to put  him  in a state of comparative comfort for some
months;  the more so, as there can be no  doubt that,  in  some instances, the
disease  may be entirely extirpated from the system, evincing  no  tendency to
return.   In some of Hey's cases, which continued under his observation, there
was no recurrence of the disease for several  years; and I have lately seen a gen-
tleman who  had his penis amputated for cancer  more  than twenty years ago, and
in whom no return has taken place.   The fact is, that we see and hear of those
cases-in which  a recurrence  takes place; but those patients who remain  free from
a return of the affection  do not divulge their infirmity; and it is exceedingly
rare  in Hospital practice to find a patient come back with  recurrent  cancer in
the stump of the penis or the lymphatic glands, which he would certainly do if
relapse took place.   In  those  cases in which the  operation  is not successful, it
generally happens that the disease has already implicated  the lymphatic  glands,
and then relief comes too late.
  Amputation of the penis  must  always be  performed towards the root of the
organ so as to get well clear of the disease; at the same time care must be taken
not to remove it too near the pubes, lest the stump retract under that bone.  The
operation may readily be done by the surgeon putting the penis upon the stretch,
drawing the integument well forward,  and then  severing the organ at one stroke
of the bistoury.   It is well not to leave too much skin lest the flap, falling over
the face of the stump, makes  the  search for any bleeding vessels  somewhat diffi-
cult,  and afterwards puckers  inconveniently.   There are usually four  arteries
requiring ligature; the dorsalis penis,  one in each corpus cavernosum, and one
in the septum.  In securing  these, trouble is not unfrequently  experienced in
consequence of the retraction of the stump  that is left.  During and  after cica-
trization, the urethral orifice has a tendency to contract;  hence it is necessary to
pass bougies from time  to time to keep it  dilated.   If the amputation be per-
formed high up, this may be  somewhat difficult, and then  it may be safer to 
DISEASES  OF  THE  SCROTUM.
875
introduce an elastic catheter before the operation, to perform the amputation upon
this, and to leave it in during cicatrization.   After the operation, the urine will
not be projected forwards,but always passes directly downwards between the legs.

                       DISEASES OF THE  SCROTUM.

  Inflammatory oedema of the  scrotum is  an  erysipeloid inflammation of this
region, which derives its chief  peculiarity from the  circumstance of its giving
rise to great effusion into, and swelling of the cellular tissue, with a tendency to
the rapid formation of slough in it, by which the integument may likewise become
affected to such an extent that the testes  and  cords speedily become denuded.
This disease usually originates  from some  local source of irritation, as fissures,
cracks, or urinary extravasation.
  The treatment consists in elevating the scrotum, fomenting it well, and mak-
ing early and free incisions into it, more particularly at the posterior and depen-
dent parts, with a view of relieving the tension to which the tissue is subjected
by the effusion into its  cells;  and thus preventing  the liability to sloughing.
Should  this occur, the case must be treated on ordinary principles, when cica-
trization will speedily ensue, however extensive  the denudation of parts may be;
the constitutional management  must always  be conducted  in  accordance with
those principles laid down in the first  division of this work, and with especial
attention to the maintenance of the patient's strength.
   Hypertrophy of the scrotum seldom occurs in  this country, though Mr. Liston
once had occasion to remove such a mass weighing 44 lbs.; but in some tropical
regions, more particularly India and China, it  is  of frequent  occurrence, and
may go on until it attain  an enormous  bulk,  forming a tumor nearly as large  as
the trunk, and perhaps weighing 60 or 70 lbs.  These enormous growths are of a
simple character, and constitute the disease termed elephantiasis of the scrotum.
Tumors of this kind necessarily require  extirpation, and in performing such ope-
rations there are two  points that demand special attention:  the first is the pre-
servation of the penis and testes, which  will usually be found buried towards the
upper part of the mass, and which may be done if the tumor  is of small size;
and the second is to endeavor to prevent the hemorrhage  being of too profuse a
character.   With this view, the operation  ought not  only to be performed  as
rapidly as possible,  but the suggestion made  by  3Ir. D. Ferrall of elevating the
tumor above the level of the body, for some time before its removal, so as  to
empty it of its blood, may be  advantageously adopted.  If the growth be very
large, it will  be better not to  make any attempt at saving the testes or penis,
which could only be dissected out by a long and tedious operation, in the course
of which there would be danger of the patient dying from hemorrhage.
   Cancerous or cancroid disease occasionally affects the scrotum, and as it prin-
cipally  occurs in chimney-sweepers,  it  has been  appropriately enough termed
chimney-sweep's cancer.   This affection  appears to arise from the irritation of the
soot lodging in the folds of the scrotum, and is  a very common  form of cancroid
disease.   It commonly commences as a tubercle or wart, which at last tends  to
crack or  ulcerate,  presenting the  ordinary  characters of cancerous ulceration.
After a time the inguinal and  pelvic glands will be  seen  to  be affected, and
the patient, if deprived of his covering of  soot, will be found  to be cachectic-
looking.
  The treatment consists  in excising widely the diseased portion of the scrotum,
provided the inguinal gland be not involved, or the patient's constitution poisoned.
This disease has a great tendency to return, and it is  seldom  that a patient long
escapes with life when once he has been affected by it. 
876
DISEASES OF  THE TESTES  AND CORD.
                          CHAPTER  LIX.


               DISEASES OF THE TESTES AND CORD.

                      MALPOSITION OF THE TESTIS.

   The testis may be situated in the inguinal canal, not having properly descended
into the scrotum, and then may become inflamed, as will presently be noticed; or
it may become affected in this situation by malignant disease, rendering its extir-
pation necessary.  The testis may be met with  in other abnormal  situations;
thus, some time ago I saw a case in which one of these organs was situated in
the  perineum close by the anus, and  cases  have occurred in which they have
been met with in the interior of the pelvis.   The organ may sometimes be turned
hindside forwards, being retroverted,  so that the epididymis is placed  in front.
In a case of this kind that I had an opportunity of examining after death a few
years ago, the epididymis and vas deferens were considerably larger than natural.
If a hydrocele  form in such a case it  will be seated behind the  testis.

                            NEURALGIA TESTIS.

   The painful or irritable condition of the testicle may occur without any actual
disease of the organ;  the  pain being  either seated in the  epididymis, which is
the part naturally most tender, in the  body of the testis, or stretching along the
cord to the loins and  groins.   It is usually  paroxysmal, and is accompanied by
great tenderness, and  commonly by some  fulness of the organ, which feels soft
and  flaccid; but it is difficult to make a proper  examination on account of the
agony that is induced by touching  the  part.  This disease  chiefly occurs in
young men of a nervous and excitable temperament, and is frequently associated
with great  mental disquietude and  despondency, often amounting to a suicidal
tendency.
   The causes are obscure;  in many cases it appears to be connected with a neu-
ralgic temperament, but in others it is associated with some dyspeptic  disorder,
or may be dependent upon local  irritation.   Thus external piles,  or the pressure
of a varicocele, will often give rise to it.
   The disease is usually of a very chronic character.   In some  instances, how-
ever, it ceases spontaneously, after having lasted for weeks or months.   AVhen
dependent upon constitutional causes,  the treatment is extremely unsatisfactory.
The administration of tonics, such as  iron, zinc, or quinine, the local application
of sedatives, as of  atropine ointment,  or the tincture of aconite, may be of ser-
vice.  In other cases, cold bathing or douching will  be beneficial, and in all,
keeping the part supported with  a suspensory bandage will be advantageous.  In
the event of there being any local irritation, that should be removed.  Thus  I
have known the disease cease  after the excision  of external  piles; and when it
is connected with varicocele, proper measures must be adopted for the  relief of
that affection.   In extreme cases, Sir A. Cooper recommends   castration;  but
such a proceeding  can scarcely be considered justifiable, inasmuch as the neural-
gic condition will usually at last cease spontaneously.

                     INFLAMMATION OF THE TESTIS.

   Inflammation of the testicle, considering the organ as a  whole, may be of two
distinct kinds, varying as to seat and as to cause.   Thus it may be seated in the 
TREATMENT OF  INFLAMED TESTIS.             877
body of the organ, constituting orchitis, or the epididymis may alone be affected.
As to cause, it may be gonorrhceal or not.
  The seat of the inflammation, at the commencement of the disease, depends
greatly upon whether its cause is seated in the urinary passages or not.   Irrita-
tion  in  any part of the urethra, whether  occasioned by the  passage of instru-
ments, the lodgment of calculi, or  the  existence of gonorrhceal  inflammation,
usually causes the epididymis to be primarily affected, and the body of the organ
to be inflamed in a secondary manner.  When, on the other hand, the inflamma-
tion  comes on from injuries, blows, strains, or other causes acting  generally, the
body of the testis is usually first affected.  To all this,  however,  exceptions will
often occur, and orchitis may supervene as the result of gonorrhoea, or epididy-
mitis, from a blow; the orchitis in such cases being in  all probability a kind of
constitutional  affection, intimately associated with inflammation of other fibrous
tissues^ especially with gonorrhceal rheumatism; the inflammation of the epididy-
mis, arising from gonorrhoea or other irritation of the urinary passages, appearing
to result from direct extension of morbid action along the  vas deferens.
  _ The symptoms necessarily vary to a certain extent, not  only according as the
disease is of an acute or chronic character, but as it primarily affects the body of
the testis or the epididymis.   AVhen commencing in the latter structure it is the
inferior globus that is commonly first affected, which becomes swollen, bard, and
tender.   The  disease  may be confined throughout to this  part, but most frequently
it invades the whole of the organ, which becomes uniformly enlarged and some-
what ovoid, frequently accompanied  by a good deal of  effusion into  the  tunica
vaginalis, then constituting the acute hydrocele of Arelpeau.  As the inflamma-
tion subsides,  the different  characters presented  by the  enlargement of the two
constituents of the organ again become apparent.   The swelling is therefore due
partly to  general enlargement of the organ, but in some  cases to inflammatory
effusion  into  the tunica vaginalis, which  may either be of a purely serous, or
partly of a plastic character.
  The  pain is  always  very severe, with  much  tenderness and  a sensation of
weight, and commonly extends up the cord into the groins and loins.   It is gene-
rally greatest when the body of the testis is affected, owing probably to the enve-
loping fibrous tunic  preventing the expansion of the organ.  Hence it is often
spasmodic and paroxysmal,  extending up the course of  the cord.   There is usu-
ally  a good deal of swelling and redness of the scrotum, with turgescence of the
scrotal veins, and a congested state of the cord, with sharp pyrexia, with nausea,
and  perhaps occasional vomiting.
  As the disease subsides the body of the testis  first resumes its  normal charac-
ter and shape, the epididymis often  continuing hardened and  enlarged for a con-
siderable  period.  In fact, the  induration that  forms  in  the epididymis may
assume a  somewhat permanent character, owing to the effusion of plastic  matter
into  it, leaving a hardened  mass, and implicating the whole  or a portion of its
convolutions.
  Subacute orchitis usually comes on with the same symptoms, though in a less
marked form  than the acute variety.  The swelling, however, is considerable,
though of a softer kind.   AVhen the disease  is chronic the testis often becomes
permanently enlarged and  hardened, assuming  an oval shape,  being smooth,
heavy, and uniformly expanded, with a sensation of weight, dragging and severe
pain, and a good deal of tenderness on pressure.   This form of orchitis occasionally
occurs in old people.
  The treatment of inflamed testicle, whether local or constitutional, is essentially
antiphlogistic.   Blood should be abstracted from  the part by puncturing the veins
of the scrotum, a far better method than applying leeches,  the bites of which are
apt to become irritated.  This little  operation may be  very effectually done by
directing  the patient  to stand up and to foment the scrotum for a few minutes 
878            DISEASES  OF  THE  TESTES  AND  CORD.

with a hot sponge, so as to distend the veins;  these  may then  be punctured at
various points with a fine lancet, and the parts well fomented afterwards, so as to
encourage the flow of blood.  In this way six or jeight ounces may be taken in
the course of a few minutes ; when enough has escaped,  the further flow may be
arrested by laying the patient down and elevating the part.
   The patient should be kept in bed  with the testis raised on a small  pillow
between  the thighs, poppy fomentations being diligently had recourse to.  If
there is much effusion into the  tunica vaginalis, relief may be afforded by punc-
turing this sac with the point of the lancet.
   The constitutional treatment  during the acute stage consists  in  the adminis-
tration of salines and antimony, with  henbane  in  full  doses, so as to give an
aperient, a diaphoretic, and a sedative together;  when this begins  to  act, great
relief is usually afforded.
   As the inflammation subsides, the treatment must be  changed.  When there
is merely swelling and hardness left, with but little pain  or tenderness the testis
may advantageously be strapped with adhesive  plaster, so as to give good support
and to promote absorption of plastic matter.  Fricke of Hamburgh, has strongly
recommended strapping in the acute stage, but I cannot say that 1 have ever seen
any advantage derived from  it at this period of the disease, though I have many
times seen it tried; it has  usually appeared  to  me to increase, and sometimes
very considerably, the pain in the part and the general uneasiness.
   In subacute orchitis much benefit is usually derived by a short course of Dover's
powder and calomel, with  early strapping  of the testis.   AVhen the  organ has
become enlarged and indurated, as the result of chronic  inflammation, it may be
advantageously strapped, either with simple plaster or with one composed of equal
parts  of the Emplast. Ammoniaci  cum Hydrargyro and soap-plaster; mercury
in small doses, more especially the bichloride, being continued  for some  length
of time, until the plastic matter is absorbed and the  hardness disappears.
   In strapping a testicle (Fig. 297), the  scrotum should  be shaved, and then
                        drawn tightly upwards on the affected side.   The  sur-
                        geon should next pass  a long strip of plaster, about an
                        inch broad, above the enlarged testicle and  round the
                        corresponding side of the scrotum, so  as so isolate it as
                        were.   Another strip is now passed from  behind, in a
                        longitudinal direction, over the lower end of  the testis,
                        and upwards  upon the anterior part of the scrotum : and
                        'thus, by a succession  of horizontal  and vertical strips,
                        neatly overlapping and drawn tightly, the organ is com-
                        pletely enveloped and compressed.
                           Abscess, as the result of inflammation  of  the testis,
                        is of  rare occurrence :  sometimes, however, the scro-
                        tum inflames  at  one  point, where  fluctuation becomes
                        apparent,  with   thinned skin  and  evident  signs of
                        suppuration ;  a puncture should here be made, and the
                        pus let out as soon as formed.  Sometimes abscess may
                        occur in another  way ; inflammation takes  place in the
 tunica albuginea, adhesion takes  place between  the  testis  and the scrotum,
 abscess forms under the fibrous coat, and  this giving way, the pus gets vent ex-
 ternally through the integuments.   Into the  aperture that necessarily results,  a
 portion of the secreting tissue of the gland sometimes projects, and becoming in-
 flamed, forms a red, granular, and  fungous mass, protruding through  and over-
 lapping the edges of the aperture.   The treatment of this condition will be
 considered  when we come to speak of the scrofulous testicle.
   Inflammation of the testis in the inguinal  canal may sometimes take place,
 even  in  adults,  when  the organ has  not descended through the  external ring,
 
RE AND  TREATMENT OF HYDROCELE.         879
giving rise tea train of symptoms  of a  somewhat puzzling  character, and that
closely resemble those  of strangulated incomplete  hernia.  On examination, in
these cases, a large, irregular tumor, in some parts hard, in others soft, very tender
to the touch, and occasioning a sickening sensation when pressed, will be found
in one ot the groins, in the situation of the inguinal canal.   There is usually a
tendency to vomiting, and some constipation, with colicky pains in the abdomen.
These symptoms, however, are generally  not very persistent, and the constipation
readily yields to the administration of purgatives.   On examining the scrotum it
will be found that the  testis on the affected side is absent, and on passing the
finger into the external ring, the  organ can be felt to be lodged in the canal.  In
consequence of the proximity of the peritoneum to the inflamed testis, this mem-
brane occasionally becomes involved in the  morbid action, and, as the result of
the constriction of the  tendinous and aponeurotic tissues in this situation, slough-
ing has occasionally occurred.   Either of these conditions may lead to a fatal ter-
mination.
  The treatment should be actively antiphlogistic.  Leeches  must be freely ap-
plied over the  part, and blood should be taken from the arm if the patient is
young and strong;  salines with antimony being at the same  time administered,
and fomentations diligently persevered in (vide p. 735).
  In some cases, the inflammation of the testis may extend to, or the disease may
from the first be limited to the cellular tissue of the cord,  giving rise to tumefac-
tion, with a good deal of pain  and tenderness  along it, and eventually the
formation of abscess, accompanied by the usual  signs of suppuration.   The  treat-
ment of such a case must be conducted on ordinary principles, early discharge
for the pus being secured.

                                HYDROCELE.
  By hydrocele is meant an  accumulation of serous fluid, formed in connexion
with the testis or cord.   3Iost frequently the fluid occupies the sac of the tunica
vaginalis,  constituting  a  true dropsy of  it; in  other instances, it appears to be
formed  in distinct cysts, situated either in connexion  with  the testis, or upon
the cord.  Hence, hydroceles are commonly divided into those that affect the
tunica vaginalis, and the encysted variety.
  Hydrocele of the tunica vaginalis may occur as the  result of acute  orchitis,
the inflammation of the testis causing the effusion of a quantity of limpid fluid
into its serous  investment.   This, however, is not  the kind of hydrocele that is
commonly met with; the fluid so poured out as the result of active inflammation,
usually becoming absorbed  as  the parts recover  their normal condition.   The
ordinary hydrocele occurs as a chronic disease, without any signs of inflammation
of the testicle, or at most slight tenderness of that organ.  It is most frequently
met with in individuals about the middle period of life,  and generally in persons
of feeble power, or in those of a cachectic or gouty constitution, commonly with-
out any evident exciting  cause.
  In young infants, hydrocele is not unfrequently seen, and in them it may affect
two forms : either the ordinary one, similar to what occurs in  adults, in whom the
tunica vaginalis constitutes a closed sac filled with fluid; or a less common variety,
in which the accumulation of fluid in the tunica vaginalis communicates, by the
persistence of  a cavity  or canal in the funicular prolongation of the peritoneum
investing  the  cord, with  the  general  cavity of that membrane.  This  form of
hydrocele is congenital, and the fluid in it occupies the same position that intes-
tine does in a congenital hernia.   It may readily be recognised by the  fluid being
made to flow back into the general  peritoneal cavity, by raising or squeezing the
tumor.  But although  this may be considered to be the  true  congenital form of
hydrocele in infants, the  other  variety of the disease also occurs in them  when
but a few days old, and very possibly even at the time of birth.
  The symptoms of hydrocele are tolerably evident.  The disease begins with a 
880            DISEASES  OF  THE  TESTES  AND  CORD.
degree of swelling and weight about the testis, which may at first be soft, but
after a while becomes hard and tense,  or it may be so from the very commence-
ment.   AArhatever its original condition, the tumor soon becomes oval or pyriform
in shape, being  narrowed  above, rounded and broad below; it  is smooth and
uniformly tense and hard, often having a  semi-elastic feel.   It reaches upwards
along the cord, towards the external abdominal  ring, which, however, is never
invaded by it, and the cord is usually distinctly to be felt above the upper margin
of the tumor.   Most commonly the size varies  from that of a  hen's  egg  to a
small cocoa-nut,  but  sometimes it may attain a considerably greater magnitude
than this, and will then cause much deformity of the parts, as it reaches up close
to the external ring, and drags over the penis, causing that organ to be buried in it.
  The most characteristic sign of hydrocele is  its translucency by transmitted
light.  This may always be detected, by the surgeon  grasping the posterior part
of the tumor with one hand, so as to  put the integuments on the fore part on
the stretch,  then placing the edge of the other hand  along the most prominent
part of the swelling, and having a lighted candle held  close behind.   On making
this examination, the  tumor will appear transparent; if, however, the walls of
the sac be thick,  or the fluid dark, the  transmission of light  through it may not
be perceived unless  the  examination be conducted in a darkened room.   We
have already seen that the ordinary hydrocele of the tunica vaginalis may vary
as to size; it may also differ as to shape; in some cases being globular, in others
constricted in the middle, or of an hour-glass shape.
  The quantity of liquid varies considerably; there is usually from six to twelve
or twenty ounces, but I have known a hydrocele contain more than one hundred
and twenty ounces.   The fluid is  generally clear and limpid, and of a straw color;
but in very  large and old hydroceles it may become of a dark-brownish or choco-
late hue, owing to the admixture of disintegrated blood;  and will then be found
to contain flakes of cholesterine.   The sac is usually thin, but in some old cases
becomes thicks and dense, lined by a  kind of  false membrane, and divided by
septa or bands, occasionally to such an extent  as almost to separate it into  dis-
tinct compartments.   AVhen  the  sac is thick,  and the fluid  opaque and turbid,
there may be considerable difficulty in detecting the translucency.
  The testis is generally somewhat enlarged, especially about the epididymis, and
                         frequently slightly tender, more particularly in  the
         Fig. 298.           early stages of the complaint.  It is almost invariably
                         situated at the posterior part of the sac (Fig. 298),
                         but may sometimes be  found towards its anterior part.
                         When this is the  case, the epididymis will be found
                         turned  towards  the  front,  owing to  the  organ being
                         retroverted.
                           The treatment of hydrocele is divided into the pallia-
                         tive and curative.    By the palliative  treatment  the
                         surgeon simply seeks to relieve the patient of the an-
                         noyance induced by the bulk or weight of the tumor;
                         but the curative has  for  its object the permanent re-
                         moval of the disease.
                           The palliative treatment consists in  the use of sus-
                         pensory bandages and cooling lotions, or of tapping
                         with  a  fine trochar.   These simple  means, however,
                         will sometimes  succeed  in effecting a radical cure.
                         Thus, in infants it will happen that the application of
                         evaporating  and discutient lotions may remove  the
                         effused fluid; and  indeed it is seldom  that any other
                         plan of treatment than this is required in young chil-
                         dren.   The best lotion for the purpose  consists of one
composed of 5J of muriate of ammonia, 3j of spirits of wine, to ^viij of water j
 
RADICAL  CURE OF HYDROCELE.
881
with this the scrotum should be kept constantly wetted, and if there be a com-
munication with the peritoneum, a truss should be  kept applied over the external
ring.   In adults it has occasionally happened that simple tapping of the tumor
has effected a radical cure.   Some years ago  a gentleman from Cuba consulted
me for a small hydrocele which had  been forming for several months; I tapped
it with a fine trochar, and drew off about five ounces of fluid.   This was followed
by a radical cure.   This case bears out a  remark made by  Sir B. Brodie, that
the few instances in which he had known simple tapping produce a radical cure
occurred in ATest Indians.   This  simple operation  is not altogether, however,
destitute of danger;  I have  known an old man die from inflammatory oedema of
the scrotum after being tapped.   After tapping it usually happens that the
hydrocele slowly forms again, attaining its former  bulk at the end of about three
months.
   In tapping a hydrocele a few precautions are necessary, the principal being to
avoid injuring the testis, or puncturing one of the  scrotal veins.  In the majority
of cases the testis is situated at the back of the tumor, and is consequently alto-
gether out of the way of the trochar, if this is introduced  as it should be, by
the surgeon putting the anterior part of the hydrocele on the stretch by grasping
it behind with his left hand, and then pushing the trochar  into the lower part
of its middle  third  in front,  carrying the instrument at first directly backwards
(Fig. 299 a), but as soon as  it has perforated the sac, directing its point upwards
(Fig. 299 b).   If the testicle  has been  found on  examination with a lighted
candle to be  on  the forepart of the tumor, where  it may sometimes be felt as
well as seen, the hydrocele should be tapped at the side or behind.  Before using
the trochar, it is well to  see  that the  canula fits  closely round the  neck of the
stylet, and above all that the instrument  is not rusty by having been carelessly
put aside after use on a previous occasion.
   The curative treatment has for its object the excitation  of a sufficient degree
of inflammation in the tunica vaginalis to
restore the lost balance between secretion               Fis-  299-
and absorption; but  it is not necessary
that the  serous cavity should  be oblite-
rated by adhesions  between its opposite
sides.   The means by which the surgeon
sets up this inflammation are either  by
the introduction of a small seton into the
tunica vaginalis, or by throwing a stimula-
ting injection into that cavity after tapping
it.   Whichever plan is adopted, a certain
amount of inflammation ought to  be set
up.  This is always attended by conside-
rable swelling of the testis, and by  the
effusion of a fresh quantity of fluid into
the tunica vaginalis.  As this is absorbed,
the part gradually resumes its  normal bulk, and  the disease will probably not
return.
  In order that the radical  cure,  in  whatever way undertaken, should be safe
and efficient, it is necessary, in  the first instance, that  the disease should have
been allowed to get into a chronic  condition, more particularly if the hydrocele
have been of rapid growth.   In order  to prevent its attaining too large a size, it
will be well to adopt palliative tapping once or twice before attempting the radical
cure.   Care must also be taken to remove all inflammation  and tenderness about
the testis before having  recourse to this means of treatment.  If attention  be
not paid  to this, recurrence of  the  hydrocele will probably ensue.   After the
proper amount of inflammation has been set up, it will be well to treat the patient
56 
882            DISEASES  OF  THE  TESTES  AND  CORD.
as if he were suffering  under an ordinary attack of orchitis, confining him  to
bed or to the couch for  a few days; indeed, I look upon care in the after-treat-
ment as of very considerable importance in  securing a favorable  result to the
case.
   The cure by the introduction of a  seton, though  formerly much employed, is
seldom practised at the  present day, chiefly on account of the danger of exciting
too much inflammation.  It may, however, conveniently be had recourse to in
the true hydroceles of children, and in some of those cases in which the injec-
tion fails, if practised in the manner that will immediately be described.
   The treatment by injection is the one that is commonly employed; it consists
in tapping £he tumor  in the usual way, and then throwing a  sufficient quantity
of stimulating fluid into the tunica vaginalis through the canula, so as to excite
a proper amount of inflammation in it.   The liquids that are employed are gene-
rally either port wine or a  solution of the sulphate of zinc of the strength of
Ji to ^xii, or most commonly the tincture of iodine.  If the port wine or solu-
tion of the sulphate of  zinc are employed, a sufficient quantity partly to distend
the sac should be injected from an India-rubber bottle or brass syringe that can
be adapted to the canula; six or  eight ounces are commonly required for  this
purpose, and it should be allowed to remain  in  for  some minutes  before being
evacuated.
   The tincture of  iodine, originally introduced by 31 r. 3Iartin  whilst practising
at Calcutta, is now commonly preferred as a  more certain and a safer  mode of
treatment  than any other.   It is  usually sufficient  to  inject  about Jii of the
tincture, either pure,  if the hydrocele be old and large, or diluted with an equal
quantity of water  if  it  be  small and  recent.  It should be  left in for a  few
minutes, in proportion to the amount of pain it occasions,  and  then allowed to
escape.  A good deal of inflammation  will usually be set up, on the subsidence
of which, the cure will be found to have been effected.
   Useful as the iodine injection is, it sometimes fails in producing a radical cure
of hydrocele; this is attributable to two causes : the first is, that in some cases suffi-
cient inflammation is not set up to induce that condition of the tunica vaginalis which
is necessary for a radical cure.   It is  well known that when a hydrocele is radi-
cally cured by injection, it is so, not by any adhesion taking place between the
two opposite surfaces  of the tunica vaginalis  and a consequent obliteration of its
cavity, but by the  inflammation that is artificially induced, exciting such a modi-
fication of this membrane as to restore  the balance between the secretion and ab-
sorption of the fluid,  by which it is  naturally lubricated.   Now in some cases
sufficient inflammation is not induced by the introduction of the irritating fluid,
to restore  the  natural  balance between these  two functions of the membrane;
and the tunica vaginalis gradually fills again after the injection, as it would after
the simple operation  of tapping.  It occasionally happens  that the patient  may
suffer excruciating agony at  the time  of the injection, from the contact of the
stimulating fluid with the surface  of the testis, and yet little or no inflammation
be excited.   The amount of suffering, therefore, at the time of the operation is
by no means proportionate to the  amount of consecutive inflammation likely to
be set up.  Indeed the reverse would  appear to be the case in  many instances;
and I have often observed that in  those cases which  progress most  steadily to a
radical cure,  there is  but a moderate amount of pain experienced at the time of
the injection.
   There is a second way in which injections  would appear to fail; a conside-
rable amount of inflammation  is  excited, effusion takes place into the  tunica
vaginalis, which, in the course of  three or four days becomes distended to the  ^
same size, or nearly so, that it had  attained  previously to  the operation; but
this effused  fluid, instead  of being absorbed by the end of the second or third 
RADICAL  CURE  OF  HYDROCELE.
883
week, remains unchanged in bulk, or absorption goes on to a certain point, and
then seems to be arrested; the tunica vaginalis remaining  distended with  a
certain quantity of fluid.
  The proportion of cases in which  the iodine injection fails to bring about a
radical cure of the hydrocele is variously estimated by different surgeons.  Thus
Mr.  3Iartin  states that in  India the failures scarcely amount  to  1 per cent.
Arelpeau calculates them  at 3  per cent.   I am not aware that any statistics of
this mode of treatment in this country have  been  collected; but the general
opinion of  surgeons would appear to be decidedly in its favor, as being the most
successful,  as well as the safest plan  of treatment that has  yet been introduced.
In this opinion I fully coincide; but yet I think it by no means  improbable that
the success of the iodine injection in this country might not prove  to be quite
so great as is generally believed.   I  have, during the last few years, seen a con-
siderable number of cases of simple  hydrocele of  the tunica vaginalis, both in
hospital and  private practice, in which a radical cure had not been effected,
although the iodine injection had been had recourse to by some of the most care-
ful and skilful surgeons of the day as well as by myself.
   There can be no doubt that, as a first remedy, the  iodine injection is prefera-
ble to the seton, in the treatment of hydrocele; but when the injection has failed,
and this from no want of care on the part of the surgeon, or of attention to the
after-treatment of the  case,  but apparently from insufficient inflammatory action
having been  set up in  the tunica vaginalis to restore the lost balance between
secretion and absorption in  this membrane, the seton will, I think, be found to
be the most certain means of accomplishing our object.  It is true that several
objections may be urged to the use of the seton : it requires much watching and
care, and is occasionally apt to excite a dangerous amount of inflammation  in the
cellular tissue of the scrotum ;  and these objections  are to my mind sufficiently
valid to prevent our employing it as  the ordinary treatment for the radical cure
of hydrocele.  But it  must  be remembered, that the  particular cases to which I
am now alluding are those in which  ordinary means  have proved insufficient to
excite proper action, and in  which, consequently, it would appear as if a greater
amount of  irritation could safely be borne.   Indeed, nothing is more remarkable
than the difference in  the intensity of the inflammation that  is set up in different
individuals by the means that are commonly employed in the treatment of  hy-
drocele.  In some cases  the most irritating injections may be thrown into  the
tunica vaginalis, or a seton be drawn through the scrotum and left there for days,
not only without giving rise to any injurious  inflammation,  but  without setting
up sufficient action to bring  about a cure of the disease; whilst in other instances
simple tapping may effect a  radical  cure, or may give rise to such an amount of
irritation as to terminate in  fatal sloughing of the scrotum.
  The seton that I employ in these cases is composed of one  or two threads of
dentists'  silk.   It may be introduced by means of a nevus needle, the fluid of
the hydrocele being allowed to drain  away through the punctures thus made, or,
far better, by tapping the hydrocele,  and then passing a needle about six inches
long armed with the seton, up the canula, to draw it  through the upper part of
the scrotum,  and then removing the canula, and cutting off the needle, to knot
the thread loosely (Fig. 122).  The thread should  not be removed until the
scrotum swells and becomes  red, with some tenderness of the testis and effusion
into  the  tunica vaginalis.  When these? effects have been produced, it may be
cut and withdrawn, and the case treated in the same way as when  the radical
cure has been attempted by iodine injection, viz.,  by rest and antiphlogistic
treatment.   The  length of  time that is necessary for the  seton to be left  in
before  sufficient,  or even  any inflammatory action is produced varies very con-
siderably   In most instances the proper amount of  inflammation is excited in
from twenty-four to thirty hours; but in other cases it may  be left in for ten or 
884
DISEASES  OF  THE  TESTES  AND  CORD.
twelve days, giving rise to but little inflammation, although a radical cure may
result.
                          ENCYSTED HYDROCELE.

  In this variety of the disease the fluid does not lie in the tunica vaginalis; but
is contained in a cyst which projects from the surface of the epididymis or testis,
and pushes the serous investment of the gland before it.
  These cysts are much more frequently found connected with the epididymis,
than with the body of the testicle.   Indeed Air. Curling has  pointed out  the
fact, that small pedunculated  cysts about the size of currants (Fig. 300), and
composed of a fine serous membrane, lined with tessellated epithelium, are very
frequently found beneath the visceral  tunica vaginalis covering the epididymis.
They are very delicate in  structure, contain a clear limpid fluid, and are very
liable to rupture.  They are met with at all ages after that of puberty.  Accord-
ing to 31. Grosselin, after the age of forty, they occurred in at least two-thirds of
the testes examined with this view.  Cysts, such as these,  may remain stationary,
of small size, and  not to be detected during life, being merely pathological phe-
nomena; they may rupture into the tunica vaginalis; or, they may enlarge and
become developed into tumors of considerable magnitude.
Fig 300.                                     Fig. 301.
  The fluid of these cysts possesses the remarkable characteristic discovered by
Mr.  Liston, of  containing  spermatozoa (Fig. 301); an  observation  that has
been  fully confirmed by many subsequent observers.   Though spermatozoa do
not always exist in this fluid, yet they are usually met with sometimes in small
quantities, at others so abundantly as to give a turbid or opalescent appearance.
This admixture  of spermatozoa, with the clear fluid of the cyst is probably due,
as pointed out by 31r. Curling, to the accidental  rupture of a seminal  duct into
an already existing cyst.   Spermatozoa  have also but very rarely been found in
the fluid  of an ordinary hydrocele of  the tunica vaginalis, and then probably
their  presence was due to the  rupture of one of those cysts into the tunica vagi-
nalis.  Hence  their  presence in the fluid of a hydrocele  may in most cases be
considered as characteristic of the encysted variety of the disease.
  The symptoms of encysted  hydrocele differ in some respects from  those pre-
sented by the ordinary form of the disease.   The tumor of the encysted  variety
being smaller, more irregular  in shape,  and not enveloping the testis completely,
but being situated behind it, and rather in connexion with the epididymis.
  The treatment consists in  injecting the  sac  with tincture  of  iodine, or, in
incising the tumor and allowing it to granulate from the bottom.  The injection
  Fig. 300. Cysts developed in the epididymis, a a.  Small cysts elevating the tunica vaginalis, lb. Small
pedunculated cysts.  (From Curling.) 
             HYDROCELE  OF  THE  CORD — HEMATOCELE.         885

by iodine, though successful in some cases, is not so frequently so in  this as in
the last variety of the disease, but usually deserves a trial;  if it fail, the incision
of the tumor will always effect a cure.

                        HYDROCELE  OF THE CORD.

  This disease is characterized by the  presence of  a round or oval tumor, situ-
ated on the  cord, below or within the inguinal canal.   It is smooth, elastic, and
if of sufficient size may be semi-transparent on examination by transmitted light.
It can  be  pushed up into the abdomen, but receives  no impulse on coughing,
and does not alter in size by being steadily compressed.  It appears to be formed,
in some cases, by the funicular portion of the peritoneal  investment of the cord
being  imperfectly closed and consolidated at points;  though it is possible that
in other instances it arises as a distinct cystic growth.  These tumors may occur
at all ages, but are chiefly met with in the young, and are not unfrequent amongst
children.  The  obliteration of the  cyst is  best  conducted by passing a seton
through, or  making an incision into  it, and letting it granulate from the bottom.
   The diffused hydrocele of the spermatic cord consists  in the infiltration of it
with serous  fluid, contained in rather distinct cells, and giving rise to an oval or
oblong irregular circumscribed  tumor, extending below and into the inguinal
canal.   The treatment  consists in the  application of blisters, or of counter-irri-
tant plasters; should the disease prove very troublesome, an incision might  be
made down  to and into the swelling, so as to let out the fluid and allow the cyst
to become consolidated.

                               HEMATOCELE.

   By hematocele is meant an accumulation of blood in the tunica vaginalis, dis-
tending that sac, and compressing the  testis.   This condition usually arises from
some accident, as a blow, by which one of the veins ramifying on the surface of
the gland, is ruptured, and blood poured into the serous sac.  It may occur in
tapping a hydrocele, by the point of the stylet being  pushed too far back, and
thus wounding the testis.  In whatever way occurring, a hematocele  slowly but
 gradually increases in size, until it attains about the magnitude of a duck's egg,
or even that of a cocoa-nut.  It is very seldom that it becomes larger than this,
but cases  are recorded in which these tumors have  attained an enormous magni-
tude.  Mr.  Curling has related a case in which the tumor was as large as the
head, and extended  half way down the thighs; on being opened, about three
pints of dark grumous fluid escaped,  and the tunica vaginalis  contained some
rounded bodies, which appeared to be  masses of coagula  adherent to the sac.
   The fluid contained in hematocele, when the disease is recent, consists of pure
blood,  but when of old standing, is  of a dark and  grumous character, owing to
disintegration of the blood corpuscles.   It then usually contains an admixture of
cholesterine.  The blood so effused  will continue fluid for years; but in some
rare instances  the  tumor becomes partly solidified by the deposit of masses of
fibrinous  coagulum, lining  the interior of the tunica vaginalis, which are some-
times arranged, as in an instance recorded by Mr. Bowman, in a laminated man-
ner, like the contents of an aneurismal sac.
   The symptoms of a hematocele are generally sufficiently obvious.  The occur-
rence of the tumor subsequently to a blow, strain, or injury, its gradual increase
in size, somewhat heavy but semi-elastic feel, its pyriform shape, and the absence
of  transparency, together with the freedom of the cord above it and the want ot
impulse in it on coughing, will indicate its true character.
   The treatment of hematocele must  vary with the  size  and  duration ot the
tumor   When small, recent, and having fluid contents, the surgeon may try the 
886
DISEASES  OF  THE  TESTES  AND  CORD.
 effect of tapping it, when it is possible that after  the  evacuation of the blood,
 closure and obliteration of the tunica vaginalis will  take place.   This happened
 in a case lately under my care, in which, though the disease had existed for three
 years, a complete cure followed the operation of tapping.   Such simple treatment
 as this, however, cannot be depended upon; and it usually becomes necessary to
 lay the sac open, and  to get it to granulate from the bottom, when the oblitera-
 tion of the cavity of the tunica vaginalis  necessarily results.   If the tumor were
 of very large size, and the  tunica vaginalis much thickened by adherent and
 laminated fibrine, castration might possibly be required.
   Hematocele of the spermatic cord has  been observed by Pott, Curling, Bow-
 man, and others;  it is a rare disease, and usually occurs in the form of a tumor
 of considerable magnitude, suddenly arising after a strain or some violent exer-
 tion.  It commences in the inguinal canal, and thence extends downwards along
 the course of the cord, through the abdominal ring into the  scrotum, but it does
 not surround or implicate the testis, which can be felt free and  movable at its
 lowest part.   On incising such a tumor as this, a quantity of blood, partly fluid
 and partly coagulated, has  been found, sometimes  contained in a cavity, occa-
 sioned by the  laceration  and separation of the tissues of the cord.  The most
 remarkable case of this kind on record, is one related by 3Ir. Bowman, in which
 the tumor, after existing for ten years, had attained so enormous a size, that it
 reached to the patella, and was so heavy as  to require both hands and a conside-
 rable effort to raise it from its bed.  In this case, death appears to have resulted
 from decomposition of the contents of the tumor.
   In its early stages, hematocele of the cord would run considerable risk of being
 confounded with an inguinal hernia.  The more diffused character of the swell-
 ing, however, its irregular feel and semi-fluctuating sensation, might enable the
 diagnosis to be made.   Hematocele of the cord may always  be distinguished from
 an accumulation of blood in the tunica vaginalis, by the testicle not being impli-
 cated in  the former case, but surrounded by the fluid in the latter instance.
   The treatment of this disease must consist in incising the tumor, turning out
 the contents, and allowing the parts to suppurate and granulate.

                                VARICOCELE.
   Varix of the spermatic veins, is a disease that is  commonly met with from the
 age of puberty to about the thirtieth year, seldom commencing later  than this.
 It usually occurs in feeble individuals having the scrotum lax  and pendulous, and
 in some cases appears to have been brought on by venereal excesses.  The sper-
 matic veins, extending as they do from  opposite  the upper lumbar vertebra} to
 the plexus pampiniforme, which constitutes the base of  the pyramidal  tumor
 formed by a fully developed varicocele, are  necessarily  subject  to  considerable
 outward pressure from the weight of so long a column of blood as that contained
 within them, to which they may eventually yield, becoming much dilated and
 tortuous.   The left spermatic vein is far more frequently affected than the right
 one, partly owing to its compression by feculent accumulations in the sigmoid
 flexure of the colon, and partly to the  obstacle at  its mouth, occasioned by its
 pouring its contents into the left renal vein, at right angles to the  current of
 blood flowing through that vessel into the vena cava.  The right spermatic veins
 are rarely affected, and never, I believe, without those  on  the left side partici-
 pating in the disease.  In these cases of double varicocele  the left is almost in-
 variably the most seriously affected, but I have seen exceptions to this in  one or
 two instances in which the veins on the right side formed the largest tumor.
   The symptoms of varicocele consist of a tumor of a pyramidal shape having a
 knotted or knobbed feel, owing to the irregularly swollen  and convoluted condition
of the veins, with its base upon the testis and the apex  stretching up to the ex-
ternal ring.   The swelling increases when the patient stands up, if he  takes a 
           TREATMENT  OF  V ARIC 0 CELE —0 PER ATION S.        887

deep inspiration, coughs, or makes any violent exertion.   Its size varies from
slight fulness of the veins to a large mass, several  inches in circumference at the
base.   When the patient lies down it goes up to a certain extent, but immediately
returns in its former magnitude when he stands  up again.  It is attended by a
sensation of weight and sometimes of pain, which is occasionally very acute, in
the scrotum, the groins, and the loins, more particularly when the tumor is un-
supported.   This pain is greatly increased on the patient walking or riding; so
much so that in some cases he is almost debarred  taking necessary exercise, and
is prevented following any active occupation.   Debility of the generative organs,
with a tendency to seminal emissions frequently accompany varicocele.
  The diagnosis  of varicocele is  always sufficiently easy; its peculiar feel, its
broad base, and narrow apex, the manner in which it goes up  when the patient
lies down ; and returns again when he stands up, are sufficient to distinguish it
from all other scrotal tumors.  From inguinal hernia the disease may be distin-
guished by attention to the test described at page 735.
  The treatment of varicocele must be conducted with reference to the severity
of the symptoms occasioned by it, and the  extent of the  disease.   AVhen, as is
usually the case, it gives rise to but slight inconvenience, palliative treatment  is
fully sufficient; but if, as occasionally happens, the disease is a source of very
intense suffering, or tends to the induction  of atrophy of the testis, or to genera-
tive debility, with much mental disquietude or hypochondriasis, then the surgeon
may feel disposed to endeavor to cure the varicocele radically.
   The palliative treatment of varicocele resolves itself into means  of various kinds,
having for their object the support of the testis and the diminution of the length,
and of the  consequent pressure of the column of blood.   This  is  usually most
conveniently  done by supporting the scrotum in a well-made suspensory bandage,
or pressure may be made upon the part, as  well as support given by inclosing the
testis in an elastic bag.  In other cases, support may be afforded by drawing the
lower portion of the scrotum on the affected side  through  a ring made of soft
metal, covered with leather.  And with the same  object, the excision of the lower
portion of the scrotum has been recommended, so that by the contraction of the
cicatrix, the testis may be pressed up against the ring, and the cord thus shortened.
This plan,  however, is somewhat severe, and though it might be attended by
temporary benefit, the advantage accruing is not likely to be very continuous.
The pressure of the pad of a truss on the spermatic cord, as it issues from the
external ring, will break the length of the column of blood in its veins,  and may
thus be of service in some cases, though many patients cannot support the irksome
pressure of the instrnment.
  In addition to these mechanical means,  the  part  may be  braced by cold
douching, sea-bathing, and the general strength improved by the administration
of iron.
  The radical cure of varicocele consists in the obliteration of the enlarged veins
by compressing them, and exciting inflammation in them,  on the same principle
that guides us in the management of varix in  other  situations.  As these
operations cannot be undertaken on the spermatic  veins without very considerable
risk of inducing an undue, and perhaps dangerous, amount of inflammation in
them and in the loose  cellular structures of  the  scrotum  and cord, they should
not be had recourse to, unless the disease be a source of very serious inconvenience
                                  Fig. 302.
and pain to the patient.  The operation for the obliteration of the spermatic 
888
DISEASES  OF  THE  TESTES  AND  CORD.
Fig. 303.
may very conveniently be done  by using the  ordinary harelip pins  and twisted
suture, as figured at page 644.  In introducing the pins behind the veins, care
must be taken to separate the plexus from the  vas  deferens.   This is best done
by letting the patient lie down so  as to empty the  vessels, when the vas can be
distinguished by its firm and corded feel.  This must be  carefully drawn to one
                                       side, and there held between the finger
                                       and thumb of an  assistant.  The sur-
                                       geon  then passes  the pins  between it
                                       and the veins, and including as little
                                       skin  as possible,  applies the  twisted
                                       sutures in the usual way.  Three pins
                                       are usually required.   A  good deal of
                                       redness and swelling of  the scrotum
                                       usually ensue, but after the  removal of
                                       the pins at the end of eight or ten days
                                       all irritation will subside,  and the dis-
                                       ease  be  permanently  cured.    The
                                       patient should afterwards wear a sus-
                                       pensory bandage.
                                         A  very ingenious  mode  of  oblite-
                                       rating the veins has been recommended
                                       by Vidal,  and which, as it does not in-
                                       duce  compression of the skin, and only
                                       requires the introduction of one pin, is
                                       attended  by less  irritation  than the
                                       former method.   It consists in passing
                                       a steel or  silver  pin, having a movable
                                       head  (fig.  302,  a), behind the veins,
                                       between them and the vas deferens, in
                                       the usual  way.   A fine silver wire is
                                       then  carried, by  means  of a  needle
having a slit to receive it (Fig. 302, b), in front of the  veins, but underneath
the integuments, being introduced and  carried out  through  the  same apertures
                             by which the  pin is  passed.   In this way the
                             plexus of vessels lies between  the pin behind and
                             the silver wire in front (Fig. 303).  The point of
                             the pin having now been removed, compression  is
                             made by twisting the ends of the wire round either
                             end of the pin, and is gradually increased by the
                             surgeon every day rolling up the pin so as to twist
                             another turn or two of the wire round it.  In this
                             way the veins are not  only compressed but  rolled
                             up and shortened, and the process is  carried on
                             usually for eight or ten days, until they are oblite-
                             rated by plastic  deposit, without being necessarily
                             cut through (Fig. 304).  Vidal speaks very favor-
                             ably of this plan, not only as effecting the oblite-
                             ration of the veins with less risk of inflammation of
                             the scrotum than attends the other method, but as
                             leaving a better result; and I can corroborate his
statement, as I have of late employed this practice  in a few  cases with very ex-
cellent results.
   [The subcutaneous operation of Ricord, for the radical cure of varicocele, is per-
formed in the following manner.   The  veins are isolated from the vas deferens,
Fig. 304.
 
VARICOCELE — SARCOCELE.
889
 and a lance-headed needle, armed with a double ligature, is thrust between them
 and the duct, completely through the scrotum.  The loop is then disengaged from
 tne eye or tne needle, which is again threaded with a double ligature. This last is
 ttien carried in a reverse direction through the same  cutaneous punctures; the
 ligature, however remaining in front of the veins instead of behind them.   The
 free ends of each ligature are then passed through the loop of the other, and being
 drawn in opposite directions, the mass of veins will  be found to be tightly con-
 stricted within the loop.   Formerly the ends of the ligatures were wound over a
 sort ot tourniquet,  but of late 31. Ricord has found that mere traction, without
 ligation, will excite  sufficient vascular action to  effect the occlusion of the vessels.
    Ihis process  of Ricord has been modified by Dr. Pancoast,* who strangulates
 the veins,  by means of a straight  needle and double ligature.  The ligature is
 carried between the veins and the duct; the needle is then  passed in front of the
 veins, between  them and the skin of  the scrotum, traversing the same punctures
 in the skin.  The  loop of the ligature  is then thrown over the shank  of the
 needle, and strangulation  effected  by tying tightly the free  ends of the liga-
 ture, upon the other extremity of the needle.
    Of late, Dr.  Pancoast has  effected  the same  object  by  a somewhat different
 proceeding.  He directs  a needle, armed with a strong silk cord,  to be  thrust
 between the duct and the veins;  the  needle, carrying  with it  the same ligature,
 is then repassed in front of the veins   These will now be found to be embraced
 within the loop of  the cord;  the free  ends of which are  then tightly knotted
 over an ivory  plate upon the  scrotum,  and thus,  complete  strangulation pro-
 duced.—Ed.]

                          TUMORS OF THE TESTIS.
    All solid tumors of the testicle are  classed together under the generic term of
 sarcocele, and when these are conjoined with fluid accumulations in the tunica
 vaginalis,  are termed hydrosarcocele.  Sarcocele  is usually  divided into  the
 simple, the syphilitic, the strumous, the cystic,  and the malignant; which, in-
 deed,  comprise so many  distinct  diseases  of   the  testis, requiring  separate
 study.
   1. Simple sarcocele is a chronic  enlargement of the testis, resulting from
 inflammatory mischief in the organ.   A testicle affected  by  this disease feels
 hard, smooth, solid, though  perhaps slightly elastic  at  points,  is ovoid in shape,
 and usually about as large as a duck's  egg.   It is heavy, and but slightly painful.
 The cord is usually somewhat thickened, and, as well as the groin, is the seat of
 pain of a dragging character.  The disease  can usually be distinctly attributed
 to a blow, squeeze,  or other injury, by which inflammation  had been excited in
 the organ.   The scrotum  is always healthy.
   On making a section of a testicle thus diseased, it will  be  found to be com-
 posed of a quantity of firm and hard bluish-gray  fibro-plastic matter,  effused
 within the  organ and between the tubuli, and also surrounding the gland, often
 in a series of solid and veiy firm glistening layers.  In  the midst of this, opaque
 yellow spots or masses, cutting smooth and firm, will be seen.   These have been
 mistaken for tubercles, but  are in  reality masses  of plastic  deposit that have
 undergone  fatty degeneration.
  In the treatment of this disease, strapping  and the administration of an altera-
 tive course of the bichloride may be  tried.   If the testis  do not diminish in
size by these means, or is  a source of much inconvenience to the patient, it must
be removed.
  2. Strumous  sarcocele  or  scrofulous testicle.—This disease  chiefly occurs in
individuals of a  feeble or  cachectic constitution, usually in  early manhood, and
* Vide Medical Examiner for March, 1843. 
890
DISEASES  OF  THE  TESTES  AND  CORD.
is very commonly associated with  a tendency to phthisis.   It is essentially cha-
racterized by the deposition of tuberculous matter in the testis.  These tubercles
may be encysted or infiltrated, varying in size  from a  pin's head to a cherry or
plum-stone.  When encysted, they are of a bright yellow  color, tolerably firm
and  laminated, contrasting  strongly with  the  inflamed gland, in the midst of
which they are deposited.   Their presence between the tubuli gives  rise to in-
flammation, and eventual disorganization of the structure of the testis.
  The symptoms of scrofulous testis are  well  marked.  The patient  perceives
that without any very  evident cause, or perhaps as  the result of an  injury,
gonorrhceal inflammation, or venereal  excesses, the testes gradually and slowly
enlarge,  often attaining a very considerable bulk, and becoming at the same
time nodulated and irregular, hard and craggy; the hardness  being confined to
                        the nodules, the gland feeling soft between them, and
        Fis- 305-          hydrocele occasionally co-existing.   The epididymis is
                        most  commonly the part that is first affected  in this
                        way, though not unusually it  is the body of the organ
                        that suffers.  Though the disease  commences  in one
                        testis, both almost  invariably eventually suffer, either
                        simultaneously or successively.  One of the nodulated
                        masses in the affected testis gradually increases in size,
                        the skin covering it becomes red, shining,-and thinned,
                        and, at last, adhesion  forms between  it and the testis,
                        indolent  suppuration takes place, and on the discharge
                        of  the abscess  a  fistulous opening is  left.   Through
                        this aperture a fungus speedily protrudes, which grows
                        sometimes slowly, at others rapidly, perhaps attaining a
                        very considerable size (Fig. 305).   As this fungus in-
                        creases, the organ atrophies.   It is in the form of a pale
reddish-yellow granular mass, and is composed  of an exuberant outgrowth of the
tubuli testis inflamed and  mixed with lymph  and tuberculous matter.   If this
fungus continue small and  firm, it may become  a very chronic complaint; but,
if large,  rapidly-growing, and loose-textured, it speedily destroys the testis.  It
is, however, surprising how long the functions of this organ will continue, though
its tissue is in a great measure destroyed,  and its structure traversed by suppura-
ting fistulae.
  The treatment of strumous testis, before the fungus has  protruded, must be
conducted  on the general principles laid down when speaking of scrofula; altera-
tives, tonics, especially the iodide of iron, with cod-liver oil, and general hygienic
means calculated to improve the health, must be steadily persevered in for some
length of time.   The best local  treatment  will  consist in  the application of
leeches from time to time,  followed by discutient iodine lotions, or the iodide of
lead ointment.
  When a fungus  has protruded through one  of the fistulous apertures, means
must be taken to repress or remove this, lest it go on to complete destruction of
the testis.  If it be of small size,  the better plan will  be to  sprinkle it with the
red oxide of mercury, and  to  strap it tightly down with a piece  of lint and
strapping.   If larger, it may be shaved  off, and the cut  surface then dressed
with the  red oxide of mercury ointment, care being taken, during  cicatrization,
to repress the granulations  below the level of the surrounding integument.
  3.  Syphilitic sarcocele, both in  its simple and strumous character, has already
been considered  (page 433), to which I would  refer the reader.
  4.  Cystic disease of the  testis, or cystic sarcocele, is a disease somewhat analo-
gous to the cystic sarcoma of the breast.   The testis becomes much enlarged,
indurated,  of a yellowish-white and opaque appearance,  and studded with a mul-
 
         CYSTIC  SARCOCELE — CANCER OF THE TESTICLE.     891

titude of cysts that vary in size, from a pin's head to a cherry, containing clear,
amber-colored, or brownish fluid (Fig. 306).  This affec-
tion, consisting in the alteration and condensation of the          Fig.ooe.
orchitic structure,  with the  formation of these distinct
independent cysts, must not be confounded with the acci-
dental occurrence  of a cyst or two in a scrofulous testis.
It is a local affection, and although the organ may attain
a considerable bulk, it never gives any -indication of ma-
lignancy.
   This  affection has  been  carefully studied by Sir A.
Cooper, who, with  great justice, adverts  to the difficulty
of distinguishing  it  from other diseases  of this organ,
more especially from hydrocele.  The points  to  be espe-
cially attended to in distinguishing the  cystic sarcocele,
are its want of translucency, the more globular  shape of
the organ, its weight, and the enlarged and varicose state
of the  veins of the  cord.   If there is any  doubt, an
exploratory puncture will resolve this, and should always
be practised.
   Cystic sarcocele requires removal of the diseased organ.
   Occasionally cystic tumors of the testicle are met with, in which the substance
of the  organ is atrophied or absorbed, and its  place  occupied  by one or more
large thin-walled  sacculi containing fluids  of different color and consistence,
dark or fatty.   One of the most remarkable of these anomalous tumors of the
testis that I have seen was under the care of my colleague, 3Ir.  3Iarshall, at the
Hospital last year.   The diseased organ, which was about the size of an ostrich's
egg, and felt partly solid and  partly fluid, was found after removal to be com-
posed of a large cyst filled with an oily fluid, like melted butter,  which solidified
on cooling.  After removal,  3Ir. 31arshall found that  the  sac  contained  some
foetal debris, and was doubtless of  an embryonic character.   The  patient, who
was about thirty years of age, had been affected with the tumor from early infancy.
   5. Malignant sarcocele, or cancer of the testicle, not unfrequently occurs, and
almost  invariably assumes the encephaloid character.   It is, indeed, a question
whether any other form of cancer ever occurs in the testicle.  Dr. AAklshe agrees
with most observers in doubting the existence of the other varieties of malignant
disease in this  organ.
   Cancer of the testicle most commonly occurs in the first instance in the body
of that  organ, rarely affecting the epididymis primarily.  The ordinary characters
of encephaloid, are  always  well marked  in  this  affection,  which  eventually
assumes a softened-down, pulpy, and fungous character.   Intermixed with the
encephaloid  are commonly found  masses of a bright yellow color, which have
sometimes been regarded as  tuberculous, but, I believe, erroneously so;  for  in
those instances in which I have had an opportunity of examining them I have
found them to consist, as  in the  simple sarcocele, of plastic matter  that was
undergoing fatty degeneration.   A malignant testicle  may rapidly attain a very
considerable magnitude, becoming  as large  as a cocoa-nut in  a few weeks  or
months.   AArhen of this size it is, of course, abundantly supplied by bloodvessels;
consequently the spermatic artery and accompanying veins will  be found a good
deal dilated.   The lymphatic glands in the neighborhood speedily become en-
larged, those in the iliac fossa especially, as may be ascertained by deep pressure
in the' flank.  The  inguinal glands do not in general become affected until the
skin has become implicated by the progress of the disease.   It is then also that
the  cancerous cachexy rapidly developes itself.
   The  sumptoms of encephaloid  testicle  are  usually somewhat obscure in the
early stages  although  they become  clearly and  distinctly developed as the dis-
 
892
DISEASES  OF  THE TESTES AND  CORD.
ease progresses.   The patient first begins to complain of some degree of dragging
pain and weight in one of the testes, which on examination will be found to be
indurated and enlarged, though preserving its normal shape.   The enlargement
continues until  the testicle attains  about the size  and shape  of a duck's egg,
being somewhat  tense and elastic, but smooth and heavy.   As it increases in
size, which it usually does  with rapidity, it becomes rounded and somewhat
doughy or pulpy in feel in parts, where, indeed, it may almost be semi-fluctuating,
though in others it becomes hard and knobbed.  This  alteration in feel is partly
due to softening of the substance of the tumor, and partly to its making  its way
through  the  tunica albuginea.   The scrotum is much distended, reddened, and
purplish, and becomes covered by a network of tortuous veins; the cord may be
felt somewhat enlarged, hard and  knotty.   As the  disease advances the scrotum
becomes adherent at some of the softened  parts,  ulceration  takes place, and a
fungus projects,  which presents all the characteristic signs of fungus haematodes;
it does not commonly happen, however, that the disease is allowed to go so far
as this before removal.   The pain  is not very severe at first, but after a time
assumes a lancinating character, extending up the  cord and into the loins.
  The only treatment of any avail in encephaloid  testicle, is the removal of the
diseased  organ.   This operation must not be performed so much with the view
of  curing the patient of his  disease,  which  will probably return in the iliac
glands or in some internal organ; but, as a means of temporary relief from  the
suffering and incumbrance of the enlarged testicle.  It is therefore an operation
of expediency, and should only be done in those  cases in which the  disease is
limited to the testicle, the cord being free and the lumbar glands not involved,
so that if recurrence takes  place  it  may not be a very speedy one.   In some
apparently most  favorable cases, I  have, however, witnessed an early return of
the disease.

                       OPERATION OF CASTRATION.
  This operation may be required for the various non-malignant affections of the
testicle, that have resisted ordinary constitutional and  local treatment, and have
become sources of great  annoyance and discomfort to the patient; in the early
forms of malignant disease it may also be advantageously practised.  The opera-
tion may be performed in the following way.   The  patient, having had the pubes
shaved, should lie upon his back with the legs and thighs hanging over the end
of the table.   The surgeon should  then take  his stand in  front of the  patient
between his legs, and grasping the tumor at its posterior part with  his left hand,
make the scrotum in front of it tense.  If the mass to be removed be of small
size he makes a  longitudinal incision over its anterior surface; if  of  large size,
a double  elliptical incision,  enclosing a  portion of the scrotum.   The incision
should commence opposite  to the  external  abdominal ring, and  be  carried
rapidly down to  the lower part of the scrotum.  By a  few touches with a broad-
bladed scalpel or bistoury, whilst the skin is kept upon the stretch, the tumor is
now separated from its scrotal attachments and merely left connected by the cord
which must then be divided.   In some  cases it will be found advantageous to
expose and divide the cord in the first instance before dissecting out  the  tumor
from the scrotum, as in this way a better command over it is obtained.
  The division of the cord constitutes the most important part of  the operation,
whether this be  done first or last;  as unless care be taken it may be retracted
through the abdominal ring into the inguinal canal, where  it  is extremely diffi-
cult to follow it,  and where the cut stump may pour out  a large and  even fatal
quantity  of blood, infiltrating the cellular tissue and between  the muscles of the
part and  into the flank.   This accident is prevented by giving an assistant charge
of the cord before its division, and directing him to hold it tightly between his
finger and thumb, or what is better, by passing a sharp hook through it, and thus
fixing it.  After the removal of the testicle,  two  or three arteries in the cord 
DIAGNOSIS  OF SCROTAL  TUMORS.
893
will generally require ligature, as well as a few bleeding branches in the scrotum;
the wound must then  be lightly dressed, and allowed to heal by granulation;
bagging in the lower part being prevented during the after-treatment.
  In cancer of the testicle it is of great consequence to  divide the cord as high
up as possible for obvious reasons.  It will not, however, be safe to do this oppo-
site the abdominal ring in the way that has just  been  described, as there would
not be  sufficient space  for the assistant to hold  the cord, above the part  to
be divided.  In such  cases as these I have found  it a good practice  to expose
the cord by dissection  up to the abdominal ring; then to draw it well down and
to include the whole in  a strong whipcord  ligature, tied round it  as  tightly as
possible.  The section is then made a quarter of an inch  below this, and the
operation completed as usual;  the cut stump of the cord may retract into the
inguinal canal, but cannot bleed if properly tied, and would  always  be  under
command by drawing upon the whip-cord.  This plan of tying the cord, en masse,
was at one time generally adopted in all  cases of castration, but it is not  now
commonly employed.  The objection to it is, that by compressing the  spermatic
nerves with the ligature  the after-pain is increased; but this certainly does not
always happen, for in two instances in which I have recently done it at the Hos-
pital, but little pain was  complained of; and the practice in malignant  disease of
the testicle has the advantage of enabling the surgeon to divide the cord  at  a
higher point than he otherwise could; which advantage  is still further increased
by the parts within and below the ligature sloughing away, and thus eventually
carrying the section to a level with the point tied.

                GENERAL DIAGNOSIS OF  SCROTAL TUMORS.
   The diagnosis of scrotal tumors is not only of considerable importance, but is
often attended with very great difficulty.  The  more so as they are  frequently
associated with one another, so that much tact and care are required to discrimi-
nate their true nature.   Thus it is not uncommon to  find a hydrocele and a hernia
(Fig. 307)—a hydrocele and a varicocele,—or, these affections co-existing with a
solid tumor of the testicle.  In other cases again, as in the annexed figure (308)
Fig. 307.                             Fig. 308.
an encephaloid tumor may co-exist with a hydrocele of the tunica vaginalis, and
with an encysted hydrocele of the cord.
  Tumors of the scrotum may, in a diagnostic point of view, be divided  into
two distinct classes :—the reducible and the irreducible.   The reducible tumors
are hernia, congenital hydrocele,  diffuse hydrocele of the cord, and  varicocele;
in all of which the swelling can be made to disappear more or less completely by
pressure and  by the patient  lying down; reappearing on  the  removal of the 
894
DISEASES OF  THE  TESTES AND CORD.
pressure, or on his assuming the erect posture. The mode in which the tumor dis-
appears tends greatly to establish its diagnosis; though the general character of
the swelling, and the history of the case, afford  important collateral evidence on
this point.
   In hernia there are the ordinary signs of this affection, such as impulse on
coughing;, &c.   On reducing the tumor it will be found that its return into the
abdomen  is accompanied by a gurgling noise,  and by the sudden slip upwards of
evidently a solid body.   In the other reducible tumors, the diminution and even-
tual disappearance under pressure are more gradual, and there is no reduction of
the mass  as a whole.
   The gradual  squeezing  out of the contents  of a congenital hydrocele together
with its translucency, and the early age at which it occurs will establish its true
character.
   In the  diffuse hydrocele of the cord, there is a uniform semi-fluctuating swelling
in and near the ring; in which, however, there is no gurgling, &c, no complete
and sudden disappearance as in hernia.   It is also less defined, and has  a less
distinct impulse on coughing.
   Varicocele may  always he  distinguished  by its pyramidal  shape, and its
knotted, soft, and irregular feel.  After  being reduced, when  the patient lies
down, it will, when he stands up, fill again, even though  the surgeon compress
the external  ring with his  fingers.   This  sign, which distinguishes it from a
hernia, occurs also in hydrocele, from  which, however, the varicocele may be
distinguished by the absence of translucency, the want  of fluctuation, and the
general feel of  the tumor.
   Irreducible scrotal tumors are of various kinds, such as omental hernia, hydro-
cele, hematocele, the  various  forms of sarcocele,  and  cancer of the testicle.
These tumors, though presenting certain characters in  common, yet differ some-
what in the predominance of particular signs; thus the shape of the tumor is
usually pyriform in  hydrocele,  globular  in  hematocele, and  oval  in sarcocele,
though this is subject to much  variation.  The weight is least in hydrocele and
greatest in sarcocele, proportionately to the size of  the tumor.  The characters
of the surface present considerable differences, being smooth and tense in hydro-
cele and hematocele; often irregular, hard or knotted  in the other varieties.
The rapidity of the formation of the tumor is greatest  in hematocele.
   An irreducible scrotal hernia may be recognised by its irregular feel, its im-
pulse on  coughing, its occupation of the canal, and by the  testicle being dis-
tinctly perceptible below it.
   A hydrocele of the tunica vaginalis is always  cognizable by its translucency;
and the amount of opacity conjoined with this will  enable  the surgeon to distin-
guish the degree of enlargement of the  testis, and how far  there is a sarcocele
conjoined with  it.
   In hematocele the tumor is of sudden or speedy formation, somewhat globular,
opaque, but not very heavy or hard, and smooth upon the surface.
   In sarcocele generally the tumor is heavy for its size, frequently globular or
irregular in shape, sometimes knobbed,  and usually attended by a good deal of
dragging pain in the groin, and frequently by some enlargement of the cord.
   The point of most importance in the diagnosis of sarcocele is to distinguish
the malignant from the non-malignant varieties.   In the malignant the rapidity
of the growth,  the softness and the elasticity of the tumor, the implication of
one testis  only, and the  early  enlargement of the  cord with its indurated and
knobbed condition are important signs, especially if the disease  occur in young
men.   In a more advanced condition the softening of  the swelling  at parts with
a tuberous condition of the rest, and the occurrence of fungus, with speedy con-
stitutional cachexy, will point to the  malignant  nature of the tumor.  In  cases
of much doubt  and difficulty an exploratory  puncture  may be made, when the
contents of the  groove in the needle or the fine canula will probably determine 
INTRODUCTION  OF  THE  SPECULUM  YAGIN_5.       895
the character of the growth.  In more than one instance, in which there was
much obscurity attending the diagnosis, I have seen the true nature of the dis-
ease cleared up in this way.
CHAPTER LX.
DISEASES  OF  THE  FE3IALE  GENITAL ORGANS.
  Some of the more important surgical affections of these organs, such as vagino-
vesical and recto-vaginal fistulae, lacerated perineum, and  the various forms  of
syphilitic  disease to which they are liable, have already  been discussed; the
remaining affections, implicating the vagina, the uterus, and the ovaries, are of
considerable practical  interest, but as their full consideration would lead me far
beyond the limits that can be assigned to them in this work, I must content my-
self with a brief indication of the principal points deserving attention.

               INTRODUCTION OF  THE SPECULUM VAGINA.
  Vaginal specula of various shapes and materials are commonly used by sur-
geons.   When  the os and  cervix of the uterus require  exploration, the most
convenient instrument is certainly the cylindrical reflecting glass speculum (Fig.
309), which, being coated with a  layer of tin-foil,  covered by India rubber,
always presents internally a mirror-like surface, by which a strong body of light
is thrown  into the bottom of the tube.  It has  the additional advantage of being
very cleanly, and not  stained by any caustics  that may be used in it.  These
specula should be of different sizes, and may be sometimes advantageously bevelled
Fig. 309.
Fig. 310.
off at the inner end.  When the wall of the vagina requires examination,
some operations for fistula, a bivalve  speculum (Fig. 310), or a cylindrical 
896       DISEASES  OF  THE  FEMALE  GENITAL ORGANS.

provided with a sliding side, may advantageously be used.  These are  generally
made of some plated metal or of pewter.
  The introduction of the speculum may readily be effected, without any expo-
sure of the person, under the  dress or bed-clothes.   There are two positions in
which the patient may conveniently be placed for this purpose.   In the first, she
lies upon her back, with the nates well raised and brought to the edge of the bed
or couch, her  legs separated, and  her  feet resting on  two chairs; the surgeon
standing or sitting in  front of the patient, introduces the fore and middle fingers
of his left hand into the vagina, dilates its walls, and  passes the  speculum, well
greased, gently and steadily between and under them.   This position is the most
convenient, when caustics require to be  applied,  but is  often objectionable to the
patient, as it appears to entail  much exposure, though in reality it need  not do
so.   Another mode of introducing the speculum, and  that which should always
be adopted when practicable, consists in placing the patient on her left side across
the bed, with the knees drawn up, and the nates near the edge;  the instrument
is then introduced in the same way as before, the surgeon sitting by the patient's
side.   In whatever way the speculum is used, no force should ever be employed;
the patient should be  placed opposite a good light, and care should be taken that
it be introduced fairly to the uterus, the position of which may have been pre-
viously ascertained by tactile examination.

               INTRODUCTION OF THE FEMALE  CATHETER.
  The use of the female catheter is often required in various diseases and opera-
tive procedures about the genito-urinary organs of women.  It  should be intro-
duced without exposure  by the aid of the touch alone.  This  may readily be
done, as the patient lies in bed, under the clothes.  The surgeon standing on her
left side, passes his left index finger downwards between the  nymphae until he
feels the projection of the meatus urinarius, immediately above the entrance into
the vagina; keeping his finger just below this,  he uses it as a  guide to direct
the point of the catheter into the canal.
           DISEASES OF THE EXTERNAL ORGANS AND VAGINA.
  The vulva and the  nymphae are the seats of numerous morbid conditions, prin-
cipally  consisting  of  hypertrophy or  of verrucous  growths from them, or the
formation of cysts in  their substance.
  Hypertrophy of the labia to a limited extent is not unfrequently met with,
one labium hanging down considerably below the other.   In  these cases it will
often be found that the  enlargement is  due to a kind of solid oedema, originally
dependent perhaps upon a fissure  or  ulcer of the  part.  In other cases again,
large fibro-cellular tumors form as outgrowths from the natural structures in this
region ; these may require removal by simple excision.
  Large condylomata or verrucee are often met with here, as the result of gonor-
rhceal  or syphilitic disease, forming  at last irregular pendulous masses, which
require extirpation, either by  knife or  scissors.  I nave had occasion  also to
remove a large nevus by ligature  from this  situation, and in  fact almost  any
growth that occurs in the fibro-cellular tissue, may be met with here.
  Cystic tumors are not unfrequently met with in the labia, and may sometimes
resemble pretty closely the ordinary forms of inguinal hernia, for which, however,
their incompressibility, irreducibility, and the absence  of impulse  on  coughing
will prevent their being confounded.  These cysts, which require removal  by a
little simple dissection, usually contain a dark, turbid, or sanguineous fluid, and
sometimes atheromatous matter.   Occasionally they project from the  inside of
the vagina, and then  require removal by dissection or ligature, as can  be best
practised.
  An imperforate vagina is occasionally met with in young children, and  occa-
sions a good deal of anxiety to the parents.   This condition, however, may always 
AL TUMORS  AND  PROLAPSUS.             897
riiTMJlSh Tf^ -fT6" > tearin^ »*> the Canal as i* ™> bJ Eg-
ging upon its walls in opposite directions and breaking through the adhesions
which are little more than epithelial, with the thumb Lil, a blunt probe  or the
handle of a scalpel  and then introducing a small pledget 'of greased Hut.
  An imperforate hymen has occasionally been met with, causing  great  incon-
venience by the retention of  the  menstrual secretion, which maylLmulate to
an immense extent, and become converted into a kind of chocolate-colored gru-
mous fluid; in these cases, incision of the membrane is the only remedv   Oc-
casionally the surgeon s advice may be sought by married women, for a rigid and
only partially perforate hymen, when incision with a probe-pointed bistoury, and
dilatation with a sponge tent may be required.
  Hypertrophy of the  clitoris is occasionally met with; this organ  becoming
enlarged elongated,  and pendulous, and in some cases attaining an enormous size"
When  enlarged, it may give rise to a good deal of irritation, and require excision
an operation that would probably be followed by rather troublesome hemorrhage'
  Removal  of the clitoris, even  though not much  enlarged, has of late years
been recommended as a means of cure in some forms of erotomania.   Last year
I performed the operation on a  patient of Dr. Horsburgh's, and  found some
difficulty in stopping the bleeding, which at last required  the  application of the
actual cautery before it could be  arrested.   The operation was I  believe followed
by marked improvement in the young lady's mental  condition.
   Tumors of various kinds are met with in the interior of the vagina,  springing
from its walls.  These  may be of  a cystic character, but occasionally true mucous
polypi  are found dependent and projecting from the side of this canal.   These
may most readily be removed by transfixing their  base by a double whip-cord
ligature, and then strangling it.  In  performing this  operation, however, when
the tumor grows from  the posterior wall, care must be  taken  to  ascertain by
proper digital examination, that a portion of the rectum  has  not been dragged
down into its base.
 ^ Prolapsus of the anterior or the posterior wall of the vagina may occur, giving
rise in the first instance to a  cystocele, in the next, to a rectocele; in either case,
but especially in the  first, occasioning very serious and troublesome consequences'
amongst which, chronic irritation of the mucous membrane of the bladder, with
perhaps phosphatic deposits in that organ,  are the most marked.   These protru-
sions may be supported by the use of properly constructed belts or pessaries.   In
some cases the surgeon may feel disposed to undertake operations, having for their
object the narrowing of the vaginal canal,  either by cauterizing it in parts with
the red-hot iron or the  electric cautery, or paring opposite portions of its walls,
bringing together the freshened surfaces,  and thus  procuring narrowing of the
canal and permanent support to the protruded part.
   Various discharges connected with the female organs of generation  fall under
the observation of the surgeon: these may occur from the external  organs, from
the mucous  membrane covering the cervix uteri, or from the interior of the cavity
of that organ.  These  discharges, when proceeding  from the mucous membrane
covering the external  organs or lining the vagina, are frequently, though not
necessarily,  of a gonorrhceal  character; and then require to  be treated in the
way that has been mentioned at page 811.   When of a simple nature, proceed-
ing from mere hypersecretion of  these parts, astringent injections and  attention
to the general health will usually succeed in effecting a cure.
  AVhen these discharges proceed from the cervix or the interior of the os uteri,
they will commonly  be found to be  dependent upon a chronically inflamed or
congested condition  of the  organ, or upon  a  papilkted, granular, fissured, or
ulcerated condition of the mucous membrane, often  connected with more or less
local thickening and induration of subjacent structures.   These various condi-
tions, often  of a  very  persistent, insidious, and destructive character, have of
    '                                57 
898       DISEASES OF  THE  FEMALE GENITAL ORGANS.

late years, been fully recognised by the labors of some of the  French  surgeons,
more particularly of Lisfranc, Emery, and  Jobert;  and in  this  country their
pathology has  been greatly  elucidated by Simpson,  Bennet, Tyler  Smith, and
Murphy.   To Dr. Bennet especially is  due  the  great credit of having pointed
out the true pathology of various  uterine diseases  that were previously but im-
perfectly  recognised, and of having shown that many of the so-called functional
diseases of the uterus are in  reality dependent  on congestion, inflammation, and
other structural lesions of this organ.
   These uterine discharges,  occurring usually as the result of chronic inflamma-
tion and its consequences, just as we find on other mucous surfaces, as that of the
urethra, throat, or eyelids, are attended by various symptoms indicative of  local
distress, such as pain in the back and thighs, and  more especially in the left
o-roin, with dysmenorrhoea and usually a good deal  of  sympathetic  constitutional
irritation, terminating in impaired digestion,  mal-nutrition, and anemia.  It is in
this condition of the system also  that many of the so-called hysterical  affections
are so apt to  arise, and the surgeon will often find that the most inveterate case
of neuralgia of  the  joints, the spine, the hip,  or  the breasts,—amaurotic, and
other obscure affections connected with nervous irritation, are primarily dependent
on chronic uterine disease, and it is only by attacking  and removing this, that he
will remedy the secondary mischief.  On examining the condition  of the cervix
and os uteri in  these  cases  by means of the speculum, various  morbid changes
will be  observed in them; the cervix is perhaps thickened, indurated  or knobbed
on  one  side,  the os is frequently  patulous, and the mucous membrane covering
these parts will be observed to be erythematous, congested, and  perhaps  excori-
ated ; not unfrequently in a  granular condition, closely resembling what may be
observed  in some forms of  granular conjunctivitis.   In other cases,  again, true
ulceration may exist both  upon the  cervix  and within  the  os.   These ulcers,
abrasions, excoriations, or by whatever term they may be designated, are unques-
tionably a fruitful source of mischief in this situation,  giving rise to considerable
thickening of subjacent structures, usually to  abundant muco-purulent discharge,
and much sympathetic irritation.   Their characters closely resemble  correspond-
ing forms of disease met with  on the mucous surface in  other situations, not
attended by loss of substance, but  by the  development of small pointed granula-
tions or papillae, from which  the discharge is poured forth.
  The treatment of these various affections  of the uterus has  been materially
simplified since their pathology has been better understood, and practitioners are
now generally agreed as to the necessity of  the  employment of energetic  local
           measures for the removal of these  morbid states.   To the surgeon
           who is in the habit of managing local  disease on other mucous sur-
           faces, and of removing the structural lesions  that result  from chro-
           nic  inflammation in other organs, the  treatment of these  cases can
           present  little difficulty, as it  is conducted on  precisely  the same
           principles  that guide  him in the management of similar  affections
           elsewhere.
              The employment of caustics is of essential service in  these various
           forms of chronic uterine disease.   In cases of simple  ulceration or
           excoriation, the nitrate of silver in stick applied every third or fourth
           day will frequently be found to effect a speedy cure.   For this pur-
           pose, the  hinge  caustic-holder will  be found a useful  instrument
           (Fig. 311).  If  there  be  much chronic induration, conjoined  with
           the affection of the  mucous membrane, the potassa cum  calce fused
           into narrow sticks, may very advantageously be -used.   In doing this,
           however, care must of course be  taken that the cauterizing  action do
           not extend too far.  Hence the  surgeon, after lightly  touching the
           diseased part, whether this be on the cervix or inside the os,  should
immediately  inject  some weak  vinegar  and  water,   so as  to neutralize the
 
INE DISCHARGES, DISPLACEMENTS  AND  TUMORS.   899
alkah.   After these applications, which should only be repeated at lengthened
intervals, the patient must  be kept quiet for  some time, and any inflammatory
symptoms that may be excited, combated in the usual way;  it very rarely hap-
pens, however, that anything untoward will result.
  After the removal of the local disease in the way pointed out, any remaining
congestion may be got rid of by the application of leeches to the cervix.   During
the time that these local measures are being adopted, proper constitutional treat-
ment must be had recourse to, with the view of improving the general health on
ordinary medical principles, which need not be detailed here, but for a full expo-
sition of which,  as well as for a vast deal of important information on the surgical
management of uterine affections, I would refer the reader to the last  edition of
Dr. H. Bennet's work on the Uterus.
  The various displacements to which the uterus is liable, whether downwards,
constituting prolapsus, or in the  direction of the axis, being twisted,  and either
retroverted or anteverted, are a cause of much local suffering and constitutional
disturbance,  and commonly require surgical  treatment.  These various condi-
tions  will  frequently be  found dependent  on inflammatory congestion of the
fundus, in  consequence of which  the organ becomes as it were top-heavy, and is
tilted to one side, or descends bodily in the pelvis.  The treatment under such
circumstances must have reference to the removal of the local turgescence by the
application of leeches, the employment of astringents,  hip-baths, and the recum-
bent position; occasionally assisted perhaps, in twist of the organ, by attempts at
replacing it by introducing the uterine sound  into  its cavity, or when it is pro-
lapsed, by supporting it with appropriate pessaries and the abdominal  bandage.
   Tumors of the uterus are of various kinds.   The most common are those of a
fibrous character: these are often of considerable  size,  and have been found
weighing  many pounds; they may occupy almost any portion  of the  uterus,
either projecting into the peritoneal cavity, occupying the interior of  the organ,
or dependent into the vagina.   These tumors seldom occur  before the age of
thirty or forty, and are not very amenable  to treatment.   In some cases, how-
ever,  considerable benefit results  from  attention  to position,  the  occasional
application of leeches to the cervix, so as to lessen the congestion of  the organ,
and the introduction into the vagina every night of a ball  composed of equal
parts  of strong mercurial ointment, wax, and lard, or one containing iodine, or
the iodide of lead, with the view  of acting as an absorbent on the morbid tissue.
   Polypi are not unfrequently met with growing  from the inner surface of the
uterus, usually from  its posterior  aspect or fundus.  These growths are generally
oval or pyriform, smooth, hard,  and insensible, and the  cause  of repeated he-
morrhage,  and it is a remarkable fact that in many cases the most violent bleed-
ing proceeds from the smallest tumors.  In other cases, the tumors of the uterus
are of a soft, fibro-cellular, vesicular or mucous character, attended like  the harder
ones by free hemorrhage.
   The treatment  of polypi of the  uterus is best  conducted  by ligaturing their
pedicle.  This may usually be readily enough effected by means of a whip-cord
ligature applied by Oooch's  double canula, which has been  variously modified
and a good deal  improved by different surgeons.  The ligature should be gradu-
ally tightened, and usually cuts its way through in from three to five days; the
tumor swelling, decomposing  often with  a good  deal  of  fetid discharge, which
requires to be carefully syringed away by means of dilute chlorinated  lotions.
It is a useful precaution, not  to  apply the  ligature too near  the uterine end of
the pedicle, as cases have occurred in  which, by so doing, the surgeon has given
rise to serious and even fatal inflammation of the womb.   Any portion of pedicle
that is left will gradually undergo absorption.
  The cauliflower excrescence from the uterus attended by copious discharge, is
a rare and  dangerous affection.   The only treatment that appears to be of any 
900       DISEASES OF THE  FEMALE GENITAL ORGANS.

avail, is to draw down the neck of the uterus by means of a vulsellum, and then
to excise the tumor with the surface from which it grows.   This operation is not
attended  by any very serious hemorrhage,  and succeeds  in ridding the patient
effectually of her disease.
   Malignant affections of the uterus usually commence in the form of scirrhous
tubercle or ulcer of the cervix, attended by the ordinary local and constitutional
symptoms of this affection;  there is much offensive discharge,  and cancerous
cachexy speedily sets in.
   The  treatment  of these cases must be of a  purely palliative character; the
administration of  opiates and  the use of chlorinated lotions must be principally
relied on.  Excision of the diseased  cervix  has  been  recommended,  and  was
formerly a good deal practised ; but this is a barbarous procedure, and one con-
trary to every principle of good surgery, as it is impossible  to rid the patient of
scirrhous  disease by the partial removal of the affected organ,  and its complete
extirpation cannot be thought of. Tumors, however, of a simple character requiring
removal are occasionally met with springing from the cervix : they must be excised
by putting  the patient in  the position  for  lithotomy, drawing  the uterus well
down with forceps and removing them with  the knife; this has been done during
pregnancy, and even during parturition, with good effects.

                                OVARIOTOMY.8
   Ovarian cysts  and tumors may require  removal, either on  account of  their
large size and the consequent inconvenience occasioned by it, or from their rapid
growth exhausting the patient,  and threatening a  speedy extinction of life.
These  operations  have of late years  been  frequently performed with success,
and their introduction into surgical practice has  been mainly due to the labors
of Drs. F. Bird and Clay.   31uch discrepancy of opinion has  existed  amongst
practitioners as to the propriety of performing these  operations, which have been
chiefly condemned on the  grounds that as the disease for which  they were per-
formed, was  not necessarily fatal, or at all events not incompatible with long life,
it was  not proper to subject the patient to a hazardous procedure for its removal;
and that the mortality from the operation  was so high as not to justify a surgeon
in performing it.
   With regard to the  first objection,  it may be  stated that  ovarian disease  is at-
tended by very great discomfort and  inconvenience  in  all cases; and  that it is
not  generally compatible with prolonged existence  so soon as  it  attains such a
size as  to require tapping.  Air.  Stafford Lee states that  of 46 patients  with
ovarian disease, who were tapped, 37 died, and only nine recovered; and that of
the  37 who died,  more than one-half did so in four months from the first tapping,
and 27 out of the 37  within a twelvemonth, and of these,  18  were only tapped
once.   In those who survive, repeated tappings are required, the interval between
each decreasing as  they  are  repeated.   The  second objection can have  little
weight with any practical surgeon.  The mortality after ovariotomy is not so high
as that after many operations, which  no surgeon would  hesitate for  a moment
in performing.  Thus, 3Ir. Phillips has collected 61 cases,  in which gastrotomy
was performed and the tumor extracted; of these,  35 were successful, and 26
died.   3Ir. Stafford Lee gives 90 cases  in which ovarian tumors  were removed,
of these,  57 recovered, and 33  died; and  Dr. Lee  has collected  102 cases of
extraction of ovarian  tumors, of which, 60  did well, and 42 terminated fatally.
When we compare this with  the rate of mortality after primary amputation of
the  thigh, amputation at the hip, that  following the ligature of  the  subclavian
or carotid arteries, or  indeed even strangulated hernia in  hospital practice, we
   a [The opinions entertained by the author upon the subject of ovariotomy, are  at variance with those
held by the  ma*> of the profession, both in this country and  abroad. The result of all operative interfe-
rence for the removal of ovarian cysts and tumors, has as yet proved most unsatisfactory; the few in-
stances of successful recovery forming but a small proportion, when compared with the numerous lamen-
table failures.—Ed.] 
OVARIOTOMY.
901
cannot consider it  as  of a magnitude to interfere with the performance of the
operation if other circumstances justify it.
  It has further been objected to ovariotomy, that  it has not unfrequently hap-
pened that after the operation has been commenced, it has been found impossible
to complete it, owing to the existence of adhesions between the tumor and the
contents of the abdomen.   This objection is certainly a grave one; but I believe
that with care in examining the tumor, ascertaining its mobility during respiration,
the existence or not of crackling under the abdominal wall during the respiratory
movements, the absence of connexion with the uterus, as determined by finding
that organ  floating on the introduction of the uterine sound, and the previous non-
occurrence of peritonitis, this mistake is not now so likely to happen as formerly,
when the liability to it was not suspected.  It must also be borne in mind that
in most cases in which the operation has been discontinued without being com-
pleted, little harm has resulted to the patient.
   Operation.—On the day  preceding the operation a  dose of castor-oil should
be administered, and  on the morning of it an enema, so that  the bowels may be
completely emptied.   The room having been raised to a temperature of at least
75° or 80° F., chloroform administered, and the bladder emptied by the catheter,
the patient must be placed upon  a table  covered with blankets, in such a way that
the legs hang over the end of it, and the abdomen is fairly and evenly exposed.
The surgeon, taking his stand between the patient's legs, makes an incision,
about four inches in length, from the umbilicus downwards, directly in  the mesial
line; by a few  touches  of the  knife, the structures, which are usually much
thinned, are divided along the linea alba, and  the abdominal cavity opened.
   There has been much discussion  as to the length to which the incision in the
abdominal  wall should be made, some practitioners recommending that this should
be of very  limited extent,  others that it should reach from the ensiform cartilage
to the pubes.  No definite rule can  be laid down upon this point.   The incision
must be proportioned  in extent to the size and nature of the tumor, and the exis-
tence or not of adhesions.   If the  tumor be cystic, and not adherent,  it may be
readily  enough extracted by making an incision, an inch or  two in  length, in
the mid-line, tapping it through this, and then  drawing the emptied cyst forwards
by means of a vulsellum.   If, on the other hand, the ovarian growth be chiefly
solid, a larger incision, from four to six inches in extent, will be required. Should
adhesions exist, it may even be  necessary to  go beyond this, though I cannot
believe  that it is ever necessary to rip up the abdomen from  the sternum to the
pubes, for the removal of  any tumor, however large or adherent.
   If it be found that the adhesions  are so extensive and firm that  the tumor
cannot be removed, it must be tapped, and the wound in the abdominal wall closed.
   The tumor now comes into view : if cystic, it must be tapped with a large tro-
char and the fluid evacuated.  Should this be very thick and viscid, the aperture
in the sac may be enlarged with a probe-pointed bistoury, and thus its contents
let out.   In this way the size of the tumor may be so much lessened as to admit
of its more ready extraction.   If  cystic and emptied, it may now perhaps be
drawn out  through the incision in the abdominal wall without further difficulty.
If solid, or if  there be any adhesions, the surgeon must introduce his  hand, and
thus assist  in removing the  mass, or gently break down any connexions it may
have formed with  adjacent  parts.  These will chiefly be found at the anterior
part, between it and the abdominal wall; seldom or ever posteriorly, or to any of
the abdominal viscera, except the uterus.  During the withdrawal of the mass
from the abdomen, an assistant on either  side must  press upon the sides of the
incision with their hands or with soft napkins, so as to prevent the protrusion of
the intestines.   This  sometimes  occasions considerable trouble, especially if the
patient  have taken chloroform and  begin to vomit,  when it may be necessary to
discontinue the operation for a time. 
902       DISEASES OF THE FEMALE  GENITAL  ORGANS.

   The separation of the pedicle is the next step, and perhaps the most impor-
tant one in the  operation.   This may best be done by drawing  the  tumor well
forwards, transfixing the pedicle with a nevus-needle carrying a strong whip-cord,
tying it firmly on either side,  and then  cutting it  across above  the  constricted
portion.   In doing all this, a few points require attention.  Care should be taken
that the needle do not transfix any large artery or vein.   This may generally be
avoided by spreading out or unravelling, as it were, the  pedicle  and  examining
its structure before passing the ligature.  After it has been transfixed, and before
the cord is tied, it is well to dissect off that portion of the peritoneal investment
of the pedicle which  corresponds to the line that will be constricted by the liga-
ture.   In doing this great care must, however, be taken not to wound the ves-
sels, especially the veins, which are  very thin-walled.  In this way there will, I
think, be  less risk of peritonitis, as there is less  chance of any slough of the
pedicle falling  into the peritoneum; and  I attribute  much of the success  that
attended the removal of an  ovarian tumor, partly solid and partly cystic, weighing
about fifteen pounds, which I recently extracted  from a lady, sixty-five years of
age, to the adoption of this precaution.
   After the  ligature  of the pedicle, it should be  divided about half an inch
above the part tied.   If it be cut across nearer the  ligatures than this, there will
be danger of the stump retracting under  them, and  thus inducing secondary
hemorrhage.
   The next point in connexion with the pedicle is fixing it properly  out of the
peritoneal cavity, so that it may not be drawn back into this, as it always has a
tendency to do, and thus excite undue  inflammation by the presence of  the liga-
tures and resulting slough in the serous membrane.   I have found the most con-
venient way to fix it is to close the lower part of the incision in the  abdominal
wall by a hare-lip pin passed across  it, about  half  an inch above its angle, and,
drawing the stump of the pedicle well out of the abdomen through this, to retain
it there by twisting the whip-cord ligature with which it has been tied, in the
usual figure of 8 manner, round  the pin;  in this way it cannot  possibly be  re-
tracted, and  there is no chance of any of the slough or  ligature falling into the
peritoneal cavity.
  The incision in the abdomen must be closed by a series of interrupted sutures
passed across from one lip to  the  other, and  the abdominal wall must  be  still
further supported by broad and long slips of plaster, and a laced  napkin round
the body.
  The after-treatment of the case will  require the most  careful attention.  The
patient should be kept in bed, in a high and uniform temperature.   Nothing but
ice and barley or Seltzer-water should be  allowed  for several  days, and opium
must be given in sufficient and repeated doses,  to keep the system slightly influ-
enced by it.  The urine must be  drawn off thrice in the twenty-four  hours, but
the bowels should be left  unrelieved  for at least  ten or twelve days, and then
merely opened  by an  enema.   As no solid food should be given during the
whole of this time, little inconvenience results.   If peritonitis  come  on, that
must be treated in accordance  with the rules laid down when speaking of stran-
gulated hernia. 
INDEX.
Abdomen,  injuries of, 315;  ruptures of  the
  viscera, ib.; buffer accidents, 16.; penetra-
  ting wounds of, 316 ; tapping, 783.
Abscess, 329; varieties of, ib.; diagnosis of,
  332;  treatment, 333;  modes of opening,
  335; sinus, 336;  fistula,  ib.;  metastatic,
  370; psoas, 605 ; iliac, 606 ; of breast, 686 ;
  prostatic, 791; urethral, 797;  perineal,  ib.;
  urinary, 825.
Acetabulum, fracture of, 217.
Adenitis, 446.
Air, entrance of,  into veins, 140; cause of,
  142; treatment of, 143.
Air-passages, foreign bodies in, 303; scalds
  of, 307.
Amputation, 82; tourniquet, ib.; instruments,
  83;  amputating knives,  ib.;  saws,  84;
  their construction, ib.; circular amputation,
  ib.;  mode  of  using,  ib.;  ligatures,  ib.;
  stumps, 86; rate of mortality, 89;  at Uni-
  versity College  Hospital, 89 ; primary,  90;
  secondary, ib.;  statistics of, 90-92 ; special,
  92; of fingers, ib.; of thumb, 93 ; of wrist,
  94; arm, 95; fore-arm, ib.;  shoulder,  96;
  Larrey's operation, 97; foot, 97 ; toes,  98;
  Syme's  operation,  99;  Hey's do.,  ib.;
  Chopart's do., ib.; of tarsus, ib.; leg, 101;
  Vermale's  operation,  102;   thigh,  103;
  Luke's do., ib.; at  hip, 104 ; in contused
  wounds, 119;  for traumatic gangrene, 120;
  in gun-shot wounds, 124 ; in fractures, 198;
  in burns, 328; in frost-bite,  329; in gan-
  grene, 347; in  hospital gangrene, 350; of
  diseased joints, 601.
Anal fistula, 765.
Anal specula, 763, 778.
Anastomosis, 137; aneurism by, 543.
Anchylosis, 593 ;  Barton's operation for,  ib.
Aneurism,  traumatic,   162; traumatic  dif-
  fused,  ib.;  traumatic  circumscribed,  ib.;
  varicose,  164; fusiform, 463;  sacculated,
  464 ; true, ib.; false, 465; dissecting, 466 ;
  structure of, 466 ; effects of,  ib.; symptoms
  of, 468 ; suppuration of, 470, 486 ; rupture
  of, 472; diagnosis of, 472; cause of, 474 ;
  treatment of, 476 ; Valsalva's method,  ib.;
  ligature in, 478; Hunterian  operation,  ib.;
  Anel's do., ib.; accidents  after ligature,
  481 ; secondary, 482; gangrene after ope-
  ration, 486; compression in, 488; galvano-
  puncture  in, 493 ; inguinal,  494 ; femoral,
  500;  popliteal,  ib.;  tibial, 508; of inno-
  minata, 509 ; distal operations for, 512; ot
  carotid, 517; of subclavian,  526;  ot axil-
  lary, 532; of  arm, 542 ; of  forearm, 543 ;
  by anastomosis, ib.
Aneurismal varix, 164.
Angeioleucitis, 445 ; treatment of, 446.
Ankles, weak, 633.
Antiphlogistic  treatment, 48.   See  Inflam-
  mation.
Antrum, diseases of, 657 ; tumors of, 658.
Anus, artificial, 724, 754 ; treatment of, 725 ;
  Physick's operation for, 727 ; faecal fistula,
  ib.; Amussat's operation,  755;  operation
  for, ib.; narrowing of, 757; imperforate, i&.;
  congenital  malformation of,  758 ;  ulcer of,
  762; fissure  of, ib.; spasm of,  764;  fistula
  in ano, 768;  prolapsus ani, 779.
Aorta, wounds of, 314;  ligature of, 499.
Aphonia, 670.
Arnica, value of, 110.
Arteries,   injuries  of,   146;   bruised,  ib.;
  wounded,  ib.; cut, permanent closure of,
  149; wounds of,  compression of, 151, 160;
  treatment  of  wounded,  ib.;   traumatic
  aneurism,  162;  traumatic   diffused,  ib.;
  traumatic  circumscribed,  ib.;  wounds  of
  carotid,  172 ;  of  temporal,  ib.;  subcla-
  vian,  173 ;  axillary,  ib.;  axillary aneu-
  risms,  traumatic,  174 ; radial  and ulnar,
  176 ;   palmar, ib.;   femoral,  177;  tibial
  and plantar,  178;  state of, in gangrene,
  343;   diseases of,  453 ;   structural  dis-
  eases  of, 456; calcification-of, 458;  rup-
  ture of, 460 ; contraction of, ib.; occlusion
  of, 461.
Arteritis, 453 ; gangrene from, 455.
Artery, cut,  retraction of, 148;  contraction
  of, ib.; forceps, 155,  compressor, 490; ex-
  ternal  iliac, 496 ;  common iliac, 498 ; inter-
  nal iliac, 500; femoral, 502 ; dorsalis pedis,
  509; tibial, 16.; carotid, 520;  innominata,
  527; subclavian, 528, 534;  axillary, 541;
  brachial, 542; radial, 543 ;  ulnar, ib.;  liga-
  ture of, ib.
Arthritis, traumatic, 233, 586; treatment of,
  590; chronic rheumatic, 619 ;  of shoulder,
  621.
Artificial respiration, 302.
Asphyxia,  300; by  drowning, ib.;  artificial,
  respiration, 302; overlaying,  303;  hanging,
  ib.
Atheroma, 457.
Axillary aneurism,  174
B.
Barbadoes, leg, 381.
Balanitis, 873.
Bed-sores, 348.
Bladder, rupture of, 322;  diseases of, 784;
  cystitis, ib.; catarrh of,  785;  sacculi in, 
EX.
904                                   in
  785 ; irritability of, ib.; distension of, 786 ;
  paralysis of,  787; retention of urine from,
  ib.;  incontinence  from,  789; extroversion
  of,  790;  puncture of, 796;  puncture per
  rectum, 796 ; stone in, 829.
Bloodvessels, wounds of, 138. See Arteries.
Boils, 352.
Bone, syphilitic diseases of, 432 ; abscess of,
  558;  trephining, 559;  structural changes
  in,  570;  mollifies  ossium, 571; fragilitas
  ossium, ib.;  tubercle in, 573; tumors of,
  575;  cystic  tumors of,  576; hydatids of,
  577 ; cancer of, ib.; sanguineous  tumor of,
  580; aneurism of, 581.
Bones, injuries of, 180; bent,  ib.;  bruised,
  ib.; broken, ib.
Bougies, 815.
Brain, injuries of, 266, 268 ;  cerebral disturb-
  ance, 266 ;  compression of, 268, 284; con-
  cussion of,  266, 272 ; treatment of cerebral
  disturbance, 272; wounds of, 284; diagno-
  sis of compression, 286.
Breast,  diseases  of, 684:  neuralgia of,  ib.;
  supernumerary, ib.; hypertrophy of, 685 ;
  galactorrhcea,  685; inflammation  of,  ib.;
  nipple,  diseased, 686 ; abscess of, ib.; en-
  cysted  abscess  of, 688;  tumors of,  ib.;
  chronic mammary tumor, 689; cystic tumor
  of,  690; sero-cystic tumor of, ib.;  cystic
  sarcoma of, 691 ;  hydatids of, 693 ; cancer
  of, ib.; operation in,  699; amputation of,
  703 ; male, disease of, 703.
Bronchocele, 682.
Bubo, 419 ;  primary, 420.
Burns, 324 ; treatment of, 328 ; amputation in,
  ib.; operation for cicatrices, ib.
Bursae, diseases of, 622; bunion,  624; gan-
  glion, 624.
                    C.

Callus, 186.
Calculi, structure of,  833; alternating, ib.;
  renal,  ib.;  vesical,  834;  encysted,  ib.;
  sounding  for,  838;   operations  for, 841 ;
  urethral, 857;  prostatic,  858;  recurrence
  of, 869 ; in women, 869.
Cancer, 386;  varieties of, ib.;  structure of,
  387; cancer-cells, ib.; scirrhus, 388 ; ence-
  phaloid, 389; colloid,  390;  melanosis, ib.;
  diagnosis of, 390; treatment of, 392; com-
  pression in, 393 ;  operations for, 394;  epi-
  thelial,  397; of skin,  443;  of bone, 577;
  of breast,  693; of rectum, 761 ; of anus,
  762 ; of penis, 873 ;  chimney-sweep's can-
  cer, 873 ; of testis, 890.
Cancrum oris, 352.
Carbuncle, 353.
Caries, 560 ; of spine, 603.
Cartilage, diseases  of, 586; loose, in  joints,
  601.
Castration, 892.
Catheters, 814 ; female, 896.
Cautery in hemorrhage, 152.
Cephaloematoma, 274.
Chancres, 408; varieties of,  409; treatment
  of, 412.
Chancrous indurations, 419.
Cheiloplastics, 651.
Chest, injuries of, 309.
Chloroform, 78 ;  administration of, ib.; cau-
  tions in  using, 79; not  to be  used in dis-
  eased  heart, ib.; injurious effects of, how
  remedied, 79.
Cholesteatoma, 382.
Cicatrix, 69; changes in, ib.; of burns,  328;
  operation in, ib.
Cicatrization, 70.
Circulation, collateral, 159.
Circumcision, 871.
Clavicle, fracture of, 204 ; dislocation of, 242.
Clitoris, hypertrophy  of, 897.
Cloacae, 565.
Clove-hitch knot, 237.
Club-foot,  629 ; Mutter's apparatus for, 631.
Coccyx, fracture of, 217.
Collodion,  115.
Compress, graduated, formation of, 153.
Condylomata, 380.
Contusions, 109 ; causes of, ib.; degrees of,
  ib.; treatment of, 110.
Corns, 438.
Coronoid process, fracture of, 212.
Cystitis,  784.
Cystocele, 705.
Cystic oxide, 832.
Cystine,  832.
Cysts, 379.

                    D.

Deformities, 626.
Delirium, traumatic, 108.
Disarticulations, 82.
Dislocations, 234 ; causes of, ib.; effects of, ib.;
  treatment of, 236 ; reduction of, 237; reduc-
  tion of old, 238; compound, ib.; complicated,
  239; spontaneous, ib.; congenital, 241;  of
  jaw, 241;  lower jaw,  ib.; clavicle, 242;
  shoulder, 244 ;  humerus,  ib.;  elbow, 249 ;
  radius, 250; ulna, ib.; wrist, 252;  fingers,
  253 ; thumb, ib.; hip, 254 ; patella,258; knee,
  260 ; ankle, 262; astragalus, 263;  foot, 262-
  265.
Drowning, 301.
Dupuytren's splint, 230.
Dysuria in  gonorrhoea, 802.
                    E.

Ear, foreign bodies in, 294; diseases of, 636.
Effusions, inflammatory, 56.
Elbow, fracture of, 211.
Elbow-joint, fractures near, 210; dislocations,
  of, 249.
Elevator, 288.
Emphysema, 310.
Empyema, 311.
Encephalitis, 267.
Enchondromata, 384, 576.
Enterocele, 705.
Enterotome, 726.
Epiplocele, 705.
Epispadias, 871.
Epistaxis. 637.
Epulis, 657.
Erysipelas, 354; causes of, 355; constitutional
  disturbance in, ib.;  varieties of, 357; ex-
  ternal, 357; phlegmonous, 358;  cutaneous,
  ib.; cellulo-cutaneous, ib.; cedematous, 359;
  simple, ib.; cellular, ib.; treatment of, 361;
  of head,  364;  scrotum, ib.;  pudenda, ib.;
  fingers, ib.; fauces,  366; larynx, 367;  of
  serous membranes, 367. 
INDEX.
905
Excision of joints, 594; shoulder, 595 ; elbow
  ib; ankle  597; astragalus,  ib.; os calcis,'
  598; cuboid, ib.; knee, 599 ;  head of femur,
  618.
Exostosis, 574.
Extravasation of faeces, 319;  of'blood into ab-
  domen, ib.; of urine, 790.
Eye, injuries of, 295.
                     F.

Face, injuries of, 293 ; plastic surgery of, 645.
False passages, 817.
Femur, fracture of, 217;  of neck of, ib.
Fever, inflammatory, 42; types of, ib.; sthenic,
  ib.; asthenic, ib.; irritative, ib.
Fibrine, 57; limiting, 62.
Fingers, fracture of, 216; dislocation of, 253.
Fistula, 336.
Fistulas, salivary, 293; of  parotid duct, ib.;
  anal, 764; recto-vesical, 781; recto-vaginal,
  ib.;  Barton's  case of,  783; vaginal, 828;
  urethro-vaginal, ib.; vesico-vaginal, 829.
Foot, deformities of, 629; talipes, ib.;  equi-
  neus, 630;  varus, ib.;  equineovarus, 633;
  valgus, ib.;  calcaneus, ib.
Forceps,  567; necrosis forceps,  ib.;  gouge
  forceps, 568; lithotomy forceps,  843.
Forearm, fracture of, 212.
Fracture, compound, 194 ; amputation in, ib.;
  nasal bones, 202; septum nasi, 203; malar
  bone, ib.; hyoid bone,  ib.; maxillary bone,
  ib.;  lower jaw, ib.; clavicle, 205 ; scapula,
  206 ;  shoulder-joint,  near, 207 ;  humerus,
  208;  elbow-joint,  near,  211; of olecranon,
  212;  coronoid process, ib.;  forearm, ib.;
  elbow, ib.;  wrist, 213; radius, ib.; fingers,
  216; pelvis,  ib.; acetabulum, ib.;  of sacrum,
  217;  coccyx, ib.; neck of femur, ib.; knee,
  near, 225;  patella, ib.;  leg, 227;  ankle-
  joint, near, 229; foot, 230; calcaneum, ib.;
  ribs, ib.; skull, 276 ; skull, base  of, 277.
Fracture-apparatus condemned, 189.
Fracture, accidents after, 192.
Fractures, 181;  direction of, 183;  causes of,
  181;  varieties  of,  182; signs of, 184;  dis-
  placement in, ib.;  crepitus in, 185; grating
  in, ib.;  union of, 186; compound union of,
  187; simple, treatment of, ib.; reduction of,
  189 ; bandages, ib.; splints,  ib.; apparatus
  for, ib.; condemned, ib.; division of tendons
  in, 192, 193; condemned, ib.; starch-ban-
  dage, 192;  accidents  after  fracture, 192;
  spasm of muscles in, ib.; gangrene,  ib.;
  hemorrhage, 193; complicated with dislo-
  cation, ib.;   ununited, 199;  irregular  union
  of, 198; resection for, 199.
Fractures, compound, union of, 188.
Fractures, simple, treatment of, 188.
Fragiliias ossium, 570.
Frost-bite, 328 ;  amputation in, ib.
Gangrene, signs of, 71; mode of arrest of, ib.;
  line of demarcation, ib.; of separation, ib.;
  after ligature, 179; causes of, 171, 342; spon-
  taneous, 343; senile, ib.; state of arteries in
  gangrene, 344; treatment of, 344 ; treatment
  of senile, 346; amputation in, 347 ;  gangre-
                                      58
  nous diseases, 348 ; hospital gangrene, 349;
  treatment of, ib.; amputation in, 350.
Gangrenous inflammation, 71; treatment of,
  72.
Gangrenous diseases, 348 ; stomatitis, 352.
Gastrotomy, 753.
Glottis, oedema of, 670.
Gonorrhoea, 798; treatment of, 799; compli-
  cations of, 802; irritability of bladder from,
  ib.; dysuria in, ib.; sequences of, 803 ; im-
  potence,  804; false spermatorrhoea in, ib.;
  gonorrhceal  inflammation  of testis,  805;
  orchitis, ib.; epididymitis, ib.;  conjunctivitis,
  805;  sclerotitis, ib.;  rheumatism in, 806;
  eruptions, ib.; in women, ib.
Granulations,  68 ; structure of,  69; vasculari-
  zation of, ib.
Gums, diseases of, 656.
Gunshot wounds, 121; nature of projectile in-
  fluences  on  wound, 76 ; apertures of entry
  and exit,  122; effects of cannon-shot, 124;
  symptoms of gun-shot wounds, 125; treat-
  ment of, ib.; amputation in,  ib.; gun-shot
  wounds of hand, 125; resection in gun-shot
  wounds,  ib.; statistics of amputation, 126 ;
  primary,  in gun-shot, ib.; temporary tourni-
  quet, 127; bullet-screw, ib.; extractor, ib.
                     H.

 Hematoma, 380.
 Hand, deformities of, 635.
 Hanging, 303.
 Hare-lip, 642.
 Head, injuries of, 266.
 Heart, wounds of, 314.
 Hectic, 64.
 Hematocele, 885.
 Hemoptysis, 309.
 Hemorrhage, 138; effects of, ib.; treatment
   of, 139;  transfusion,  ib.;  arrest of,  147;
   natural arrest of, ib.; application of cold in,
   152; styptics, ib.;  use of cautery, ib.;  for-
   mation of graduated  compress, ib.;  torsion
   of arteries, ib.; ligature for, 153; its history,
   ib.; mode of applying ligature in, 155 ; artery
   forceps, ib.; secondary, 168.
 Hemorrhagic diathesis, 549.
 Hemorrhoids.  See Files.
 Herpes preputii, 873.
 Hernia, 704 ; hernial sac, ib.; enterocele, 705
   epiplocele, ib.; hydrocele of hernial sac, 706
   ccecal, ib.; cystocele, 707;  reducible, 708
   inflamed, 710; irreducible, ib.; strangulated
   711; stricture in, ib.; taxis in, 714;  opera
   tion  for strangulated, 717; peritonitis, 720
   state of gut in, 721;  omentum in, 723
   wound of gut in operations, 723 ; operation
   without  opening sac, 727; subcutaneous
   operation, 729 ; reduction of, in  mass, 730;
   inguinal,731; congenital, 737; infantile, 738;
   femoral,  739; operation for, 742; umbilical,
   744; ventral, 745;  vaginal, ib.; obturator,
   ib.;  perineal, 747;  pudendal, ib.;  sciatic,
   ib.; diaphragmatic, i&.
Hernia knife, 718.
Hernia director, 718.
Hey's saw, 287.
Hip, disease of, 613;  excision of, 618; rheu-
  matic arthritis of, 619.
Hospital gangrene, 349.
Humerus, fracture of,  208; dislocation of, 244. 
906
IND
EX.
Hunterian operation for aneurism, 478.
Hydrarthrosis, 584.
Hydrocele, 879; radical cure of, 881; encysted,
  884; spermatozoa in, 884; of cord, 885.
Hymen, imperforate, 897.
Hypospadias, 870.
Hysterical joints, 602.

                    I.

Iliac abscess, 623.
Incised wounds, treatment of, 86.
Incisions, 51.
Inflammation, 36 ; phenomena of, ib.; state of
  vessels in, 37;  changes of blood in, 38; state
  of red and  white blood corpuscles in, ib.;
  coagulation  of blood in, 39 ;  symptoms of,
  ib.; local signs of, ib.; pain in, 41; heat in,
  ib.; constitutional symptoms of, 42 ;  causes
  of, 45 ; effects of, 46 ; resolution, {6.; metas-
  tasis, ib.; terminations of, ib.; extension of,
  ib.; duration of, 45 ; intensity of, ib.; cha-
  racters of, ib.; treatment of, 46; preventive
  treatment of, 47; curative treatment of, 47;
  antiphlogistic  treatment in,  48;  bloodlet-
  ting in, i&.; guides in  bloodletting, ib.; value
  of mercurials  in, 49  ; aconite in, ib.;  local
  bleeding, 50;  leeches, ib.; cold, 51;  heat,
  ib.; fomentations, ib.; stimulants, 55; se-
  condary forms of, 56; adhesive, 57 ; suppu-
  rative, 60; ulcerative, 65; gangrenous, 71.
Inflammation, chronic, 51; treatment of, ib.;
  local treatment of, 53; issues in, 54;  mode
  of applying, ib.;  seton in,  ib.;  mode of
  introducing, ib.
Inflammation, asthenic, 55 ; treatment of, ib.
Inflammation, active, 49; treatment of,  ib.
Inflammatory  effusions, 56.
Intestinal obstruction,  748.
Intestines, wounds of, 318 ; stitching of, 321.
Iritis, syphilitic, 433.
Irrigation, mode of applying, 47.
Issues, mode of applying, 54.
                    J.

Jaw, fracture of, 203; dislocations of, 241.
Joints, false, 199; operations for, 201; injuries
  of, 232;  wounds of, ib.;  diseases of, 583;
  suppuration  of, 590; strumous diseases of,
  591; stiff, 593 ; excision of, 593 ; shoulder,
  595 ; elbow,  596; ankle, 597 ;  astragalus,
  ib.; os calcis, 598;  cuboid, ib.;  knee, 599;
  diseased, amputation of, 601;  cartilages,
  loose in, ib.; neuralgia of, 602; hysterical,
  ib.; hip,  618.

                    K.

Knee, dislocation of, 260; excision of, 592.
Knee-knock, and contracted, 634.

                    L.

Labia, hypertrophy of, 936 ; cystic tumors in,
  ib.
Larynx, foreign bodies in, 303 ;  erysipelas of,
  367; diseases of, 668;  necrosis  of, 673;
  tumors of, 674.
Laryngitis, 668; acute,  ib.; cedematous, ib.;
  chronic,  670.
Laryngeal  sponge, 671.
 Laryngeal syringe, 673.
 Laryngotomy, 676.
 Leg, fracture of, 227.
 Leucorrhoea, 808.
 Ligaments, diseases of, 588.
 Ligature, 153 ;  history of, ib.; mode of apply.
   ing,  154 ;  of artery, 155 ;  changes induced
   by, in artery, 156 ;  separation of, 157; col-
   lateral circulation,  158; anastomosis, ib.;
   in  aneurism, 478; accidents after, 481;  of
   iliac artery, 496;  common iliac, 499;  aorta,
   ib.; internal iliac, 500 ; superficial femoral,
   502; tibial, 509; dorsalis pedis, ib.; caro-
   tid, 520; innominata, 527;  subclavian, 528,
   534 ;  brachial, 542 ; radial, 543;  ulnar, ib.;
   of  varicocele, 888.
 Lipoma, 381, 639.
 Lips, disease of the, 642; hare-lip,  ib.; can-
   cer of, 645 ;  plastic surgery of, 644; cheilo-
   plastic operations  on, 650.
 Lithotomy,  841; knives, 842; forceps, ib.;
   scoops, ib.; lateral operation of, ib.; bilateral
   operation of, 856; after-treatment of, 847;  in
   children, ib.; difficulties of, 848; dangers in,
   850;  causes of death after, 851;  by high
   operation,  854; supra-pubic operation, ib.;
   lithotomy  and lithotrity compared, 865.
 Lithotrity,   858;  circumstances modifying,
   859;  lithotrite, 861; scoop, ib.;  operation
   of,  862;  accidents, "863;   danger of, ib.;
   lithotrity and lithotomy compared, 865.
 Lung, injury of, 309;  hernia of, 313.
 Lupus, 440.
 Lymph, 57; characters of, ib.;  development
   of,  59 ; vascularization of, ib.
 Lymphatics, 443; lymphatitis, ib.; lymphatic
   glands diseased, 446 ; enlargement of. 447.

                     M.

 Malar bone, fracture of, 203.
 Mammae, 684.  See Breast.
 Maxillary bone, fracture of, 203.
 Mercurials, value of, in inflammation, 48.
 Metastasis, 44.   See Inflammation.
 Mollities ossium, 571.
 Mortification.  See Gangrene.
 Mumps, 681.
 Muscles, strains of, 626 ; contractions and re-
   tractions of, ib.

                     N.

 Nails, diseases of, 438.
 Necrosis„562;  pathology of, 563 ;  operations
   for, 567.
 Nerves, injuries of, 137.
 Nervous system, diseases of, 549.
 Neuralgia, 549 ; of joints, 602.
 Neuritis, 550.
 Neuroma, 552.
 Nevus, 545; ligatures for, 547.
 Nose,  diseases of, 637;  epistaxis, ib.;  plug-
   ging  of nostrils,  638; ozaena, ib.; lipoma,
   639;  polypi,  ib.; plastic surgery  of,  646;
   rhinoplastic operations, 647; tagliacotian
   ditto, 648.
 Nostrils, foreign bodies in, 294.

                     O.

 (Esophagus, injuries  of, 308;  stricture  of,
• .  667. 
INDEX.
907
Olecranon, fracture of, 212.
Onychia, 438.
Operative  surgery,  74; importance of dex-
  terity in, ib.
Operations, circumstances that influence, 75 ;
  influence  of constitution  on, ib.;  causes  of
  death after, ib.;  shock,  75, 108 ; hemor-
  rhage, ib.; surgical fever, ib.;  preparations
  for, 77;  administration of chloroform, 78;
  caution  to be used in administering, 79;
  not to be used in diseased heart,  ib.; inju-
  rious  effects of chloroform, how remedied,
  ib.; administration of ether, 79;  incisions,
  80; sutures,  ib.;  dressing of wounds, ib.;
  plasters,  ib.;  management of wound  in
  operation, ifi.; after-treatment, 81; diet, ib.;
  amputation, 82; disarticulation, ib.; tourni-
  quet, 83 ; amputating instruments, ib.; cir-
  cular amputation, 84; flap-amputation, 84:
  amputating knives, ib.;  saws, their con-
  struction, ib.; mode of using, ib.;  ligatures,
  85 ; stumps, 86 ; mortality, 88; at Univer-
  sity  College  Hospital,  89; primary, ib.;
  secondary, ib.; statistics of, 90-92 ; special,
  92;  traumatic  delirium,  108;   phthisis,
  influence of, on, 601.
 Orbit, injuries of, 295.
 Osteitis, 558.
 Osteo-aneurism, 582.
 Osteo-cancer, 577.  -
 Osteo-cephaloma, 577.
 Otitis,  636.
 Otorrhcea, 636.
 Ovariotomy, 899.
 Ozaena, 638.

                     P.
  791; enlarged, ib.; retention of urine from
  enlarged, 794.
Prostatic abscess, 791; calculi, 858.
Prostatitis, 790.
Psoas abscess, 605.
Pulmonary hemorrhage, 309.
Purulent infection, 368.
Pus, 60; characters of, 61;  pyogenesis, ib.;
  circumstances that favor its formation, 64 ;
  within cranium, 272;  treatment  of, ib.; in
  blood, 371.
Pyemia, 372; causes of,  371; treatment of,
  373.

                     R.

Radius, fracture of, 213;  dislocation of, 250.
Ranula, 656.
Rectum, foreign bodies in, 323;  stricture of,
  759 ;  cancer of, 761; polypi of, 762.
Resolution, 44.   See Inflammation.
Rhinoplasties, 647.
Rickets, 570.
Rupture of viscera,  315; of liver, 316;  of
  stomach, 317; of intestines, 16.; of bladder,
  322;  of ureter, 311; of urethra, ib.
                     S.
Sacrum, fracture of, 217.
Sarcocele,  886;  strumous, ib.; simple, 888 ;
  cystic, 890;  malignant, ib.
Sarcoma, 381.
Saws, construction of, 84; mode of using, ib.;
  Hey's, 287.
Scalds,  324.
Scald, injuries of, 274.
Scapula, fracture of, 206.
Scrofula, 400; of tissues and organs, 401;
  treatment of, 403.
Scrotal  tumors, diagnosis of, 892.
Scrotum, diseases  of, 875 ;  hypertrophy of,
  ib.; chimney-sweep's  cancer,  ib.; inflam-
  matory oedema of, ib.
Serous  membranes, erysipelas of, 368.
Seton, mode of introducing, 54.
Seutin's pliers, 191.
Sequestrum, 565.
Shock,  106.
Shoulder-joint fractures, 207;  dislocations,
  244 ;  excision of, 595.
Sinus, 336.
Skin, diseases of,  437;  fibro-vascular tumor
  of, 440 ;  cancer of, 443.
Skull, injuries of, 276 ; fractures of, ib.;  frac-
  ture by contre-coup, ib.; of base, 277.
Sloughs, what, 71 ; separation of, 73.
Sloughing phagedaena, 349.
Sounds, 814, 838.
Speculum  vaginae, 895; ani, 763, 778.
Sphacelus, 340.
Spina ventosa, 576 ; bifida, 612.
Spine,  injuries of, 288 ; fracture of, ib.;  divi-
  sion of spinal cord in, 290; paralysis, ib.;
  dislocations of, 292; diseases of, 603  ; caries
  of, 604 ;  angular curve, ib.; lateral curve of,
  608;  spina bifida, 612.
Splay-foot, 633.
Sprains, 232.
Squint, 627.
Staphyloraphy, 663.
Starch-bandage, 190.
Strains, 626.
Palate, diseases of, 643 ; cleft, ib.
Palmar arches, wounds of, 177.
Paraphimosis, 872.
Parotid, disease of, 681; tumors of, ib.
Parotitis, 681.
Patella, fracture of, 225 ; dislocations of, 258.
Pelvis, fracture of, 216 ; injuries of, 322.
Penis, diseases of, 870 ; phimosis, ib.; para-
  phimosis, 872; warts on,  873 ; cancer of,
  ib.; amputation of, 874.
Perineal section,  819.
Perineum,  laceration of, 324.
Periostitis, 557.
Peritonitis, traumatic,  321.
Petit's operation, 727.
Phagedaena, 349; sloughing, ib.
Phlebitis, 446.
Phthisis, influence of, on xiperations, 601.
Phimosis, 871; operations for, ib.
Piles, 768; external, 771; internal, 772 ; ope-
  rations for, 776.
Plasters, 114.
Plastic surgery, 645.
Pneurtiocele, 313.
Pneumonia, 311.
Pneumo-thorax,  310.
Polypi, 381 ; cheloid, ib.; of the ear, 637; ot
  the nose, 639;  of the rectum,  762; ot the
  uterus, 899.
Pott's fracture, 229.
Prepuce, diseases of, 871.
Pressure in  cancer, 393;  of herpes, 873; ol
  hypertrophy, ib.
Prolapsus ani, 873.                         .
Prostate,  diseases  of,  790;  hypertrophy of 
908
INDEX.
 Stricture in hernia, 711; of rectum, 759;  of
   colon, ib.; of urethra, 808; complication of,
   823 ; division of, 819.
 Struma.  See Scrofula.
 Stumps, 86 ; mode of dressing, ib.; structure
   of, ib.; morbid conditions of,  87;  necrosis
   in, 88; conical, ib.;  painful, ib.; spasmodic,
   ib.; aneurismal, ib.;  aneurismal varix of,
   ib.; fatty, ib.; hemorrhage from, 169.
 Styptics, 152.
 Sutures,  79; varieties of,  114;  in wounds,
   ib.;  interrupted,   ib.;   continuous,  ib.;
   twisted, ib.; quilled, ib.; beaded, ib.
 Suppuration, 60; symptoms of, 63; hectic, 64;
   treatment of, 65.
 Synovitis, 583.
 Syphilis, 70; primary treatment of, 412; use
   of mercury, 414 ; consecutive, 418;  syphi-
   litic cicatrix, ib.; primary, 419 ;  secondary,
   422;  constitutional, ib.;   syphilides, 427;
   diseases of skin in, ib.; alopecia, 428  ; ony-
   chia, ib.; warts, 429 ;  condylomata,  ib.;  of
   lips, 430; tongue,  ib.; throat, ib.; larynx,
   431 ;  nose, ib.; nodes, 432; of bones, ib.;
   iritis, syphilitic, 433 ; of testis, ib.; tendons,
   434 ;  muscles, ib.; infantile, 434.

                     T.

 Talipes, 629;  equineus, 630;   varus,  ib.;
   equineo-varus, ib.; valgus, 633; calcaneus,
   ib.
 Tendo Achillis, rupture of,  180.
 Tendons, 179; injuries of, ib.; rupture of, 180;
   rupture of tendo Achillis, ib.; diseases of,
   626.
 Tenotomy, 627.
 Testis, malposition of, 876; diseases of, ib.;
   neuralgia of, ib.; scrofulous, 889 ; strumous
   sarcocele, ib.; cystic diseases of, 890; cystic
   sarcocele, ib.; cancer of, ib.;  malignant sar-
   cocele, ib.
 Tetanus, 553;  chloroform in, 556.
 Throat, injuries of, 297 ;  cut, ib.
 Thumb, dislocation of, 253.
 Tic, 549.
 Tongue, diseases of, 652; prolapsus of, ib.;
   glossitis, ib.; cracks in, 653 ;  cancer of, 654;
   operations on, 655.
 Tonsils, enlarged, 665 ; removal of, 666.
 Torsion of arteries, 153.
 Torticollis, 628.
 Tourniquets, 83, 152.
 Trachea, foreign bodies in, 304.
 Trachea tubes, 680.
 Tracheotome, 678.
 Tracheotomy, 676.
 Trephine,  287;  operation  of, ib.; for long
   bones, 560.
 Tubercle, 411.
 Tumors, 374 ; varieties of, ib.; encysted, 376;
  atheromatous,  ib.;  sebaceous, 377;  of the
   scalp,  378; cystic,  379;  pilo-cystic, 380;
  sanguineous, ib.; fatty, 382; fibro-cellular,
  380;  fibrous, ib.; semi-malignant, ib.; fi-
  brous malignant, 384 ; recurring fibroid, ib.;
  cartilaginous, ib.; malignant, 385; removal
  of, 399.

                     U.

Ulceration,  66; essential  causes  of,  ib.;
  stages of, 68.
Ulcerative inflammation, 65.
Ulcers, 70,  337; diagnosis of,  ib.; mode of
  healing, 41; varieties of, 338.
Union of wounds,  111; incised, ib.; by first
  intention, ib.;  by scabbing, 112; primary
  adhesion,  ib.;  organization of lymph, 113;
  by granulation, ib.
Ununited fractures, 199.
Urethra, laceration of, 323 ; diseases of, 797;
  stricture of, 808;  tumors of, 830 ; calculi in,
  857.
Urethral lithotrite, 863 ; forceps, 864.
Urethritis, 797.
Urethrotomy, 819.
Urine, retention  of, 788; incontinence of, 189;
  in stricture, 825; extravasation of, 825.
Urinary  abscess, 826; fistulae, ib,;  deposits,
  830.
Uterus, diseases of, 896; discharges from, t'6.;
  tumors of, 897; polypi  of, ib.; cauliflower
  excrescence, 899.
Uvula, removal of, 665; elongated, ib.
                     V.

Vagina, foreign bodies in, 323; imperforate,
  896 ; tumors of, 898; prolapsus of, ib.
Valsalva's treatment, 491.
Varicocele, 886;  operation for, 888;  ligature
  of, ib.
Varicose aneurism, 165 ; at bend of arm, 176 ;
  of thigh, 177; veins, 450; of carotid, 517.
Varix, 450.
Vascularization of lymph, 59 ; of granulations,
  69.
Veins, wounds of, 140; entrance of air into,
  ib.;  cause  of,  142;  canalization  of, ib.;
  treatment of, 143 ; diseases of, 448 ; inflam-
  mation, ib.
Vena cava, wounds of, 315.
Venereal warts, 421.
                    W.

Warts,  380;  venereal,  421; of the cuticle,
  437 ; on penis, 873.
Wens, 380.
White swelling, 591.
Windpipe, operations on, 674.
Wounds, incised,  110; union of, ib.', by first
  intention, ib.; by scabbing, 111; primary
  adhesion,  ib.; organization of lymph, 112;
  granulation in wounds, ib.; treatment of in-
  cised,  ib.; coaptation of, 113; sutures,  ib.;
  plasters, 114; collodion, 115; contusions and
  lacerations,  ib.;  traumatic  gangrene, 117,
  120; varieties of, ib.; contused  wounds,
  treatment,  117,  119;  lacerated  wounds,
  treatment, ib.;  gun-shot wounds, 121;  na-
  ture, ib.;  punctured, 128; poisoned, 130; of
  bloodvessels, 138; of veins, 146; of arte-
  ries, ib.; arterio-venous, 164; of subclavian,
  173 ; of axillary,  ib.; of brachial, 175; palmar
  arches, 177;  ulnar artery, ib.;  radial,  t'6.;
  femoral, 177; tibials, 178; plantar, ib.
Wrist, fracture of, 43 ; dislocation of, 252.
Wry-neck, 628.

                    X.

Xanthine, 833. 
                    CATALOGUE
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A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN.
  r nnr?i n  m f?S6|denvjed from Hospital and Private Practice. With Additions by Paul Beck
      AED' iV1, u'  Second American edition. In one octavo volume, of 5:20 pages.

  One of the very best works ever issued from the
press on the diseases of females.-Western Lancet

«2 __S,™! SSSS.'9 work.-**""*  Medical
                          ARNOTT  (NEILL), M. D.

ELEMENTS  OF  PHYSICS;   or Natural  Philosophy,  General and Medical
  Written for universal use, in plain or non-technical language.  A new edition, by Isaac Hays
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                      ABERCROMBIE  (JOHN), M.D.
PATHOLOGICAL AND PRACTICAL RESEARCHES ON DISEASES OF
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  of 260 pages.
                         BENNETT  (HENRY),  M. D.

A PRACTICAL  TREATISE  ON  INFLAMMATION OF  THE UTERUS,
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  This edition will be found materially improved over its predecessors, the author having carefully
revised it, and made considerable additions, amounting to between seventy-five and  one hundred
pages.
 We shall not call it a second edition, because, as
Dr. Bennett truly observes, it is really a new work.
It will be found to contain not only a faithful histo-
ry of the various pathological changes produced by
inflammation in the uterus and its annexed organs,
in the different phases of female life, but also an ac-
curate analysis of the influence exercised by inflam-
mation in the production of the various morbid con-
ditions of the uterine system, hitherto described and
treated as functional.—British and Foreign Medico-
Chirurgical Review.

 Few works issue from the medical press which
are at once original and sound in doctrine ; but such,
we feel assured, is the admirable treatise now before
us.  The important practical precepts which the
author inculcates are all rigidly deduced from facts.
. .  . Every page of the book is good, and eminently
practical. ... So far as we know and believe, it is
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Monthly Journal of Medical Science.

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for information on a hitherto most obscure and diffi-
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Journal.
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               BLAKISTON (PEYTON), M. D., F
PRACTICAL  OBSERVATIONS   ON  CERTAIN
                                                     R. S.,  &c.
                                                     DISEASES
CHEST* and on the Principles of Auscultation.  In one volume. 8vo., pp. 384.
OF  THE
                          BENEDICT (N.  D.), M. D.

COMPENDIUM OF LECTURES ON THE  THEORY  AND PRACTICE
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                        BURROWS (GEORGE), M. D.

ON DISORDERS  OF THE CEREBRAL  CIRCULATION,  and on  the Con-
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ON  DISEASES  OF  THE  LIVER.   Second American,  from  the second  and
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CiLIMCAL LECTURES  ON  SURGERY.   1 vol.  8vo., cloth.  850 pp.

                                BY THE SAME AUTHOR.

PATHOLOGICAL  AND  SURGICAL   OBSERVATIONS  ON  THE  DIS-
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                                BY THE SAME AUTHOR.

LECTURES ON THE DISEASES OF  THE  URINARY ORGANS.   1 vol.
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  *jfc* These three works may  be had neatly bound together, forming a larare volume of" Brodie's
Surgical Works."  pp. 780.
                     BIRD  (GOLDING), A. M., M. D., &c.

(URINARY   DEPOSITS:   THEIR   DIAGNOSIS,   PATHOLOGY,  AND
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  The new edition of Dr. Bird's work, though not
increased  in size, has been greatly modified, and
much of it rewritten,  it now presents, in a com-
pendious form, the gist of all that is known and re-
liable in this department. From its terse style and
convenient size, it is particularly applicable to the
student, to whom we cordially commend it.— The
Medical Examiner.
  It can scarcely be necessary for us to say anything
of the merits of this well-known Treatise, which so
admirably brings into practical application the re-
sults of those microscopical  and chemical researches
regarding  the physiology and pathology of the uri-
nary secretion, which have contributed so much to
the increase of our diagnostic powers, and 10 the
extension and satisfactory employment of our thera-
peutic resources.  In the preparation of this new
edition of his work, it is obvious that Dr. Golding
Bird has spared no pains to render it a faithful repre-
sentation of the present state of scientific knowledge
on the subject it embraces.
  Although, of course, there are many topics which
are open to differences of opinion, we cannot point
to any well-substantiated result of inquiry which
the author has overlooked.— The British and Foreign
Medico-Chirurgical Review.
                                BY THE SAME AUTHOR.

ELEMENTS  OF NATURAL PHILOSOPHY; being an  Experimental Intro-
  duction to the Physical Sciences.  Illustrated with nearly four hundred wood-cuts.  From the
  third London edition.  In one neat volume, royal 12mo.   pp. 402. 
AND  SCIENTIFIC PUBLICATIONS.                  5
      -  ,     ,„      BARTLETT  (ELISHA), M. D.,
      f rofcssor of Materia Medica and Aledical Jurisprudence in the College of Physicians and
—,—,—,                           Surgeons, New York.                     0

  of tSJ^tS?^ £.T4,GN0SIS>  and  TREATMENT OF THE  FEVERS
  nf«ivi;,.„^_       u    -?^  Third  edition, revised and improved.  In one octavo volume,
  of six hundred pages, beautifully printed, and strongly bound.

vat?onr«mrT„llI,-eWt-edili011 uf this standard work, the author has availed himself of such  obser-
endeavoreH Ztt^T*?* **?* .appeared since the publication of his  last revision, and  he has

it has beenf huhert^rSeT  ^ " W°rthy °f * contin"ance °f the veT marked favor with which

                                           Of the value and importance of such a work, it is
                                          needless here to speak; the profession of the United
                                          States owe much to the author for the very able
                                          volume which he has presented to them, and for the
                                          careful and judicious manner in which he has exe-
                                          cuted his task.  No one volume with which  we are
                                          acquainted contains so  complete a history of our
                                          fevers as this.  To Dr. Bartlett we owe our best
                                          thanks for the very able volume he has given us, as
                                          embodying certainly the most complete, methodical,
                                          and satisfactory account of our fevers anywhere to
                                          be met  with.— The Charleston Med. Journal and
  The masterly and elegant treatise, by Dr. Bartlett
is invaluable to the American student and practi-
tioner.—Dr. Holmes's Report to the Nat. Med Asso-
ciation.

  We regard it, from the examination we have made
of it, the best work on fevers extant in our lano-uuge
and  as such cordially recommend it to the medica!
public—St. Louis Medical and Surgical Journal.

  Take it altogether, it is the most complete history
of our fevers  which  has yet been published, and
every practitioner should avail  himself of its con-
tents.— The Western Lancet.
                                          Review.

                               BY THE SAME AUTHOR.

AN  INQUIRY INTO  THE DEGREE  OF  CERTAINTY IN MEDICINE,
  and into the Nature and Extent of its Power over Disease.  In one volume, royal 12mo.  pp. 84.


                         BOWMAN (JOHN  E.),  M.D.
PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.   In  one neat
  volume, royal 12mo., with numerous illustrations,  pp. 288.

                                BY THE SAME AUTHOR.

INTRODUCTION  TO  PRACTICAL  CHEMISTRY,  INCLUDING  ANA-
  LYSIS.  With numerous illustrations.  In one neat volume, royal 12mo.  pp.350.


                        BARLOW (GEORGE H.), M. D.
A MANUAL OF  THE PRINCIPLES  AND PRACTICE  OF  MEDICINE.
  In one octavo volume.  (Preparing.)

                          COLOMBAT DE L'ISERE.
A TREATISE  ON  THE   DISEASES  OF  FEMALES, and on  the Special
  Hygiene of their Sex.  Translated, with many Notes and Additions, by C. D. Meigs, M. D.
  Second edition, revised and improved.  In one large volume, octavo, with numerous wood-cuts.
  pp. 720.
  The treatise of M. Colombat is a learned and la-
borious commentary on  these diseases, indicating
very considerable research, great accuracy of judg-
ment, and no inconsiderable personal experience.
With the copious notes and additions of its experi-
enced and very erudite translator and editor, Dr.
Meigs, it presents, probably, one of the most com-
plete and comprehensive works  on the subject we
possess.—American Med. Journal.
  M. Colombat De LTsere has not consecrated ten
years of studious toil and research to the frailer sex
m vain; and although we regret to  hear it is at the
expense of health, he has imposed a debt of gratitude
as well upon the profession, as upon the mothers and
daughters of beautiful France, which that gallant
nation knows best how to acknowledge.—New Or-
leans Medical Journal.
                 COPLAND (JAMES),  M-  D.,  F. R. S., <_c.

OF  THE  CAUSES,  NATURE,  AND  TREATMENT  OF  PALSY  AND
  APOPLEXY, and of the Forms, Seats, Complications, and Morbid Relations of Paralytic and
  Apoplectic Diseases.  In one volume, royal 12mo., extra cloth,  pp. 326.

                 CHAPMAN (PROFESSOR N.), M. D., &.c.

LECTURES  ON  FEVERS,   DROPSY,  GOUT,  RHEUMATISM,  &c. &c.
  In one neat 8vo. volume, pp. 450.
                    CLYMER (MEREDITH), M. D., &.C.

FEVERS-  THEIR  DIAGNOSIS,  PATHOLOGY,  AND  TREATMENT.
  Prermred a'nd Edited, with large Additions, from the Essays on Fever in Tweedie's Library of
  Practical Medicine.  In one octavo volume, of 600 pages.

                         CARSON (JOSEPH), M. D.,
          Professor of Materia Medica and Pharmacy in the University of Pennsylvania.

SYNOPSIS OF THE  COURSE  OF LECTURES ON MATERIA MEDICA
  AND PHARMACY, delivered in the  University of Pennsylvania.  In one very neat octavo
  volume, of 208 pages. 
6
BLANCHARD  &  LEA'S  MEDICAL
              CARPENTER (WILLIAM  B.), M. D., F. R. S., &.C.,
           Examiner in Physiology and Comparative Anatomy in the University of London.

PRINCIPLES OF HUMAN  PHYSIOLOGY; with  their chief  applications  to
   Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine.  Fifth American, from
   the fourth and enlarged London edition.   With Ihree hundred and fourteen illustrations. Edited,
   with additions, by Francis Gurney Smith, M. D..  Professor of ihe Institutes of Medicine in the
   Pennsylvania Medical College, &c.  In one very large and beautiful octavo volume, of about 1100
   large pages, handsomely printed and strongly bound in leather, with raised bands.  New edition.
   (Just Issued.)

                      From tJie Author's Preface to  the present Edition.

   "When the author, on the completion of his ' Principles of General and Comparative Physiology,'
applied himself to the preparation of his ' Principles of Human Physiology,' lor the press, he found
that nothing short of am entire remodelling of ihe preceding edition would in any degree satisfy his
notions of what such a treatise ought lo be.  For  although no fundamental change had taken place
during the interval in the fabric of Physiological  Science, yet a large number  of less important
modifications had been effected, which had combined  to produce a very considerable alteration in
its aspecl. Moreover, the progressive maturation of his own views, anVl his increased experience
as a teacher, had not only rendered him more keenly alive to the  imperfections which were inherent
in its original plan, but had caused him to look upon many topics in a light very different from that
under which he had previously regarded them ; and, in particular, he felt a strong desire to give to
his work as practical a character  as possible, without foregoing the position which (he trusts he
may say without  presumption) he had succeeded in gaining for  it, as a philosophical exposition of
one  important department of Physiological Science.  He was led, therefore, to  the determination
of, in reality, producing a new treatise, in which  only those  parts of the old should be  retained,
which  might express the existing state of knowledge, and of his own opinions on the points to which
they relate."

  The  American edition has been printed from sheets  prepared for the purpose by the author, who
has introduced nearly one hundred illustrations not in the London edition ; while it has also enjoyed
the advantage of a careful superintendence on the part  of the editor, who has added notices of such
more recent investigations as had escaped the author's attention.   Neither care nor expense has
been spared in the mechanical execution of the work lo render it superior to former editions, and it
is confidently presented as in every way one of the handsomest  volumes as yet  placed before the
medical profession in this country.
  The most complete work on the science in our
language.—Am. Med. Journal.

  The most complete exposition of physiology which
any language can at present give.—Brit, and For.
Med.-Chirurg. Review.

  We have  thus adverted to some of the leading
"additions and alterations," which have been  in-
troduced by the author into this edition of his phy-
siology.  These will be found, however, very far to
exceed the ordinary limits of a new edition, "the
old materials having been incorporated with the
new, rather than the new with the old."  It now
certainly presents the most complete treatise on the
rubject within the reach  of the American  reader;
nnd while, for availability as a text-book, we may
perhaps regret its growth  in bulk, we are sure, that
the student of physiology will feel the impossibility
of presenting a  thorough  digest of the facts of the
science within a more limited compass.—Medical
Examiner.

  The greatest, the most reliable, and the best book
on the subject which we know  of in  the English
language.—Stethoscope.

  The most complete work now extant in our lan-
guage.—JV. O. Med. Register.

  The changes are too numerous to admit of an ex-
tended notice in this place. At every point where
the recent diligent labors of organic chemists and
micrographers have furnished interesting and valu-
able facts, they have been appropriated, and no pains
"have been spared, in so incorporating and arranging
them that the work may constitute one  armonious
system.—Southern Med. and Surg. Journal.
  The best text-book in the language on this ex-
tensive subject.—London Med. Times.
  A complete cyclopaedia of this branch of science.
—N. Y. Med. Times.
  The standard of authority on physiological sub-
jects. * * * In the present edition, to particularize
the alterations and additions which have been made,
would require a review of the whole work, since
scarcely a subject has not been revised and altered,
added to, or entirely remodelled to adapt it to the
present state of the science.—Charleston Med. Journ.
  Any reader who desires a treatise  on physiology
may  feel  himself entirely safe in ordering this.—
Western Med. and Surg. Journal.
  From this hasty and imperfect allusion it will be
seen by our readers  that the alterations and addi-
tions to this edition render it almost a new work—
and we can assure our readers that it is one of the
best summaries of the existing facts of physiological
science within the reach of the English student and
physician.—JV. Y. Journal of Medicine.
  The profession of this country, and perhaps also
of Europe, have anxiously and for some time awaited
the announcement of this new edition of Carpenter's
Human Physiology.  His former editions have for
many years been almost  the only text-book on Phy-
siology in all our medical schools, and its circula-
tion among the profession has been unsurpassed by
any work in any department of medical science.
  It is quite unnecessary for us to  speak of this
work as  its  merits would justify.  The mere an-
nouncement of its appearance will afford the highest
pleasure to every student of Physiology,  while  its
perusal will be of infinite  service  in  advancing
physiological science.—Ohio Med. and Surg. Journ.
                                   BY THE SAME AUTHOR.

PRINCIPLES  OF  GENERAL   AND  COMPARATIVE  PHYSIOLOGY.
  Intended as an Introduction  to the Study of Human Physiology;  and as a Guide to the Philo-
  sophical pursuit of Natural History.  New and improved edition, (preparing.)

                            by the same  author.   (Preparing.)

THE MICROSCOPE  AND  ITS  REVELATIONS.   In one handsome volume,
  beautifully illustrated with plates and wood-cuts. 
AND SCIENTIFIC  PUBLICATIONS.
■1
                 CARPENTER (WILLIAM B.),  M. D.,  F. R. S.,
          Examiner in Physiology and Comparative Anatomy in the University of London.

E™™_rT_ J°n? MANUAL)  OF  PHYSIOLOGY,  INCLUDING  PHYSIO-
  _UtrlOAE ANATOMY.  Second American, from a new and revised London edition.  With
  one hundred and ninety illustrations.  In one very handsome octavo volume. (Lately Isstied.)

  In publishing the first edition of this work,  its title was altered from that of the  London  volume,
by the substitution of the word "Elements"  for that of « Manual," and with the author's  sanction
the title of  filements  is still retained as being more  expressive of  the scope of the treatise.  A
comparison  of the present edition with the former one will show a material improvement, the
author having revised it thoroughly, with a view of rendering it completely on a level with the
most advanced state of the  science. By condensing the less important portions, these numerous
additions have been introduced without materially increasing the bulk  of the volume, and while
numerous illustrations have been added, and the general execution of the work improved, it has
been kept at its former very moderate price.
  To say that it is the best manual of Physiology
now before the public, would not do sufficient justice
to the author.—Buffalo Medical Journal.

  In his former works  it would seem  that he had
exhausted the subjectof Physiology. In the present,
he gives the essence, as it were, of the whole.—N. Y.
Journal of Medicine.

  Those who have occasion for an elementary trea-
tise on  Physiology, cannot do better than to possess
themselves of the manual of Dr. Carpenter.—Medical
Examiner.
  The best and most complete expos<§ of modern
Physiology, in one volume, extant in the English
language.—St. Louis Medical Journal.

  With such an aid in his hand, there is no excuse
for the ignorance often displayed respecting the sub-
jects of which it treats.  From its unpretending di-
mensions, it may not be so esteemed by those anxious
to make a parade of their erudition; but whoever
masters its contents will have reason to be proud of
his  physiological  acquirements.  The illustrations
are well selected and finely executed.—Dublin Med.
Press.
                                  BY THE SAME AUTHOR.

A PRIZE ESSAY ON THE USE OF ALCOHOLIC  LIQUORS  IN HEALTH
  AND DISEASE.  New edition, with a Preface by D. F. Condie, M. D., and explanations of
  scientific words.  In one neat 12mo. volume.   (Now Ready.)

  This new edition has been prepared with a view to an extended circulation of this important little
work, which is universally recognized as the best exponent of the laws of physiology and pathology
applied to the subject of intoxicating liquors, in a form suited both for the profession and the public.
To secure a wider dissemination of its doctrines the publishers  have done up copies  in flexible
cloth, suitable for mailing, which will be forwarded through the post-office, free, on receipt of fifty
cents.  Societies and others supplied in quantities for distribution at a liberal  deduction.
                             CHELIUS (J. M.>, M. D.,
                    Professor of Surgery in the University of Heidelberg, &c.

A SYSTEM  OF SURGERY.   Translated  from  the  German,  and accompanied
  with additional Notes and References, by John F. South.  Complete in three very large octavo
  volumes, of nearly 2200 pages,  strongly bound, with raised bands and double titles.
  We do not hesitate to pronounce it the best and
most comprehensive system of modern surgery with
which we are acquainted.—Medico-Chirurgical Re-
view.

  The fullest and ablest digest extant of all that re-
lates to the present advanced state of surgical pa-
thology.—American Medical Journal.

  As complete as any system of Surgery can well
be.—Southern Medical and Surgical Journal.
  The most learned and complete systematic treatise
now extant.—Edinburgh Medical Journal.
 r:
  A complete  encyclopaedia of surgical science.—a
very complete surgical  library—by far the most
complete and  scientific system of  surgery in  the
English language.—iV. Y. Journal of Medicine.

  The most extensive and comprehensive account of
the  art and science of Surgery in our  language.—
Lancet.
             CHRISTISON (ROBERT), M. D., V. P.  R. S. E.,  &.C.

A DISPENSATORY;  or, Commentary on  the  Pharmacopoeias of Great Britain
  and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac-
  tion* Use* and Doses of the Articles of the Materia Medica.  Second edition, revised and im-
  proved with a Supplement containing the most important New Remedies.   With copious Addi-
  tions and two hundred and thirteen large wood-engravings.  By R. Eglesfeld Griffith, M. D.
In one very large and handsome octavo volume, of over 1000 pages

It  is not needful that we should compare _H with
the other pharmacopoeias extant, which f^oy and
merit the confidence of the P«:iti««i8
to say that it appears to us as perfect as a Dispensa-
 ory/in the present state of pharmaceu"eal sc ence
cou Id be made.  If it omits any details pertaining t„
this branch of knowledge which the  student has a
right to expect in such a work, we«^ft« the om»
sion has escaped our scrutiny. WVco *wMV recom
mend this work to such of our reader, a. are «i need
of a Dispensatory.  They ^^^f^surTery
better.—Western Journ. of Medicine and Surgery.
  There is not in any language a more complete and
perfect Treatise.—JV. Y. Annalist.
  In  conclusion,  we need scarcely say that we
strongly recommend this work to all classes of our
readers. Asa Dispensatory and commentary on the
Pharmacopoeias, it is unrivalled  in the English or
any other language.—The Dublin Quarterly Journal.

  We earnestly recommend Dr.  Christison's  Dis-
pensatory to all our readers, as an indispensable
companion, not in the Study only, but in the Surgery
also.—BritisH and Foreign Medical Review. 
s
BLANCHARD fe LEA'S  MEDICAL
                          CONDIE (D.  F.),  M. D.,  &.c.

A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN.   Fourth
  edition, revised and augmented.  In one large volume, 8vo., of nearly 750 pages.  (NowReady.)

                             From the Author's Preface.
  The demand for another edition has afforded the author an opportunity of again subjecting the
entire treatise to a careful revision, and of incorporating in it every important observation recorded
since the appearance of the last edition, in reference to the pathology and therapeutics of Ihe several
diseases of which it treats.                          »
  In the preparation of the present edition, as in those which have preceded, while the author has
appropriated to his use every important  fact that he has found recorded in the works of others,
having a direct bearing upon either of the subjects of which he treats, and the numerous  valuable
observations—pathological as well as practical—dispersed throughout the pages  of the  medical
journals of Europe and America, he has, iieverlheless, relied chiefly upon his own observations and
experience, acquired during a long and somewhat extensive practice, and under circumstances pe-
culiarly well adapted for the clinical study of the diseases of early life.
  Every species of hypothetical reasoning has, as much as possible, been avoided.  The author has
endeavored throughout the woik to confine himself to a simple statement of well-ascertained patho-
logical facts, and  plain therapeutical  directions—his  chief desire being to render  it what its title
imports it to be, a practical treatise on the diseases of children.
  Dr. Condie's scholarship, acumen, industry, and
 practical sense are manifested in this, as in all his
 numerous contributions to science.—Dr. Holmes's
 Report to the American Medical Association.
  Taken as a whole, in our judgment, Dr. Condie's
 Treatise is the one from  the perusal of which the
 practitioner in this country will rise with the great-
 est satisfaction —Western Journal of Medicine and
 Surgery.
  One of the best works upon the Diseases of Chil-
dren in the English language__Western Lancet.
  Perhaps the most full and complete work now be-
fore the profession of the United States; indeed, we
may say in the English language.  It is vastly supe-
rior to most of its predecessors.—Transylvania Med.
Journal.
  We feel assured from actual experience that no
physician's library can be complete without a copy
of this work.—N. Y. Journal of Medicine.

  A veritable paediatric encyclopsedia, and an honor
to American medical literature.—Ohio Medical and
Surgical Journal.

  We feel persuaded that the American medical pro-
fession will soon regard it not only as a very good,
but  as the very best "Practical Treatise on the
Diseases of Children."—American Medical Journal.

  We pronounced the first edition to be the best
work on the diseases of children  in the English
language, and, notwithstanding all that has  heen
published, we still regard it in that light.—Medical
Examiner.
                       COOPER (BRANSBY B.), F.  R. S.,
                           Senior Surgeon to Guy's Hospital, &c.

LECTURES ON  THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.
  In one very large octavo volume, of 750 pages.  (Lately Issued).
  For  twenty-five years Mr. Bransby Cooper  has I Cooper's Lectures as a most va]
been surgeon to Guy's  Hospital; and the volume | our surgical literature, and one
before  us may be said to consist of an account of  to be of service both to students
                                                                    valuable addition to
                                                                      which cannot fail
                                                               omdenis and to those who
the results of his surg _l experience during that  are actively engaged in the practice of their profes-
long period. We cordiallv recommend Mr. Branshv  rhwi.—ta/i./,«,.,        i»-«.n«.e 01 men proies
: cordially recommend Mr. Bransby I sion.—The Lancet.
                   COOPER (SIR ASTLEY  P.), F. R. S.,  &c.

AJREATISE  ON  DISLOCATIONS AND FRACTURES  OF THE JOINTS
  w™Sy BARAKSB* B- -CoopE,R'. F- R; S-, &c.  With  additional Observations by Prof. J c'
  tins on wn^ "eW Amencan edl,10n-  In one handsome  octavo volume, with numerous illustra-
BY THE SAME AUTHOR.
ON  THE ANATOMY  AND  TREATMENT OF  ABDOMINAL  HERNIA.
  One large volume, imperial 8vo., with over 130 lithographic figures.
BY THE SAME AUTHOR.
^nl^mm^rFI^^?  DISEASES  OF THE ' TESTIS,  AND  ON
  THE THYMUS GLAIsD.  One vol. imperial 8vo., with 177 figures, on 29 plates.
                                BY THE  SAME AUTHOR.

°? THE  ANATOMY AND  DISEASES  OF  THE  BREAST, with  twenty-
  MpuJes?               S   PaperS-  °',e krge V°lume' imPeTid{ 8vo-> with 252 %""*> on

h J£e«»Irt",h-r? VO'U?ieS fomP'ete V* surS™l writings of Sir Aslley Cooper.  They are very
^S^l^S^i^^r^'of ^^^ ~d in £*»« « A «* - 
AND  SCIENTIFIC  PUBLICATIONS.
9
                CHURCHILL  (FLEETWOOD),  M.  D.,  M.  R. I. A.

ON  THE THEORY  AND PRACTICE OF  MIDWIFERY.  A new American,
  trom the last and improved English edition.  Edited, with  Notes and  Additions, by D. Francis
  vxwdie, M. D., author of a "Practical Treatise on the Diseases of Children," &c.  With 139
  illustrations.  In one very handsome octavo volume, pp. 510.   (Lately Issued.)

  To bestow praise on a book that has reCeived such
marked approbation would be superfluous  We need
only say, therefore, that if the first edition was
thought worthy of a favorable reception  by the
medical public, we can confidently affirm  that this
will be found much more so. The lecturer, the
practitioner, and the student, may all have recourse
to its pages, and derive from their perusal much in-
terest and instruction in everything  relating to theo-
retical and practical midwifery.—Dublin Quarterly
Journal of Medical Science.
  A work of very great merit, and  such as we can
confidently recommend to the study of every obste-
tric practitioner.—London Medical Gazette.

  This is certainly the most perfect system extant.
It is the best adapted for the purposes of a text-
book, and that which he whose necessities confine
him to one book, should select in preference to all
others.—Southern Medical and Surgical Journal.

  The most popular work on midwifery ever issued
from the American press.—Charleston Med. Journal.

  Were  we reduced to the necessity of having but
one work on midwifery, and permitted  to choose,
we would unhesitatingly take Churchill.—Western
Med. and Surg. Journal.
  It  is  impossible to conceive  a more useful and
elegant  manual  than  Dr. Churchill's Practice  of
Midwifery.—Provincial Medical Journal.

  Certainly,  in our opinion, the very best work  on
the subject which exists.—N.  Y. Annalist.
  No work holds a higher position, or is more de-
serving of being placed  in the hands of the tyro,
the advanced student, or the practitioner.—Medical
Examiner.

  Previous editions, under the editorial supervision
of Prof R.  M. Huston, have been received with
marked favor,  and they deserved it; but this, re-
printed from a very late Dublin edition, carefully
revised and brought up by the. author to the present
time, does present  an unusually accurate and able
exposition of every important particular embraced
in the department of midwifery. * * The clearness,
directness, and precision of its teachings, together"
with the great  amount of statistical research which
its text exhibits, have served to place it already in
the foremost rank of works in- this department of re-
medial science.—N. O. Med. and Surg. Journal.

  In our opinion, it forms one of the best if not the
very best text-book and epitome of obstetric science
which we at present possess in the English lan-
guage.— Monthly Journal of Medical Science.

  The clearness and precision of style in  which it is
written, and the great amount of statistical research
which it contains, have served to place it in the first
rank of works in this department of medical science.
— iV. Y. Journal of Medicine.

  Few treatises will be  found better adapted as  a
text-book for the student, or as a manual for the
frequent consultation of  the young practitioner.—
American Medical Journal.
BY THE SAME AUTHOR.
ON THE  DISEASES OF INFANTS  AND CHILDREN.   In one  large and
  handsome volume of over 600 pages.
  We regard this volume as possessing more claims
to completeness  than any  other of the kind with
which we are acquainted.  Most cordially and earn-
estly, therefore, do we commend it to our profession-
al brethren, and  we feel assured that the stamp of
their approbation will in due time be impressed upon
it.  After an attentive  perusal of its contents, we
hesitate not  to say,  that it is one of the most com-
prehensive ever  written upon the diseases of chil-
dren, and that, for copiousness of reference, extent of
research, and perspicuity of detail, it is scarcely to
be equalled, and not to be  excelled, in any  lan-
guage.—Dublin Quarterly  Journal.

  After  this  meagre, and we know, very imperfect
notice of Dr. Churchill's work, we shall conclude
by saying, that it is one that cannot fail from its co-
piousness, extensive research, and general accuracy,
to exalt  still  higher  the reputation of the author in
this country.  The American reader will be particu-
larly pleased  to find that Dr. Churchill has done full
justice throughout his work to the various A meriean
authors  on this  subject.  The  names of Dewees,
Eberle,  Condie, and  Slewart, occur on nearly every
page, and these authors  are constantly referred toby
the author in terms  of the  highest praise, and with
the most liberal courtesy.— The Medical Examiner.
  The present volume will  sustain the  reputation
acquired by the  author from his previous works.
The reader will find in it full and judicious direc-
tions for the management of infants at birth, and a
compendious, but clear account of the diseases to
which children are liable, and the most successful
mode of treating them.  VVe must not close this no-
tice without calling attention to the author's style,
which is perspicuous and polished to a degree, we
regret to say, not  generally characteristic of medical
works.  We recommend the work of Dr. Churchill
most cordially, both to students and practitioners,
as a  valuable and reliable guide in the treatment of
the diseases of children.—Am. Journ. of the Med.
Sciences.

  We know of no work on this department of Prac-
tical Medicine which presents so candid and unpre-
judiced  a statement or posting up of our actual
knowledge as this.—N. Y. Journal of Medicine.

  Its claims to merit both as a scientific and practi-
cal work, are of the  highest order.  Whilst  we
would not elevate it above every other treatise on
the same subject, we certainly believe that very few
are equal to it, and none superior.—Southern Med.
and Surgical Journal.
BY THE SAME AUTHOR.
ESSAYS ON  THE PUERPERAL FEVER, AND OTHER DISEASES PE-
  CULIAR TO WOMEN.  Selected from the writings of British Authors previous to the close of
  the Eighteenth Century.  In one neat octavo volume, of about four hundred and fifty pages.
To these papers Dr. Churchill has appended notes
       g whate
       ofessior

     occ^^e-mr^r^Uon^thevolume,^
         '■■..__:_i  .L-.»/>h nf the nnncinal epi-
           ipers Dr. unurcnui iw »i'i""-" ...•.--,
embodying whatever information has been laid be-
fore the profession since their authors time  He has
also  prefixed to the  Essays on  Puerperal; Fever,
wnicn occupy mc  iuik<->  i,", ..   „_;„„:„.. i cn;
interesting  historical  sketch of the principal epi-
demies of that disease.  The whole forms a very
valuable collection of papers, by professional writers
of eminence, on some of the most important accidents
to which the puerperal female is liable.—American
Journal of Medical Sciences.    ' 
10
BLANCHARD & LEA'S MEDICAL
           CHURCHILL  (FLEETWOOD), M. D.,  M. R. I. A.,  &c.

ON THE DISEASES  OF WOMEN;  including  those of Pregnancy and Child-
  bed.  A new American edition, revised by the Author.  With Notes and Additions, by D  Fran-
  cis Condie, M. D., author of "A Practical Treatise on the Diseases of Children."  In one large
  and handsome octavo volume, with wood-cuts, pp. 684.  (Just Issued.)

                               From the Author's Preface.
  In reviewing this edition, at the request of my American publishers, I have inserted several new
sections and chapters, and I have added, I believe,  all the information we have derived from recent
researches; in addition to which the publishers have been fortunate enough to secure the services
of an able and highly esteemed editor in Dr. Condie.
  We now regretfully take leave of Dr. Churchill's
book. Had our typographical limits permitted, we
should gladly have borrowed more from  its richly
stored pages.  In conclusion, we heartily recom-
mend it  to the profession, and  would at the same
time express our firm conviction that it will not only
add to the reputation of its author, but will prove a
work of great and extensive utility to obstetric
practitioners.—Dublin Medical Press.

  Former editions of this work have been noticed in
previous numbers of the Journal. The sentiments of
high commendation expressed in those notices, have
only to be repeated in this; not from  the fact that
the profession at large are not aware of the high
merits which this work really possesses, but from a
desire to see the principles and doctrines therein
contained more generally recognized, and  more uni-
versally carried out in practice.—N.  Y. Journal of
Medicine.

  We know of no author who deserves that appro-
bation, on " the diseases of females," to the same
extent that Dr. Churchill does.   His, indeed, is the
only thorough treatise we know of on thjs subject;
and it may be commended to practitioners and stu-
dents as a masterpiece in its particular department.
The former editions of this work have been com
mended strongly in this journal, and they have won
their way to an extended, and a well-deserved popu-
larity.  This fifth edition, before us. is well calcu-
lated to maintain Dr. Churchill's high reputation.
It was  revised and enlarged by the author, for his
American publishers, and it seems to us that there is
scarcely any species of desirable information on its
subjects that may not be found in this work.—The
Western Journal  of Medicine and Surgery.

  We are gratified to announce a new and revised
edition  of Dr. Churchill's valuable work on the dis-
eases of females   We have ever regarded it as one
of the  very best works  on the subjects embraced
within  its scope, in the English language;  and the
present edition, enlarged and revised by the author,
renders it still more entitled to the confidence of the
profession.  The valuable notes of Prof  Huston
have been retained, and contribute, in  no small de-
gree, to enhance the value of the work.  It is a
source  of congratulation that the publishers have
permitted the author to  be, in  this  instance, his
own editor, thus securing all the  revision  which
an author alone is capable of making.—The Western
Lancet.

  Asa  comprehensive manual for students, or a
work of reference for practitioners, we only speak
with common justice when we say that it surpasses
any other that has ever  issued on the same sub-
ject from  the British press.—The Dublin Quarterly
Journal.
                         DEWEES (W.  P.),  M.D.,  &.c.

A  COMPREHENSIVE  SYSTEM  OF  MIDWIFERY.  Illustrated  by  occa-
  sional Cases and many Engravings.  Twelfth edition, with the Author's last Improvements and
  Corrections.  In one octavo volume, of 600 pages.  (Just Issued.)
BY THE  SAME AUTHOR.
A TREATISE ON  THE  PHYSICAL  AND  MEDICAL TREATMENT OF
  CHILDREN.  Tenth edition.  In one volume, octavo, 548 pages.  (Just Issued.)
BY THE  SAME AUTHOR.
A TREATISE  ON  THE  DISEASES  OF  FEMALES.  Tenth edition.  In
  one volume, octavo, 532 pages, with plates.  (Just Issued.)
                   DICKSON  (PROFESSOR  S.H.), M.D.
ESSAYS ON LIFE, SLEEP,  PAIN,  INTELLECTION,  HYGIENE,  AND
  DEATH.  In one very handsome volume, royal 12mo.
                                DANA (JAMES D).
ZOOPHYTES  AND  CORALS.   In one volume,  imperial quarto,  extra cloth,
  with wood-cuts.
AN ATLAS  TO  THE ABOVE, one volume, imperial folio, with sixty-one mag-
  nificent plates, colored after nature.  Bound in half morocco.
ALSO,
ON  THE   STRUCTURE  AND   CLASSIFICATION  OF  ZOOPHYTES.
  Sold separate, one vol., cloth.
              DE  LA  BECHE  (SIR  HENRY  T.), F. R. S., &c.
THE  GEOLOGICAL OBSERVER.  In one very large  and  handsome  octavo
  volume, of 700 pages.   With over three hundred wood-cuts.  (Just Issued.) 
AND  SCIENTIFIC PUBLICATIONS.
11
                      DRUITT  (ROBERT),  M.R.  C.S.,  &.C.

THE  PRINCIPLES AND PRACTICE  OF  MODERN  SURGERY.    A  new
  American  from the last and improved London edition.  Edited  bv F. W.  Sargent, M. D.,
  r"„   t°   Mlnor Surgery,"  &c.   Illustrated  with one hundred and hinetv-three wood-engrav-
t           _.   i      —    *"wiiaicu  wmi unc uuiiuicu auu nine
in one very handsomely printed octavo volume, of 576 large pages
  No work, in our opinion, equals it in presenting
so much valuable surgical matter in so small a
compass.—St. Louis Med. and Surgical Journal.

  Druitt's Surgery is too well known to the Ameri-
can medical profession to require its announcement
anywhere.  Probably no work of the kind has ever
been more cordially received and extensively circu-
lated than this   The fact that  it comprehends in a
comparatively small compass, all the essential ele-
ments of theoretical and practical Surgery—that it
is found tri contain reliable and  authentic informa-
tion on the nature and treatment of nearly all surgi-
cal affections—is a sufficient reason for  the liberal
patronage it has  obtained.  The work before us is a
new edition,  greatly  enlarged and extended by the
author—its practical part having undergone a tho-
rough revision, with fifty pages of additional matter
The editor, Dr. F.W. Sargent, of Philadelphia, has
contributed much to enhance the value of the work,
by such American  improvements as are  calculated
more  perfectly to  adapt it  to our own views and
practice in this  country.  It abounds everywhere
with spirited  and life-like illustrations, which to the
young surgeon,  especially,  are  of no minor consi-
deration.  Every medical man frequently needs just
such a work as this, for immediate reference in mo-
ments of sudden emergency, when he has not time to
consult more elaborate  treatises.  Its mechanical
execution is of the very best quality, and as a whole,
it deserves and will receive from the  profession, a
liberal patronage.—The Ohio Medical and Surgical
Journal.

  The author has evidently ransacked  every stand-
ard treatise of ancient and modern times, and all that
is really practically  useful at the bedside will be
found in a form at once clear, distinct,  and interest-
ing.—Edinburgh Monthly Medical Journal.

  Druitt's work, condensed, systematic, lucid, and
practical as it is,  beyond  most works on Surgery
accessible to the American student, has had much
currency in this country, and under its present au-
spices promises to rise to yet higher favor.  The il-
lustrations of the volume are good, and,  in a word,
the publishers have acquitted  themselves fully of
their duty.—The  Western Journal of Medicine and
Surgery.

  The most accurate and ample resumfe of the pre-
sent state of Surgery that we are acquainted with.—
Dublin Medical Journal.

  A better book  on the principles and practice of
Surgery as now understood in England and America,
has not been given to the profession.—Boston Medi-
cal and Surgical  Journal.

  An unsurpassable compendium, not only of Sur-
gical, but of Medical  Practice.—London Medical
Gazette.

  This work merits our warmest commendations,
and we strongly recommend it to young surgeons as
an admirable digest of the principles and practice of
modern Surgery.—Medical Gazette.

  It may be said with  truth that  the work of Mr.
Druitt affords a  complete, though brief and  con-
densed view, of the entire field of modern surgery.
We know of no work on the same subject having the
appearance of a  manual, which includes so many
topics of interest to the surgeon ; and the terse man-
ner in which each has been treated evinces a most
enviable quality of  mind on the part of the author,
who seems to have an  innate  power of searching
out and grasping the leading facts and features of
the most elaborate productions of the pen. It is a
useful handbook for the  practitioner, and we should
deem a teacher of surgery unpardonable who did not
recommend it to his pupils.  In our own opinion, it
is admirably adapted to the wants of the student.—
Provincial Medical and Surgical Journal.
           DUNGLISON,  FORBES, TWEEDIE,  AND  CONOLLY.

THE CYCLOPEDIA  OF  PRACTICAL  MEDICINE: comprising Treatises on
  the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women
  and Children, Medical Jurisprudence,  &c. &c.  In four large super royal  octavo volumes, of
  3254 double-columned pages, strongly and handsomely bound.

  *#* This work contains no less than four hundred and eighteen distinct treatises, contributed by
sixty-eight distinguished physicians.
  The most complete work on Practical Medicine
extant;  or,  at least,  in  our  language.— Buffalo
Medical and Surgical Journal.

  For reference, it is above all price to every prac-
titioner.—Western Lancet.

  One of the most valuable medical publications of
the day__as a work of reference it is invaluable.—
Western Journal of Medicine and Surgery.

  It has been to us, both as learner and teacher, a
work for ready and frequent reference, one in which
modern  English medicine is exhibited  in the most
advantageous light.—Medical Examiner.

  We rejoice that this work.is to be placed within
the reach of the profession in this country, it being
unquestionably one of very great value to the prac-
titioner.  This estimate of it has not been formed
from a hasty examination, but after an intimate ac-
quaintance derived from  frequent consultation  of it
during  the past nine or ten years.  The editors are
practitioners of established reputation, and the list
of contributors embraces  many of the most eminent
professors and teachers of London, Edinburgh, Dub-
lin, and Glasgow.  It is, indeed, the great merit of
this work that the principal articles have been  fur-
nished  by practitioners who have not only devoted
especial attention to the diseases about which  they
have written, but have also enjoyed opportunities
for an extensive practical acquaintance with them,
and whose reputation carries the assurance of their
competency  justly to appreciate the opinions  of
others, while it stamps their own  doctrines with
high and just authority.—American Medical Journ.
                          DUNGLISON  (ROBLEY),  M.D.,
        Professor of the Institutes of Medicine, in the Jefferson Medical College, Philadelphia.

HUMAN HEALTH;  or, the Influence  of Atmosphere and Locality, Change of
  Air and Climate, Seasons, Food, Clothing, Bathing, Exercise, Sleep, &c. &c, on Healthy Man;
  constituting Elements of Hygiene.  Second edition, with many modifications and  additions.  In
  one octavo volume, of 464 pages. 
12
BLANCHARD  &  LEA'S  MEDICAL
                         DUNGLISON  (ROBLEY),  M.D.,
          Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia.

MEDICAL  LEXICON;   a Dictionary of Medical Science, containing a  concise
  Explanation of the various Subjects and Terms of Physiology, Pathology, Hygiene, Therapeutics,
  Pharmacology, Obstetrics, Medical Jurisprudence, &c.  With the French and other Synonymes;
  Notices of Climate and of celebrated Mineral Waters; Formulae for various Officinal, Empirical,
  and Dietetic Preparations, etc.  Tenth edition,  revised.   In one very thick octavo volume, of
  over nine  hundred large  double-columned pages, strongly bound in leather, with raised bands.
  (Just Issued.)
  Every successive edition of this work bears the marks of  the industry of the author, and of his
determination to keep it fully on a level with the most advanced state of medical science.  Thus
the last two editions contained about nine thousand subjects and terms not comprised in the one
immediately preceding, and the present has not less than four thousand not in any former edition.
As a complete Medical Dictionary, therefore, embracing over FIFTY THOUSAND  DEFINI-
TIONS  in all the branches of the science, it is presented as meriting a continuance of the great
favor and popularity which have carried it, within  no very long space of time, to a ninth edition.
  Everv precaution has been taken in the preparation of the  present volume, to render its mecha-
nical execution and typographical  accuracy worthy of its extended reputation and universal  use.
The very extensive additions have been accommodated, without materially increasing the  bulk  of
the volume by the employment of a small but exceedingly clear type, cast for this  purpose.   The
press has been watched with great care, and every effort used to insure the verbal accuracy so ne-
cessary to a work of this nature.  The whole is printed on  fine white paper; and, while thus exhi-
biting in every respect so great an improvement over former issues, it is presented at the original
exceedingly low price.
  A miracle of labor and industry in one who has
writfen able and voluminous works on nearly every
branch of medical science.  There could be no more
useful book to the  student or practitioner,  in the
present advancing age, than one in which would be
found, in addition to the ordinary meaning and deri-
vation of medical terms—so many of which  are of
modern introduction—concise descriptions of their
explanation and employment; and all this and much
more is  contained in the volume before us.  It is
therefore almost as indispensable to the other learned
professions as to our own.  In  fact, to all who may
have occasion to ascertain the meaning of any word
belonging to the many branches of medicine.  From
a careful examination of the present edition, we can
vouch for  its  accuracy,  and for its being brought
quite up to the date of publication ; the author states
in his preface  that he has added to it about four thou-
sand terms, which are not to be found in the prece-
ding one. — Dublin Quarterly Journal of Medical
Sciences.
  On  the  appearance of the  last edition of  this
valuable work, we directed the attention of our
readers to  its peculiar  merits;  and we  need do
little more than  state,  in reference to the present
reissue,  that,  notwithstanding  the  large additions
previously made to it, no fewer than  four thou-
sand terms, not to be found  in  the preceding  edi-
tion, are  contained  in  the volume  before  us.—
Whilst it  is a wonderful monument of its author's
erudition and  industry, it is also a work of great
practical utility, as we  can testify from our own
experience; for we keep it constantly within our
reach,  and make  very  frequent reference  to it,
nearly always finding in it the information we seek.
—British and Foreign Med.-Chirurg. Review.
  It has the rare merit that it certainly has no rival
in the English language for accuracy  and  extent
of references.  The terms generally include short
physiological  and pathological descriptions, so that,
as the author  justly observes, the reader  does not
possess in this work a mere dictionary, but a book,
which, while  it  instructs him in medical etymo-
logy, furnishes him with a large amount of useful
information.  The  author's labors  have been pro-
perly appreciated by his own countrymen ; and we
  Upon every topic embraced in the work the latest
information will be  found  carefully posted up.—
Medical Examiner.

  The student of medicine will  find, in these  two
elegant volumes, a mine of facts, a gathering of
precepts and advice from the world  of experience,
that will nerve him  with courage,  and faithfully
direct him in his efforts to relieve the physical  suf-
can only confirm their judgment, by recommending
this most useful volume  to the notice of our cisat-
lantic readers. No medical library will he complete
without it.—London Med. Gazette.

  It is certainly more complete and comprehensive
than any with  which we are acquainted in the
English language.  Few, in  fact, could be found
belter qualified than Dr. Dunglison  for the produc-
tion  of such  a  work.  Learned, industrious, per-
severing, and accurate,  he brings to the task all
the peculiar  talents necessary  for  its successful
performance;  while, at  the same time, his fami-
liarity with the writings of the ancient and modern
" masters of our art," renders him skilful to note
the exact usage  of  the  several  terms of  science,
and the various modifications which medical term-
inology has  undergone with  the change  of theo-
ries or  the progress of  improvement. — American
Journal of the Medical Sciences.

  One of the most complete and copious known to
the cultivators  of medical science.—Boston Med.
Journal.
  A most complete Medical Lexicon—certainly one
of the best works of the kind in  the language.—
Charleston Medical Journal.

   The  most  complete Medical  Dictionary in the
English language.— Western Lancet.

  It has not its  superior, if indeed its equal, in the
English language.—St. Louis Medical and Surgical
Journal.
  Familiar with nearly all the medical dictiona-
ries now in print,  we consider the one before us
the most complete, and an indispensable adjunct to
every medical library.—British American Medical
Journal.
  We  repeat  our declaration, that  this is the best
Medical Dictionary  in the language.—West. Lancet.

  The very best  Medical Dictionary now extant.—
Southern Medical and Surgical Journal.

  The most comprehensive and best English Dic-
tionary of medical terms extant.—Buffalo Medical
Journal.
ferings of the race.—Boston Medical and Surgical
Journal.

  It is certainly the most complete treatise of which
we have any knowledge.— Western Journal of Medi-
cine and Surgery.

  One of the most elaborate treatises of the kind
we have.—Southern Med. and Surg. Journal.
BY THE SAME AUTHOR.
THE PRACTICE  OF MEDICINE.   A Treatise on  Special Pathology  and  The-
  rapeutios.  Third Edition.  In two large octavo volumes, of fifteen hundred pages. 
AND SCIENTIFIC PUBLICATIONS.
13
          Pmf      f,   PUNGLISON  (ROBLEY),  M.D.,
          Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia.


HSVvlALle?IdI0^0(>7--.Seventh  edition-   Thoroughly revised  and  exten-
  someVorS^                   nearly five  hu»dred illustrations/In  two large and hand-
  somely printed octavo volumes, containing nearly 1450 pages.

it llZ^bl^^lT?^^^  haS the aUthOT bestowed ™reczre than on the present,
which it°tS but ako ,h~ t  entire  scrutiny,  not only as regards the  important matters, of
has he felt as satisfiedwit£\!anS"?ge '« which they are conveyed;  and on no former occasion
fhe science                 his endeavors to have the work on a level with the existing state of

  It has long since taken rank as one of the medi-
cal classics of our  language.  To say that it is by
far the best text-book of physiology ever published
in this country,  is but echoing the general testi-
mony of the profession.—N. Y. Journal of Medicine.

  There is no single book we would recommend to
the student or physician, with  greater  confidence
than the present, because in it, will be found a mir-
ror of almost every standard physiological work of
the day. We most cordially recommend the work
to every member of the profession, and  no student
should be without it.  It is the completes! work on
Physiology in the English language, and is highly
creditable to  the author and publishers.—From the
Canadian Medical Journal.

  The most  complete and satisfactory system  of
Physiology in the English language.—Amer. Med.
Journal.

  The best work of  the kind  in the  English lan-
guage.—Silliman's Journal.

  The most full and complete system of Physiology
in our language.—Western Lancet.
BY THE SAME  AUTHOR.
GENERAL  THERAPEUTICS   AND   MATERIA  MEDICA;  adapted for  a
  Medical Text-book.  Fifth edition, much improved.  With one hundred and eighty-seven illus-
  trations.  In two large and handsomely printed octavo vols., of about 1100 pages. (Now Ready.)
  The new editions of the United States Pharmacopoeia and those of London and Dublin, have ren-
dered necessary a thorough revision of this work.   In accomplishing thistheauthor has spared no
pains in rendering it a complete exponent of all that is  new and  reliable, both in the departments
of Therapeutics and Materia Medica.  The book has thus been somewhat enlarged, and a like im
provemetit will be found in every department of its  mechanical execution.
  In this work of Dr. DungIison,we recognize the
same untiring industry in the collection and  em-
bodying of facts on the several subjects of which he
treats, that  has heretofore distinguished him,  and
we cheerfully point to these volumes, as two of the
most interesting that we know of.  In noticing the
additions to this, the fourth  edition, there  is very
little in  the periodical or annual  literature of the
profession, published  in the interval which  has
elapsed since the issue of the first, that has escaped
the careful search  of the author.  As a book for
reference, it is invaluable.—Charleston Med. Jour-
nal and Review.
  As a text-book for students, for whom it is par-
ticularly designed, we  know of none superior to
it.—St. Louis Medical and Surgical Journal.

  It purports to be a new edition, but it is rather
a new book, so  greatly has  it been improved, both
in the amount and quality  of the matter which it
contains.—N. O. Medical and Surgical Journal.

  We bespeak for this edition, from the profession,
an increase of  patronage over any  of its former
ones, on account  of its increased merit. — N.  Y.
Journal of Medicine.
  It may be said to be. the work now upon the sub-   We consider this work unequalled.—Boston Med.
jects upon which it treats.— Western Lancet.        I and Surg. Journal.
BY THE SAME  AUTHOR.
NEW REMEDIES, WITH FORMULAE  FOR  THEIR  ADMINISTRATION.
  Sixth edition, with extensive Additions.  In one very large octavo volume, of over 750 pages.
  One of the most useful of the author's works.—
Southern Medical and Surgical Journal.

  This well-known  and  standard book has now
reached its sixth edition, and has been enlarged and
improved by the introduction of all the recent gifts
to therapeutics which the last few years have so
richly produced, including the anaesthetic  agents,
Sec.   This elaborate and useful volume should be
found in every medical library, for as a book of re-
ference, for physifians, it is unsurpassed  by any
other work in  existence, and the double index for
diseases and  for remedies, will be found greatly to
enhance its value.—New York Med. Gazette.

  The great learning of the author, and his remark-
able industry in pushing his researches into every
source whence information is derivable, has enabled
liim to throw together  an extensive mass of facts
and statements, accompanied  by  full reference to
authorities; which last feature renders the work
practically valuable to  investigators who desire to
examine the original papers.—The American Journal
of Pharmacy.
                   DUFTON  (WILLIAM),  M.R.C.S.,  &.C.
THE  NATURE  AND  TREATMENT  OF  DEAFNESS  AND DISEASES
  OF THE EAR; and the Treatment of the Deaf and Dumb.  One small 12mo. vol.  pp. 120.
                             DURLACHER  (LEWIS).

A  TREATISE  ON  CORNS,   BUNIONS,  TffE  DISEASES   OF   NAILS,
  AND  THE  GENERAL MANAGEMENT  OF  THE  FEET.  In  one 12mo. volume, cloth.
  pp. 134. 
14
BLANCHARD &  LEA'S  MEDICAL
                         DE  JONGH (L.  J.), M. D., &.c.
THE  THREE KINDS  OF COD-LIVER OIL, comparatively considered, with
  their Chemical  and Therapeutic Properties.  Translated,  with  an  Appendix and  Cases, by
  Edward Carey, M. D.   To which is added an article on the subject from "Dunglison on New
  Remedies."  In one small 12mo. volume, extra cloth.
                            DAY  (GEORGE E.), M. D.

A PRACTICAL  TREATISE  ON THE  DOMESTIC MANAGEMENT AND
  MORE  IMPORTANT DISEASES OF ADVANCED LIFE.  With an  Appendix on a new
  and successful mode of treating Lumbago and other forms of Chronic Rheumatism.   One volume,
  oclavo, 226 pages.

                           ELLIS (BENJAMIN), M.D.

THE  MEDICAL FORMULARY:  being a Collection of  Prescriptions, derived
  from the writings and practice of many of the most eminent physicians of America and Europe.
  Together with the usual Dietetic Preparations and Antidotes for Poisons.  To which is added
  an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform.   The
  whole accompanied with a few brief Pharmaceutic and Medical Observations.  Tenth edition,
  revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the
  Philadelphia College of Pharmacy.   In one neat octavo volume, of two hundred and ninety-six
  pages.  (Now Ready.)

  This work has received a very complete revision at the hands of the editor, who has made what-
ever alterations and additions the progress of medical and pharmaceutical science has rendered ad-
visable, introducing fully the new remedial agents, and revising the whole by the latest improvements
of the Pharmacopoeia.   To accommodate these additions, the size of the page has been increased,
and the volume itself considerably enlarged, while  every effort has been made to secure the typo-
graphical accuracy which has so'long merited the confidence of the profession.
                               ERICHSEN  (JOHN).
                    Professor of Surgery in University College, London, ice.
THE  SCIENCE  AND ART  OF SURGERY;  being a Treatise on Surgical
  Injuries, Diseases, and Operations.  In one very  large and handsome octavo volume, with
                  (Nearly Ready.)
260 illustrations.
                      FERGUSSON  (WILLIAM),  F. R. S.,
                     Professor of Surgery  in King's College, London, &c.
A SYSTEM  OF  PRACTICAL SURGERY.  Fourth American, from the third
  and enlarged London edition. In one large and beautifully printed octavo volume, of about seven
  hundred pages, with three hundred and ninety-three handsome illustrations.  (Now Ready.)
  The most important subjects in connection with
practical  surgery which have been more recently
brought under the notice of, and  discussed by, the
surgeons of Great Britain, are fully and dispassion-
ately considered by Mr. Fergusson, and that which
was before wanting has now been  supplied, so that
we can now look upon it as a work on practical sur-
gery  instead of  one  on operative surgery alone,
which many have hitherto considered it to be.  And
we think the author has shown a wise discretion in
making the additions on surgical disease which are
to be found in the present volume, and has very
much enhanced its value; for, besides two elaborate
chapters on the diseases of bones and joints, which
were wanting before he has headed each chief sec-
tion of the work by a general description of the sur-
gical  disease and injury of that region of the body
which is treated of in each, prior to entering into the
consideration of the more special morbid conditions
and their  treatment.  There is also, as in former
editions, a  sketch of the anatomy of particular re-
gions. AVe have now pointed out some of the prin-
cipal  additions  in this work.  There was some
ground formerly for the complaint before alluded to,
that it dwelt too  exclusively on operative surgery ;
but this defect is now removed, and the book is more
than ever adapted for the purposes of the practitioner,
whether he confines himself more  strictly  to the
operative department, or follows surgery on a more
comprehensive scale.—Medical Times and Gazette.

  No work was ever written  which more  nearly
comprehended the necessities  of the student and
practitioner, and was more carefully arranged to
that single purpose than this.—N. Y. Med. and Surg.
Journal.
  The addition of many new pages makes this work
more than ever indispensable to the studentand prac-
titioner.—.Ranfcing-'s Abstract, January, 1853.

  For the general practitioner, who does not make
a specialty of surgery,  it is certainly invaluable.
The style is concise, pointed,  and clear. The de-
scriptions of the various operations a.re concentrated
and accurate, so that in cases of emergency, the
principles of the most difficult operations may be
obtained by a reference of a  few  moments to its
pages.—Western Lancet.
  Among the numerous works upon surgery pub-
lished of late  years,  we know of none we value
more highly than the one before us.  It is perhaps
the very best we have for a text-book and for ordi-
nary reference, being concise and eminently practi-
cal.—Southern Med. and Surg. Journal.
                            FRICK (CHARLES),  M.  D.
RENAL  AFFECTIONS;  their  Diagnosis and Pathology.
  One volume, royal 12mo., extra cloth.
With  illustrations.
                        GUTHRIE (G.  J.),  F. R. S., Sec.
THE  ANATOMY  OF  THE  BLADDER  AND URETHRA,  and  the Treat-
                                                         In one volume, oclavo, 150 pages.
ment of the Obslructions to which those Passages are liable. 
AND  SCIENTIFIC  PUBLICATIONS.                    15
                         FOWNES  (GEORGE),  PH. D., _.c.
ELEMENTARY   CHEMISTRY;  Theoretical and Practical.   With  numerous
  illustrations.  A new American, from the last and revised London edition.  Edited, with Addi-
  tions, by Robert Bridges, M. D.  In one large royal 12mo. volume, of over 550 pages, with 181
  wood-cuts, sheep, or extra cloth.  (Just Ready.)
  The lamented death of the author has caused the revision" of this edition to pass into the hands of
those distinguished chemists, H.  Bence Jones and A. W.  Hoffman, who have fully sustained its
reputation by the additions which they  have made, more especially in the portion devoted to Organic
Chemistry, considerably  increasing the size of the  volume.  This  labor has  been so thoroughly
performed, that the American Editor has found but little to add, his notes consisting chiefly of such
matters as the rapid advance of the science has rendered necessary, or of investigations which had
apparently been overlooked by the  author's friends.
  The volume is therefore again presented as an exponent of the most advanced state of chemical
science, and as not unworthy a continuation of the  marked  favor  which it  has received as  an ele-
mentary text-book.
  The  work of Dr. Fownes has long been before
the public, and its  merits have been fully appreci-
ated as the best  text-book on  chemistry now in
existence.  We do not. of course, place it in a rank
superior to the works of Brande, Graham,  Turner,
Gregory, or Ginelin, but we say that, as  a work
for students, it is preferable to any of them.—Lon-
don Journal of Medicine.

  A work well adapted to the wants of the student.
It is an excellent exposition of the chief doctrines
and facts of modern chemistry. The size of the work,
and still more the condensed yet  perspicuous style
in which it is  written, absolve it from the charges
very properly urged against most manuals termed
popular, viz.: of omitting details of indispensable
importance, of avoiding  technical  difficulties,  in-
stead of explaining them, and of treating subjects
of high scientific interest in an unscientific way —
Edinburgh Monthly Journal of Me ileal Science.

  The rapid sale of this Manual evinces its adapta-
tion to the wants of the student of chemistry, whilst
the well-known merits of its lamented author have
constituted a guarantee for its value, as a faithful
exposition of the general principles and most  im-
portant facts of thy science to  which it professes to
be an introduction.—British and Foreign Medico-
Chirurgical Review.
                           GRAHAM  (THOMAS),  F.!R. S.,
                    Professor of Chemistry in University College, London, &c.

THE  ELEMENTS OF  CHEMISTRY.   Including the application of the Science
  to the Arts.  With numerous illustrations.  With Notes and Additions,  by Robert Bridges,
  M. D., &c. &c.   Second American, from the second and  enlarged London edition
PART I. (Lately Issued) large 8vo., 430 pages, 185 illustrations.
PART II. (Preparing) to match.
  The great changes which the science of chemistry has undergone within the last few years, ren-
der a  new edition of a treatise  like the present,  almost a new work.  The author has devoted
several years to the revision of his  treatise, and has endeavored to embody  in it every  fact and
inference  of importance which has been observed and recorded by the great body of chemical
investigators who are so rapidly changing the  face of the science.   In this manner the work has
been greatly increased in size, and the number of illustrations doubled ; while the labors of the editor
have been directed towards the introduction  of such matters  as have escaped  the attention of the
author, or as have  arisen since the publication of the first portion of this edition in London, in 1850.
Printed in handsome style, and at a very low price, it is therefore confidently presented to the pro-
fession and the student as a very complete and thorough text-book of this important subject.
                            GROSS  (SAMUEL  D.), M.  D.,
                    Professor of Surgery in the Louisville Medical Institute, &c.
A  PRACTICAL  TREATISE ON  THE DISEASES  AND  INJURIES  OF
  THE URINARY ORGANS.   In one large and beautifully printed octavo volume, of over seven
  hundred pages.  With numerous illustrations.
  A volume replete with truths and principles of the
utmost value in the investigation of these diseases.—
American Medical Journal.
  Dr. Gr"S8 has brought all his learning,  experi-
ence, tact, and judgment to the task, and has pro-
duced a work worthy of his high  reputation.  We
feel perfectly safe in recommending it to our read-
ers as a monograph  unequalled  in  interest and
practical value by any other on the subject in our
language; and we cannot help saying, that we es-
teem it a. matter of just pride,  that another work
so creditable  to our country has been contributed
to our medical literature by a Western physician.
—The Western Journal of Medicine and Surgery.

  We regret that our limits preclude such a notice
as this  valuable contribution  to our  American
Medical  Literature  merits.  We have  only  room
to say that the author deserves the thanks of the
profession for this  elaborate  production;  which
cannot fail to  augment the exalted reputation ac-
quired by his former works, for which he has been
honored at home and abroad.—N. Y. Med Gazette.

  Whoever will peruse the vast amount of valuable
practical information it contains, and  which we
have been unable even to notice, will, we think,
agree with us, that there is no work in the English
language which can make any just pretensions to
be its equal.  Secure in the esteem and confidence
of the profession in this country, at least, its distin-
guished author will doubtless receive their warmest
congratulations that he has succeeded  in producing
a treatise so creditable to himself, and, as we hum-
bly believe, to American surgical literature.—N. Y.
Journal of Medicine.

  It has remained for an  American writer  to wipe
away this reproach ; and so completely has the task
been fulfilled,  that we venture  to predict for Dr.
Gross's treatise a permanent place in the literature
of surgery, worthy to rank with the best works of
the present age.  Not merely  is the matter good,
but the getting up of the volume  is most creditable
to transatlantic enterprise; the  paper and print
would do credit to a first-rate London establishment;
and the numerous wood-cuts which illustrate it, de-
monstrate that America is inakin.' rapid advances in
this department of art. We have, indeed, unfeigned
pleasure in congratulating all concerned in this pub-
lication, on the result of their labours; and expe-
rience a feeling something like whatanitnates a long-
expectant husbandman, who, oftentimes disappointed
by the produce of  a favorite field, is at last agree-
ably  surprised  by  a stalely crop  which may  hear
comparison with  any of its former  rivals.  The
grounds of our high appreciation of the work will
be obvious as we proceed; and we doubt  not that
the present  facilities for  obtaining American books
will induce many of our readers  to verify our re-
commendation  by their own perusal of it.—British
and Foreign Medico-Chirurgical Review. 
16
BLANCHARD  <fc LEA'S  MEDICAL
                  GRIFFITH (JOHN  WILLIAM),  M. D.,  8cc.
A  PRACTICAL   MANUAL   ON  THE  BLOOD  AND  SECRETIONS OF
  THE HUMAN BODY.  Royal 12mo., with plates.  (See » Manuals on Blood and Urine.")
                           GLUGE (GOTTLIEB),  M. D.,
        Professor of Physiology and Pathological Anatomy in the University of Brussels, &c.

AN  ATLAS  OF  PATHOLOGICAL  HISTOLOGY.   Translated, with Notes
  and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylva-
  nia.  In one volume, very large imperial quarto, with  three hundred and twenty figures, plain
  and colored, on twelve copperplates.
  We are glad to see this excellent work of Gluge
translated into English by so competent a hand, and
put within the reach of the profession  in this coun-
try.  The history of the development and changes of
the elements of pathological  tissues, has  become
now a necessary introduction to the study of morbid
anatomy. It can no longer be looked upon as merely
accessory.  Bearing the same  relation to it as does
normal  histology to normal anatomy, it appears to
us to be of still higher importance, since it has a
closer and more direct bearing upon practical medi-
cine.  Whatever makes our Knowledge of diseased
structure clearer, must throw light also upon the
plan of cure, and show us, too, in many  instances,
where a cure is  impossible.  This being, as far as
we know, the only work in which pathological his-
tology is separately treated of in a comprehensive
manner, it will, we think, for this reason, be of infi-
nite service to those who desire to investigate the
subject systematically, and who have  felt the diffi-
culty of arranging in their mind the  unconnected
observations of a great number of authors.  The
development of the morbid tissues, and the formation
of abnormal products, may now be followed and
studied with the same ease and satisfaction as the
best  arranged  system  of  physiology. — American
Med. Journal.

  Professor Gluge's work will be found a very valu-
able  addition to the  necrologist's collection.  It
contains, in the compass of one volume, a concise
description  and well-executed  illustrations of the
elements to be observed under the microscope in the
principal pathological  lesions.—Dublin Quarterly
Journal of Medical Science.
                     GRIFFITH (ROBERT  E.), M. D., &c.

A UNIVERSAL FORMULARY, containing the methods of  Preparing and Ad-
  ministering Officinal and  other Medicines.  The whole adapted to Physicians and Pharmaceu-
  tists.  In one large octavo volume, of 568 pages, double columns.
  Dr. Griffith's Formulary is worthy of recommen-
dation, not only on account of the care which has
been bestowed on it by its estimable author, but for
its general accuracy, and the richness of its details.
—Medical Examiner.

  Most cordially we  recommend this  Universal
Formulary, not forgetting its adaptation to drug-
gists and  apothecaries, who would find themselves
vastly improved by a familiar acquaintance with
this every-day book of medicine.—The Boston Med.
and Surg. Journal.

  A very useful work, and a most complete compen-
dium on the subject of materia medica.  We know
nf no work in our  language, or any other, so com-
prehensive in all its details.—London Lancet.
  Pre-eminent among the best and most useful com-
pilations of the present day will be found the work
before us, which can have been produced only at a
very ^reat cost of thought and labor. A short de
scription will suffice to show that we do not put
too high an estimate on this work.  We are not cog-
nizant of the existence of a parallel work.  Its value
will  be apparent to our readers from  the sketch of
its contents above given.  We strongly recommend
it to  all who  are engaged either in practical medi-
cine, or more exclusively with its literature.—Lond.
Med. Gazette.

  A valuable acquisition to the medical practitioner,
and a useful book of reference to the apothecary on
numerous occasions.—Amer. Journal of Pharmacy.
                                  BY THE SAME AUTHOR.

MEDICAL BOTANY;  or, a Description of all the  more important Plants used
  in  Medicine, and of their Properties, Uses, and Modes of Administration.  In one large octavo
  volume, of 704 pages, handsomely printed, with nearly 350 illustrations on wood.
  One of the greatest acquisitions to American medi-
eal literature. It should by all means be introduced,
at the very earliest period, into our medical schools,
and occupy a place in the library of every physician
in the land.—South-western Medical Advocate.
  Admirably calculated for the physician and  stu-
dent — we have seen  no  work  which  promises
greater advantages  to the profession.—A". O. Med.
and Surg. Journal.
  One of the few books which supply a positive de-
ficiency in our medical literature.—Western Lancet.

  We hope  the day is not distant when  this work
will not only be a text-book in every medical school
and college  in the Union, but find a place in the li-
brary of every private practitioner.—JV. Y. Journal
of Medicine.
                       GREGORY  (WILLIAM), F. R. S.  E.,
                   Professor of Chemistry in the University of Edinburgh, &e.

LETTERS   TO  A CANDID  INQUIRER   ON  ANIMAL
  Description and Analysis of the Phenomena.  Details of Facts and Cases.
  royal 12ino., extra cloth.
 MAGNETISM.
In one neat volume,
                        GARDNER (D. PEREIRA), M. D.

MEDICAL CHEMISTRY, for the use of Students  and  the  Profession: being a
  Manual of the Science, with its Applications to Toxicology, Physiology,  Therapeutics, Hygiene,
  &c.  In one handsome royal 12mo. volume, with illustrations. 
                             HASSE (C. E.>, M. D.
AN ANATOMICAL  DESCRIPTION OF THE  DISEASES OF  RESPIRA-
  TION AND CIRCULATION.  Translated  and Edited by Swaine.  In one volume, octavo.
                          HARRISON  (JOHN), M.D.
AN  ESSAY  TOWARDS  A CORRECT THEORY  OF THE NERVOUS
  SVSTEM.  In one octavo volume, 292 pages.
                               HUNTER (JOHN).

TREATISE  ON  THE  VENEREAL DISEASE.   With copious Additions, by
  Dr. Ph. Ricord, Surgeon to the Venereal Hospital of Paris.  Edited, with additional Notes, by
  F. J. Bumstead, M. D.  In one octavo volume, with plates.  (Now Ready.)

                          From the Translator's Preface.
  " The school, of which M. Ricord is the head, has, by its adherence to some of the most import-
ant views of the immortal Hunter, and  more particularly by its adoption of Hunter's division of
constitutional syphilis into two periods, and  of his belief in the non-contagiousness of secondary
symptoms, acquired for itself the name of Hunterian.  It is not without reason, therefore, that the
names of these two distinguished authors, though separated by more than half a century, appear
conjointly on the title-page of  this volume.
  " M. Ricord's annotations to Hunter's Treatise on the Venereal Disease were first published at
Paris, in 18-10, in connection with Dr. G. Richelot's translation of the work, including the contribu-
tions of Sir Everard Home and Mr. Babington.  In a second edition, which has recently appeared,
M. Ricord has thoroughly revised his part of the work, bringing it up  to the knowledge of the
present day, and so materially increasing it that it now constitutes full one-third of the volume.
  " This publication has been  received with great favor by the French, both because it has placed
within their reach an important work of Hunter, and also because it is the only recent practical
work which M. Ricord has published, no edition of his Traite des Maladies Veneriennes having
appeared for the last fifteen years."

  Besides the translation of M Ricord's Notes, Dr.  Bumstead has added such further remarks as
appeared necessary to render the work a complete and systematic exponent of the most recent views
on this important subject.  As a thorough and practical work, combining the distinguished names
of Ricord and Hunter, it is therefore presented as possessing especial claims to the notice and con-
fidence of the profession.

Also, HUNTER'S COMPLETE WORKS, with Memoir, Notes, &c. &c.  In four neat octavo
  volumes, with plates.

                       HORNER (WILLIAM E.), M. D.,
                   Professor of Anatomy in the University of Pennsylvania.
SPECIAL  ANATOMY  AND.  HISTOLOGY.  Eighth edition.   Extensively
  revised and modified.  In two large  octavo volumes, of more than one thousand pages, hand-
  somely printed, with over three hundred illustrations.

  This work has enjoyed a thorough and laborious  revision on the part of the author, with the
view of bringing it fully up to the existing state of knowledge on the subject of general and special
anatomy.  To adapt it more perfectly to the wants of the student, he has introduced a large number
of additional wood-engravings, illustrative of the objects described, while the publishers have en-
deavored to render the mechanical execution of the work worthy of the extended reputation which
it has acquired.  The demand which has carried it to an EIGHTH EDITION  is a sufficient evi-
dence of the value of the work, and of its adaptation  to the wants of the student and professional
reader.

                        HOBLYN (RICHARD D.), A. M.

A  DICTIONARY OF  THE  TERMS  USED  IN MEDICINE  AND  THE
  COLLATERAL SCIENCES.  Revised, with numerous Additions, from the  second London
  edition, by Isaac Hays, M.  D., &c.  In one large royal 12mo. volume, of four hundred and two
  pages, double columns._______________

                        HOPE (J.), M. D., F. R. S., &.C.

A TREATISE ON  THE DISEASES »OF THE  HEART AND GREAT
  VESSELS.   Edited by Pen.mock.  In one volume, octavo, with plates,  572 pages.


                HERSCHEL (SIR JOHrIM  F. W.), F. R. S., &.C.

OUTLINES  OF  ASTRONOMY.   New American, from the third London edition.
  In one neat volume, crown octavo, with six plates and numerous wood-cuts..  (Just Issued.)


            JOHNSTON  (ALEXANDER  KEITH),  F. R. S., &.c.

THE PHYSICAL ATLAS OF NATURAL  PHENOMENA.   For the  use of
  Colleges, Academies, and Families.   In one large volume, imperial quarto, handsomely and
  stron|ly bound, with twenty-six Plates, engraved and colored in the best style.  Together  with
  112 pages of descriptive letter-press, and a very copious Index. 
18
BLANCHARD  &  LEA'S MEDICAL
                     JONES  (T. WHARTON),  F. R. S., 8tc.
THE PRINCIPLES AND  PRACTICE OF  OPHTHALMIC  MEDICINE
  AND SURGERY.  Edited by Isaac Hays, M. D., &c.  In one very neat volume, large royal
  12mo., of 529 pages, with four plates, plain or colored, and ninety-eight wood-cuts.
  We are confident  that the reader will find, on
perusal, that the execution of the work amply fulfils
the promise of the preface, and sustains, in every
point the already  high reputation of the  author as
an ophthalmic  surgeon as well as a physiologist
and pathologist.  The book is evidently the result
of much labor  and research, and has been written
with the greatest care and  attention; it  possesses
that best quality which a general work, like a sys-
tem or manual can show, viz.: the quality of having
all the materials whennesoever derived, so thorough-
ly wrought up, and digested in the author's mind,
as to come forth with the freshness and impressive-
ness of an original production.  We regret that we
have received  the book at so late a period as pre-
cludes our giving more than a mere notice of it, as,
although essentially and necessarily a compilation, it
contains many things which we should be glad to
reproduce in our pages whether in the shape of new
pathological views, of old errors corrected, or of
sound principles of practice in doubtful cases clearly
laid down.  But we dare say  most of our readers
will shortly have an opportunity of seeing these in
their original locality, as we entertain little doubt
that this book will become what its author hoped it
might become, a manual for daily reference and
consultation by the student and the general practi-
tioner.  The work is  marked  by that correctness,
clearness, and  precision of style which distinguish
all the productions of the learned author.—British
and Foreign Medical Review.
JONES  (C. HANDFIELD),  F. R. S.,  &.  EDWARD  H. SIEVEKING, M- D.
A MANUAL  OF PATHOLOGICAL ANATOMY.   With numerous engravings
                                     (Preparing.)
on wood.  In one handsome volume.
                   KIRKES  (WILLIAM SENHOUSE),  M. D.,
             Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c; and

                             JAMES  PAGET, F.  R. S.,
            Lecturer on General Anatomy and Physiology in St. Bartholomew's Hospital.

A  MANUAL  OF   PHYSIOLOGY.   Second  American, from  the second and
  improved  London edition.  With one hundred bnd sixty-five illustrations.  In one large and
  handsome royal 12mo. volume,   pp. 550.  (Just Issued.)

  In the present edition, the Manual of Physiology
has been brought up to  the actual condition of the
science, and fully sustains the reputation which it
has already so deservedly attained.  We  consider
the work of MM. Kirkes and Paget to constitute one
of the very best handbooks of Physiology we possess
—presenting just such an outline of the science, com-
prising an account of its leading facts and generally
admitted principles, as the student requires during
his attendance upon a course of lectures, or for re-
ference whilst preparing for examination.  The text
is fully and ably ijlustrated by a series of very supe-
rior wood-engravings, by which a comprehension of
some of the more intricate  of the subjects treated of
is greatly facilitated— Am. Medical Journal.

  We need only say, that, without entering  into dis-
cussions of unsettled questions, it contains all  the
recent improvements in  this department of medical
science. For the student beginning  this study, and
the practitioner who has but leisure to refresh his
memory, this book is invaluable,  as it  contains all
that it is important to know, without special details,
which are read  with interest only by those who
would make a specialty, or desire to possess a criti-
cal knowledge of the subject.—Charleston Medical
Journal.

  One of the best treatises that can be put into the
hands of the student.—London Medical Gazette.

  The general favor with which the first edition of
this work was received, and its adoption as a favor-
ite text-book by many of our colleges, will insure a
large circulation to this improved edition.  It will
fully meet the wants of the student. — Southern
Med. and Surg. Journal.

  Particularly adapted to those who desire to pos-
sess a concise digest of the facts of Human Physi-
ology.—British and Foreign Med.-Chirurg. Review.

  We conscientiously recommend it as an admira-
ble " Handbook of Physiology."—London journal
of Medicine.
                             KNAPP  (F.),  PH. D.,  &.c.

TECHNOLOGY;  or, Chemistry applied to the Arts and to Manufactures.  Edited,
  with numerous Notes and Additions, by Dr. Edmund Ronalds and Dr. Thomas Richardson.
  t irst American edition, with Notes and Additions, by Prof. Walter R. Johnsox.  In two hand-
  some octavo volumes, printed and illustrated in the highest style of art, with about five hundred
  wood-engravings.
                                     LEHMANN.
PHYSIOLOGICAL   CHEMISTRY.    Translated  by  George  E.  Day, M. D.
  In one very large octavo volume.   (Preparing.)
                      LEE (ROBERT),  M. D.,  F. R. S., &c.

CpIiyi?Ap  MI,DWIFERY;  comprising  the  Histories of  Five Hundred and
  xheXcZ\ J,oSnHn°n  V^cuh' TPre,erna,ul;a1' a»" Complicated Labor, with Commentaries.  From
  the ^econd London edition.  In one royal 12mo. volume, extra cloth, of 238 pages.

                           LA  ROCHE  (R.),  M. D.,  &,c.
P^_TU?l??TIf AN,D AUTUMNAL FEVERS IN  THEIR  RELATION  TO
  MALARIA.  Iii one handsome octavo volume, of about 450 pages.  (Now Ready.) 
AND  SCIENTIFIC PUBLICATIONS.                  19
                        LAWRENCE (W.), F. R. S.,  &.C.

A TREATISE  ON  DISEASES  OF  THE  EYE.   Third American edition,
  much improved and enlarged.  With over two hundred illustrations.  By Isaac Hays, M. D.,
  surgeon to Wills Hospital, Philadelphia, &c.   In one very large and handsome octavo volume,
  of about nine hundred pages.   (Just Ready.)

  This work, by far the largest and most comprehensive on the subject within reach of the  profes-
sion in this country, has received an entire  revision on the part of the editor.   Brought up in this
manner to the most advanced state of science, and presenting an equal improvement over its prede-
cessors as regards mechanical execution, it is confidently presented as worthy of the extended repu-
tation which it has hitherto enjoyed.
BY THE  SAME AUTHOR.
A TREATISE  ON  RUPTURES; from the fifth London edition.
  volume, sheep, 480 pages.
In one octavo
                            LEIDY  (JOSEPH),  M. D.
                  Professor of Anatomy in the University of Pennsylvania, &c.

ATLAS  OF PATHOLOGICAL  HISTOLOGY.   By Gottlieb Gluge, M. D.
  Translated from the German, with Additions, by Joseph Leidy, M. D , Professor of Analomy
  in the University of Pennsylvania.  In one vol., large  imperial quarto, with 320 figures, plain
  and colored, on twelve plates.

                                 BY THE SAME AUTHOR.

HUMAN ANATOMY.  By Jones Quain, M. D.  From the fifth London edition.
  Edited by Richard Quain, F. R. S., and William Sharpey, M.D., F. R. S.,  Professors of
  Anatomy and Physiology, in University College, London. Revised, with Notes and Additions,
  by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylvania.  Complete in
  two large 8vo. vols, of about 1300 pages, beautifully illustrated with over 500 engravings on wood.
                       LISTON (ROBERT), F. R. S.,  <_c.
LECTURES  ON  THE  OPERATIONS  OF SURGERY, and on Diseases and
  Accidents requiring Operations.  Edited, with numerous Additions and Alterations, by T. D.
  Mutter, M. D.  In one large and handsome octavo volume, of 566 pages, with 216 wood-cuts.
  We  can only say, in  conclusion, that Liston's
Lectures, with Mutter's additions, should  be in
every  surgeon's  library, and in every student's
hand, who wishes to post up his surgical knowledge
to the present moment.—N. Y. Journ. of Medicine.
  It is a compendium of the modern practice of Sur-
gery as complete and accurate as any treatise of
similar dimensions in the English language.—West-
ern Lancet.
                                LALLEMAND (M.).

THE   CAUSES,  SYMPTOMS,  AND  TREATMENT  OF   SPERMATOR-
  RHCEA.  Translated and edited by Henry J. McDougal.  In one volume, octavo, 320 pages.
  Second American edition.  (Now Ready.)
                   LARDNER (DIONYSIUS), D. C. L., &.c.

HANDBOOKS   OF   NATURAL  PHILOSOPHY  AND  ASTRONOMY.
  First Course, containing Mechanics, Hydrostatics, Hydraulics, Pneumatics, Sound  and Optics.
  In one large royal 12ino volume, of 750 pages, with 424 wood-cuts.  Second Course, containing
  Heat, Electricity, Magnetism, and Galvanism, one volume, large royal 12mo., of 450 pages, with
  250 illustrations.   Third Course (just ready), will contain Meteorology and Astronomy, with
  numerous steel-plates and wood-cuts.  Revised, with numerous Additions, by the American editor.
  The work furnishes a very clear and satisfactory
account of our knowledge in the important depart-
ment of science of which it treats".  Although the
medical schools of this country do not include the
study of physics in their course of instruction, yet
no student or practitioner should be ignorant of its
laws. Besides being of constant application in prac-
tice, such knowledge is of inestimable utility in fa-
cilitating the study of other branches of science. To
students, then, and to those who, having already en-
tered upon the active pursuits of business, are desir-
ous to  sustain and improve their knowledge of the
general truths of natural philosophy, we can recom-
mend this work as supplying in a clear and satis
factory manner the information  they desire.—The
Virginia Med. and Surg. Journal.

  The present treatise is a most complete digest of
all that has been developed in relation to the great
forces of nature, Heat, Magnetism, and Electricity.
Their laws are elucidated in a manner both pleasing
and familiar, and at the same time perfectly intelli-
gible to the student.  The illustrations are suffi-
ciently numerous and appropriate, and  altogether
we can cordially recommend the work as well-de-
serving the notice both  of the practising physician
and the student of medicine.—The Med. Examiner. 
20
BLANCHARD  & LEA'S MEDICAL
                          MEIGS (CHARLES  D.), M. D.f
            Professor of Obstetrics, Ac, in the Jefferson Medical College, Philadelphia.

OBSTETRICS: THE SCIENCE  AND  THE  ART.   Second edition,  revised
  and improved.  With one hundred and thirty-one illustrations.  In one beautifully printed octavo
  volume, of seven hundred and fifty-two large pages.  (Lately Published.)

  The rapid demand  for a second edition of this work is a sufficient evidence that it has  supplied
a desideratum of the profession, notwithstanding the numerous treatises on the same subject which
have appeared within the last  few years.  Adopting a system of his own, the author has combined
the leading principles of his interesting and difficult subject,  with a thorough exposition of its rules
of practice, presenting the results of long and extensive experience and of familiar  acquaintance
with all  the modern writers  on this  department of medicine.  As an American Treatise on Mid-
wifery, which has at once assumed the position of a classic, it possesses  peculiar claims to the at-
tention and study of the practitioner and  student, while the numerous alterations and revisions
which it  has undergone in the  present edition are shown by  the great enlargement  of the work,
which is  not only increased as to the size of the page, but also in the number.  Among other addi-
tions may be mentioned
         A NEW AND IMPORTANT CHAPTER ON « CHILD-BED  FEVER."

  As an elementary treatise—concise, but, withal,
clear and  comprehensive—we know of no one better
adapted for the use of the student; while the young
practitioner will find in it a body of sound doctrine,
and a series of excellent practical directions, adapted
to all  the conditions of the various forms of labor
and their  results, which  he will be induced, we are
persuaded, again and again to consult, and always
with profit.  It has seldom been our lot to peruse a
work  upon the subject,  from which we have re-
ceived greater satisfaction, and which we believe to
be better calculated to communicate to the student
correct and definite views upon  the several topics
embraced within the scope of its teachings.—Am.
Journal of the Medical Sciences.
                                  BY THE SAME AUTHOR.

WOMAN:  HER  DISEASES  AND  THEIR  REMEDIES.   A Series of Lee-
  tures to his Class.  Second edition, revised.   In one large and beautifully printed oetavo volume,
  of nearly seven hundred large pages.

  It contains a vast amount of practical knowledge,
by one who has accurately observed and retained
the experience of many years, and who tells the re-
sult in a free, familiar, and pleasant manner.—Dub-
lin Quarterly Journal.
  There is an off-hand fervor, a glow, and a warm-
heartedness infecting the effort of Dr. Meigs, which
is entirely captivating,  and which  absolutely hur-
ries the reader through from beginning to end.  Be-
sides,  the  book  teems with solid instruction, and
it shows the very highest evidence of abilitv, viz.,
the clearness with which the information is  pre-
sented. We know of no better test of one's under-
standing a subject than  the evidence of the power
of lucidly explaining it.  The most elementary, as
well as the obscurest subjects, under the pencil of
Prof. Meigs, are isolated and made to stand out in
such bold relief, as to produce distinct impressions
upon the  mind and memory of the reader.— The
Charleston Med. Journal:
  Professor Meigs has enlarged and amended this
great work, for such it  unquestionably is, having
passed the ordeal of criticism at. home and abroad,
but been improved thereby ; for in  this  new edition
the author has introduced real improvements, and
increased the value  and utility of  the book im-
measurably.  It presents so many novel,  bright,
and sparkling thoughts;  such an exuberance of new
ideas on almost every page, that we confess our-
selves to have become  enamored  with the book
and its author; and cannot withhold  our congratu-
lations from our Philadelphia confreres, that such a
teacher is in  their service.  We  regret that our
limits will not allow of a more extended notice of
this work, but must content ourselves with thus
commending  it as worthy of diligent perusal by
physicians as well as students, who are seeking  to
be thoroughly instructed in the  important practical
subjects of which it treats.—N.  Y. Med. Gazette.
                                  BY THE SAME AUTHOR.

OBSERVATIONS  ON  CERTAIN   OF   THE   DISEASES   OF  YOUNG
  CHILDREN.  In one handsome octavo volume, of 214 pages.
  It puts forth no claims as  a  systematic work,
but contains an amount of valuable and useful mat-
ter, scarcely to be found  in the same space in our
home literature.   It cannot but prove an acceptable
offering to the profession at large.—JV. Y. Journal of
Medicine.

  We take much pleasure in recommending  this
carbuncle, and its fascinating pages often beguiled
us into  forgetfulness of agonizing pain. May it
teach others to relieve the afflictions of the young.—
Western  Journal of Medicine and Surgery.

  The work  before us  is undoubtedly a valuable
addition  to the fund of  information which has al-
ready been treasured up on the subjects in question.
excellent little work to the attention  of medical j It is practical,  and  therefore eminently adapted to
practitioners.  It  deserves their attention, and af-  the general practitioner. Dr. Meigs's works have
ter they commence its perusal, they will not wil-  the same  fascination which belongs to himself.—
lingly abandon it,  until  they  have  mastered  its j Medical Examiner.
contents. We read the work while suffering from a I
                           BY THE SAME author.  (Preparing.)
ON  THE  NATURE,  SIGNS,  AND   TREATMENT  OF  PUERPERAL
  FEVER.  In one handsome octavo volume.
                           BY the same author.   (Just Ready.)

A TREATISE ON ACUTE  AND  CHRONIC  DISEASE  OF THE NECK
  OF THE UTERUS.   With numerous plates, drawn and colored from nature in the  highest
  style of art.  In one handsome octavo volume.  '

  This important monograph will be thoroughly illustrated with colored plates  of the pathological
conditions of the uterus, carefully and accurately executed, from drawings by the author, after na-
ture.  As a work of art, nothing handsomer has as yet been produced in this country. 
AND SCIENTIFIC  PUBLICATIONS.                   21
                           MILLER (JAMES), F. R. S.  E\,
                     Professor of Surgery in the University of Edinburgh, &c.

PRINCIPLES  OF  SURGERY.   Third American, from the  second  and revised
  Edinburgh edition.  Revised, with Additions, by F. W. Sargent, M. D., author of " Minor Sur-
  gery," &:c.  In one large and very beautiful volume, of seven hundred and fifty-two pages, with
  two hundred and forty exquisite illustrations on wood.  (Extensively used as a text-book.)

  The publishers have endeavored to render the present edition of this work, in every point of me-
chanical execution, worthy of its very high reputation, and they confidently present  it to the pro-
fession as one of the handsomest volumes as yet issued in this country.

                                               guage.  This  opinion,  deliberately formed  after a
                                               careful study of the  first edition^ we have  had  no
                                               cause to change on  examining  the  second.  This
                                               edition has undergone thorough revision by the au-
                                               thor;  many expressions have  been modified, and a
                                               mass of new matter introduced.  The book is got up
                                               in the finest style, and is an evidence of the progress
                                               of typography in our country.—Charleston Medical
                                               Journal and Review.

                                                 We recommend it to both student and practitioner,
                                               feeling assured that  as it now comes  to us, it pre-
                                               sents the most satisfactory exposition of the modern
                                               doctrines of the principles of surgery to be found in
                                               any volume  in  any  language.—N.  Y. Journal of
                                                Medicine.
  This edition is far superior, both in the abundance
and quality of its material, to any of the preceding.
We hope it will be extensively read, and  the sound
principles which are herein taught treasured up for
future application.  The work  takes  rank with
Watson's  Practice of Physic ;  it certainly does not
fall behind that great work in  soundness of princi-
ple or depth of reasoning and research.  No physi-
cian who values his reputation, or seeks the interests
of his clients, can acquit himself before his God and
the world without making himself familiar with the
sound and  philosophical views developed in the fore-
going book.—New Orleans Medical and  Surgical
Journal.

  Without doubt the ablest  exposition of the prin-
ciples of that branch of the healing art in  any lan-
                           BY the same author.  (Now Ready.)

THE PRACTICE  OF  SURGERY.   Third  American  from the second  Edin-
  burgh edition.  Edited, with Additions, by F. W. Sargent, M.D , one of theSurge*ons to Will's
  Hospital, &c   Illustrated  by three  hundred and  nineteen engravings on wood.  In one large
  octavo volume, of over seven hundred pages.

  This new edition will be found greatly improved and enlarged, as well by the addition of much
new matter as by the introduction of a large and  complete series  of handsome illustrations.  An
equal improvement exists in  the  mechanical execution of the work, rendering it in every respect
a companion volume to the "Principles."
  We had occasion in a former number of this Jour-
nal, to speak in deservedly high terms of Professor
Miller's work on the " Principles of Surgery," and
we are  happy to be able  to pronounce an equally-
favorable judgment on the manner in which the pre-
sent volume  is executed.  *  *  *  We  feel no
hesitation in recommending Professor Miller's two
volumes as affording to the student what  the author
intended, namely, a complete text-book of Surgery.
—British and Foreign Medical Review.

  Although, as we are modestly informed in the
preface, it is  not put forth in rivalry of  the excel-
lent works on Practical  Surgery which already
exist, we think we may take upon ourselves to say
that it will form a very successful and formidable
rival to most of them.—Northern Journ. of Medicine.

  Taken together thev form a very condensed and
complete system of Surgery, not  surpassed,  as a
text-book, by any  work with which we are ac-
quainted.—/^, and Ind. Med. and Surg. Journal.

  Mr. Miller has said more in a few words than any
writer since the days of Celsus.—N. O.  Med. and
Surg. Journal.
                                 MALGAIGNE (J. F.)
OPERATIVE SURGERY, based on Normal and Pathological Anatomy.   Trans
  lated from the  French,  by Frederick Brittan, A. B., M D
wood.
                                                     With numerous illustrations on
In one handsome octavo volume, of nearly six hundred pages.
  "We have long been accustomed to refer to it as one
of the most valuable text-books in our library.—
Buffalo Med. and Surg. Journal.
  Certainly one of the best books published on ope-
rative surgery.—Edinburgh Medical Journal.
  To express in a few words our opinion of Mai-
gaigne's work, we unhesitatingly pronounce it the
very best guide in surgical operations that has come
before the profession in any language.—Charleston
Med. and Surg. Journal.
      MOHR (FRANCIS),  PH. D., AND REDWOOD (TH EOPH I LUS).

PRACTICAL  PHARMACY.   Comprising the  Arrangements, Apparatus, and
  Manipulations of the Pharmaceutical Shop and  Laboratory.   Edited, with extensive Additions,
  by Prof William  Procter, of the Philadelphia  College of Pharmacy.  In one  handsomely
  printed octavo volume, of 570 pages, with over 500 engravings on wood.

  It is a book, however, which will be in the hands
of almost everyone who is much interested in phar-
maceutical operations, as we know of no other pub-
lication so well calculated to fill a void long felt.—
Medical Examiner.
  The book is strictly practical, and describes only
manipulations or methods of performing the nume-
rous processes the pharmaceutist has to go through,
in the  preparation and manufacture of medicines,
together with all the apparatus and fixtures neces-
sary thereto.  On these matters, this work is very
full and complete, and details, in a style uncom-
monly clear and lucid, not  only the more compli-
cated and difficult processes, but those not less im-
portant ones, the most simple and common.—Buffalo
Medical Journal.
  The country practitioner who is obliged to dis-
pense his own medicines, will find it a most valuable
assistant.—Monthly Journal and Retrospect. 
22
BLANCHARD  & LEA'S  MEDICAL
                         MACLISE (JOSEPH),  SURGEON.


                 SURGICAL   ANATOMY.

                    FORMING ONE VOLUME, VERY LARGE  IMPERIAL QUARTO.

With Sixty-eight large and splendid Plates, drawn in the best style, and beautifully colored.

        Containing one hundred and ninety Figures, many of them the size of life.

                    TOGETHER  WITH COPIOUS AND EXPLANATORY LETTER-PRESS.

Strongly and handsomely bound in extra cloth, being one of the cheapest and best executed Surgical
                              works as yet issued in this  country.

                Copies can be sent by mail, in five parts, done up in stout covers.

  This great work being now concluded, the publishers confidently present it to the attention of the
profession  as worthy in every respect of their approbation and patronage.   No complete work of
the kind has yet been published in the  English language, and it therefore will supply a want  long
felt in this  country  of an accurate and comprehensive Atlas of Surgical  Anatomy to which  the
student and practitioner can at all times refer, to ascertain the exact  relative position of the various
portions of the human frame towards  each other and to the surface, as well as their abnormal de-
viations.  The importance of such awork to the student in the absence of anatomical material, and
to the practitioner when about attempting an operation, is evident, while  the price of the book, not-
withstanding the large  size, beauty, and finish of the very  numerous illustrations, is so low as to
place it  within  the reach of every member of the profession.  The publishers therefore confidently
anticipate a very extended circulation  for this magnificent work.

                                                vailed, both for accuracy of drawing, beauty  of
                                                coloring,  and all the requisite explanations of the
                                                subject in hand.  To the publishers, the profession
                                                in America is deeply indebted for  placing such a
                                                valuable, such a useful work, at its disposal, and
                                                at  such a moderate price.  It is one of the most
                                                finished and complete pictures of Surgical Anato-
                                                my ever  offered  to the profession  of America.—
                                                With these plates before them, the student and prac-
                                                titioner can never be at a loss, under the most despe-
                                                rate circumstances. We do not intend  these  for
                                                commonplace  compliments. We are  sincere; be-
                                                cause we  know the work will  be found invaluable
                                                to the young, no less than  the old, surgeon.  We
                                                have  not  space to  point out  its beauties, and  its
                                                merits; but we speak of  it en masse, as a whole,
                                                and strongly urge—especially those who, from their
                                                position, may be debarred the privilegeand opportu-
                                                nity of inspecting the fresh subject, to furnish them-
                                                selves with the  entire  work.—The New Orleans
                                                Medical and Surgical Journal.

                                                 This  is  by far the ablest work on Surgical Ana-
                                                tomy that has come under our observation.  We
                                                know of no other work that would justify a stu-
                                                dent,  in any degree, for neglect of actual dissec-
                                                tion.  A careful  study  of these  plates, and of the
                                                commentaries on them, would almost make an ana-
                                                tomist of a diligent  student.  And to  one who has
                                                Btudied anatomy by dissection, this work is invalu-
                                                able as a  perpetual remembrancer, in matters of
                                                knowledge that may slip  from the  memory.  The
                                                practitioner can scarcely consider himself equipped
                                                for the duties of his profession without such a work
                                                as this, and this has no rival, in his library.  In
                                                those sudden  emergencies that so often arise,  and
                                                which require the instantaneous command of minute
                                                anatomical knowledge, awork of this kind keeps the
                                                details of the dissecting-room perpetually fresh in the
                                                memory.  We appeal to our readers, whether any
                                                one can justifiably undertake the practice of medi-
                                                cine who is not prepared to give all needful assist-
                                                ance,  in all matters demanding  immediate relief.
                                                We repeat that no  medical library, however large,
                                                can be complete without  Maclise's Surgical Ana-
                                                tomy.  The American edition is well entitled to the
                                                confidence of the  profession, and should command,
                                                among them, an extensive sale.   The investment of
                                                the amount of the cost of  this work will prove to
                                                be a very profitable  one, and if practitioners would
                                                qualify themselves thoroughly with such important
                                                knowledge as is contained in works  of this kind,
                                                there would be fewer of them  sighing for employ-
                                                ment.  The medical profession should spring towards
                                                such an opportunity as is presented in this republica-
                                                tion, to encourage frequent repetitions of American
                                                enterprise of this kind.— The Western Journal of
                                                Medicine and Surgery.
   One of the greatest artistic triumphs of the age
 in Surgical Anatomy.—British American Medical
 Journal.

   Too much cannot be said in its praise; indeed,
 we have not language to do it justice.—Ohio Medi-
 cal and Surgical Journal.

   The most admirable surgical atlas we have seen.
 To the practitioner deprived of demonstrative dis-
 sections upon the human subject, it is an invaluable
 companion.—N. J. Medical Reporter.

   The most accurately engraved  and beautifully
 colored plates  we have ever seen in an American
 book—one of the best and cheapest surgical works
 ever published.—Buffalo Medical  Journal.

   It is very rare that so elegantly printed, so well
 illustrated, and so useful  a work, is ofTered at so
 moderate a price.—Charleston Medical Journal.

   Its plates can boast a superiority which places
 them almost beyond the reach of competition.—Medi-
 cal Examiner.

   Every practitioner, we think, should have a work
 of this kind within reach.—Southern Medical  and
 Surgical Journal.

   No such lithographic illustrations of  surgical re-
 gions have hitherto, we think, been given.—Boston
 Medical and Surgical Journal.

   As a surgical anatomist, Mr. Maclise  has proba-
 bly no  superior.—British and Foreign Medico-Chi-
 rurgical Review.

   Of great value to the student engaged in dissect-
 ing, and to the  surgeon at a distance from the means
 of keeping up his anatomical  knowledge.—Medical
 Times.

  The  mechanical  execution cannot be excelled.—
 Transylvania Medical Journal.

  A work which has no parallel in point of accu-
 racy and cheapness in the English language.—N. Y
 Journal of Medicine.

  To all  engaged in the study or  practice  of their
 profession, such a work is  almost indispensable.—
 Dublin Quarterly Medical Journal.

  No practitioner whose means will  admit should
 fail to possess it.—Ranking's Abstract.

  Country practitioners will find these plates of im-
mense value.—N. Y. Medical Gazette.
  We are extremely gratified to  announce to the
profession the completion of this truly magnificent
work, which,  as a whole,  certainly  stands  unri-
  m° The very low price at which this work is furnished, and the beauty of its execution,
require an extended sale to compensate the publishers for  the heavy expenses incurred. 
AND  SCIENTIFIC  PUBLICATIONS.                  23
                       MULLER (PROFESSOR J.),  M. D.

PRINCIPLES OF PHYSICS  AND METEOROLOGY.   Edited, with  Addi-
  r-Wh' w^.iT^n,LES!,ELD. Gri1™. M. D.  In  one large and handsome octavo volume, extra
  cloth, with 550 wood-cuts, and two colored plates.

nnTaM^th'^^^I^UV1 WOrk ^^ comPIete- I tion to the scientific records of this country may be
could not havebeenKknow"to English Science duly estimated by the fact that the cost of the ofigi-
o'sulpassine interest  TtJ'V^r £he wor _ is I nal Swings and engravings alone has exceeded the
01 surpassing interest.  The value of this contribu- | sum of £2,000.—Lancet.
                   MAYNE  (JOHN), M. D.,  M. R. C. S.,

A DISPENSATORY AND  THERAPEUTICAL REMEMBRANCER.  Com-
  prising the entire lists of Materia Medica, with every Practical  Formula contained in the three
  British Pharmacopoeias. With relative Tables subjoined, illustrating, by upwards of six hundred
  and sixty examples,  the Extemporaneous Forms and Combinations  suitable for the different
  Medicines.  Edited, with the addition of the Formulae of the United States Pharmacopoeia, by
  R. Eglesfeld Griffith, M. D.  In one 12mo. volume, extra cloth, of over 300 large pages.
                             MATTEUCCI (CARLO).
LECTURES ON THE PHYSICAL PHENOMENA  OF LIVING BEINGS.
  Edited by Pereira.  In one neat royal 12mo. volume, extra cloth, with cuts, 388 pages.
                             MARKWICK (ALFRED).
A GUIDE  TO  THE  EXAMINATION  OF  THE  URINE  IN  HEALTH
  AND DISEASE.  Royal 12mo.  (See Manuals on Blood and Urine.)
                MEDLOCK (HENRY),  AND F.  SCHOEDLER.

BOOK  OF  NATURE; or Elements of the Science of Physics, Astronomy, Chem-
  istry, Mineralogy, Geology, Botany, Zoology, and Physiology.  (See Schoedler.)  In one vol.,
  large 12mo.  An admirable work for families and District Schools.
                              NEILL (JOHN),  M.  D.,
Demonstrator of Anatomy in the University of Pennsylvania;  Surgeon to the Pennsylvania Hospital, &c;
                                            and
                      FRANCIS  GURNEY SMITH, M.D.,
              Professor of Institutes of Medicine in the Pennsylvania Medical College.

AN  ANALYTICAL  COMPENDIUM  OF THE  VARIOUS  BRANCHES
  OF MEDICAL SCIENCE ; for the Use and Examination of Students.  Second edition, revised
  and improved.  In one very large  and handsomely printed royal  12mo. volume, of over one
  thousand pages, with three hundred and fifty illustrations on wood.  Strongly bound in leather,
  with raised bands.   (Extensively used by students.)

                         PREFACE  TO THE NEW EDITION.
  The speedy sale of a large impression of this work has afforded to the authors gratifying evidence*
of the correctness of  the views which actuated them in  its preparation.  In meeting the demand
for a second edition, they have therefore been desirous te render it more worthy of the favor with
which it has been received.  To accomplish this, they  have  spared neither time nor labor in embo-
dying in it such discoveries and improvements as have been made since its first appearance, and
such alterations as have  been suggested  by  its practical use in the class and examination-room.
Considerable modifications have thus been introduced throughout all the departments treated of in
the volume, but more especially in the portion  devoted to  the "Practice of Medicine," which has
been entirely  rearranged and rewritten.  The authors therefore again submit their work to the
profession, with the hope that their efforts may tend, however humbly, to advance the great cause
of medical education.
  Notwithstanding the increased size and improved execution of this work,  the price has not been
increased, and it is confidently presented as one of the cheapest volumes now before the profession.
  In the  rapid course of lectures, where work for
the students is heavy, and  review necessary for an
examination, a compend is not only valuable, but
it is almost a sine qua non.  The one before us is,
in most of the divisions, the most unexceptionable
of all books of the kind that we know of.  The
newest and soundest doctrines and the latest im-
provements and discoveries are explicitly, though
concisely, laid before  the student.  Of course it is
useless for us to recommend it to all last course
students, but  there  is a class  to whom-we very
sincerely commend  this cheap  book as worth its
weight in silver — that class  is the graduates in
medicine of more than ten years' standing, who
have not studied medicine since. They will perhaps
find out from it that the science is not exactly now
what it was when they left it off.—The Stethoscope
  Having made free use of this volume in our ex-
aminations of pupils, we can speak from experi-
ence in recommending it  as an admirable compend
for students, and as especially useful to preceptors
who examine their pupils. It will save the teacher
much labor by enabling him readily to recall all of
the points upon which his pupils  should be ex-
amined. A work of this sort should be in the hands
of every one who takes pupils into his office with a
view of examining them ;  and this is unquestionably
the best of its class. Let every practitioner who has
pupils provide himself with it, and he will find the
labor of refreshing his knowledge so much facilitated
that he will be able to do justice to his pupils at very
little cost, of time or trouble to himself.—Transyl-
vania Med. Journal. 
24                     BLANCHARD &  LEA'S  MEDICAL
In
one
               NELIGAN  (J. MOORE),  M. D.,  M. R. I. A., 8ic.

A  PRACTICAL  TREATISE  ON  DISEASES   OF  THE  SKIN.
  neat royal 12mo. volume, of 334 pages.  (Just Issued.)
  We know of no other treatise on this  interesting I   The greatest value of Dr. Neligan's treatise con-
and important class of diseases that so happily meets | sists in the plain and thoroughly practical exposition
the urgent wants of the great mass of physicians.— I he has  given of this  class of maladies.—Brxt. and
N. Y. Journal of Medicine.                     I For. Med.-Chirurg. Review.
                     PHILLIPS (BENJAMIN), F.  R. S., &.C.

SCROFULA;   its Nature,  its Prevalence, its Causes, and  the Principles  of its
  Treatment.  In one volume, octavo, with a plate.
             PEREIRA  (JONATHAN), M. D., F. R. S., AND L. S.

THE  ELEMENTS   OF  MATERIA   MEDICA   AND  THERAPEUTICS.
  Third American edition, enlarged and improved by the author;  including Notices of most of the
  Medicinal Substances in  use  in the civilized  world, and forming an Encyclopedia  of Materia
  Medica.  Edited by Joseph Carson, M. D., Professor of Materia Medica and Pharmacy in the
  University of Pennsylvania.  In two very large octavo volumes, on small type, with about four
  hundred illustrations.

Volume I.—Lately issued,  containing the Inorganic Materia Medica,  over 800  pages, with  143
  illusl rations.
Volume II.—Just ready, embracing the Organic  Materia Medica, was  left by the late author in
  nearly a complete state.   The unfinished portion has been revised with his MSS., by Alfred S.
  Taylor and G. Owen Reese.  Large 8vo., 1250 pages, with plates and several hundred wood-cuts.

  The present edition of this favorite and standard work, will be found far superior to its predeces-
sors.  Besides very large additions and alterations which were  made  in the last London edition,
the work  has undergone a. thorough revision on the part of the author expressly for this country;
and has farther received numerous additions  from the editors.  It is thus greatly increased in size,
and most completely brought up to the present state of our knowledge on this important subject.
A  similar  improvement will be found in its mechanical execution, being printed with new type on
fine white paper, with a greatly extended series of illustrations, engraved in the highest style of art.
  The work, in its present shape, and so far as can
be judged from the portion before the public, forms
the most comprehensive and complete treatise on
materia  medica extant in the English language.—
Dr. Pereira has been nt great pains to introduce
into his work, not only all the information on the
natural, chemical, and commercial history of medi-
cines, which might be serviceable to the physician
and surgeon, but whatever might enable his  read-
ers to understand thoroughly the mode of prepar-
ing and  manufacturing various articles employed
either for preparing medicines, or for certain pur-
poses in the arts connected with  materia medica
and the practice of medicine.  The accounts of the
physiological and therapeutic effects of remedies are
given with great clearness and accuracy, and in a
manner calculated  to  interest  as well as instruct
the reader.—The Edinburgh Medical and Surgical
Journal.
               PAGET (JAMES), F. R. S., AND W.  S. KIRKES.
MANUAL  OF  PHYSIOLOGY.   Second American edition.   One vol., large
  12mo.  (See Kirkes.)
                         PIRRIE (WILLIAM), F. R. S. E.,
                       Professor of Surgery in the University of Aberdeen.

THE  PRINCIPLES  AND  PRACTICE'  OF  SURGERY.   Edited  by  John
  Neill, M. D., Demonstrator of Anatomy in  the University of Pennsylvania, Surgeon to the
  Pennsylvania Hospital, &c.   In one very handsome octavo volume, of 780 pages, with 316 illus-
  trations.   (Just Issued.)

  However well it may be adapted for a text-book
(and in this respect it may compete with the best of
them) of this much our reading  has convinced us,
that as a systematic treatise, it is carefully and ably
written, and can hardly fail to command a prominent
position in the library of practitioners; though not
complete in the fullest sense of the word, it never-
theless furnishes the student and practitioner with
as chaste and concise a work as  exists in  our  lan-
guage. The additions to the volume by Dr. Neill,
are  judicious; and while they render it more com-
plete, greatly enhance its practical value, as a work
for  practitioners  and  students.—N. Y. Journal of
Medicine.

  We know of no other surgical work of a reason-
able size, wherein there is so much theory and prac-
tice, or where subjects are more soundly or clearly
taught.—The Stethoscope.

  There is  scarcely a disease of the  bone or soft
parts, fracture, or dislocation, that is not illustrated
by accurate wood-engravings.  Then, again, every
instrument employed by the surgeon is thus repre-
sented.  These engravings are not only correct, but
really beautiful, showing  the astonishing degree of
perfection to which the art of wood-engraving has
arrived. Prof. Pirrie, in the work before us, has
elaborately discussed the principles of surgery, and
a safe and effectual practice predicated upon them.
Perhaps no work upon this subject heretofore issued
is so full upon the science of the art of surgery.—
Nashville Journal of Medicine and Surgery.

  We have made ourselves more intimately acquaint-
ed with its details, and can now pronounce  it  to be
one of the best treatises on  surgery in the English
language.  In conclusion, we very strongly recom-
mend  this excellent work, both to the practitioner
and student.—Canada Med. Journal.

  Our impression is, that as a manual  for students,
Pirrie's is the  best work extant.—Western Med. and
Surg. Journal. 
AND  SCIENTIFIC  PUBLICATIONS.
25
                     RAMSBOTHAM (FRANCIS  H.), M.D.

T5Sr?rSlNCIIVLES AND  PRACTICE OF OBSTETRIC  MEDICINE AND
  SURGERY, in reference to the Process of Parturition.  Sixth American, from the last London
  edition  Illustrated with one hundred and forty-eight Figures, on fifty-five Lithographic Plates.
  In one large and handsomely printed volume, imperial octavo, with 520 pages.

  In this edition, the plates have all been redrawn, and the text carefully read  and  corrected.  It
i« therefore presented as in every way worthy the favor with which it has so long been received.

                          From Prof. Hodge, of the University of Pa.
.J? tI,e ^me.rica,n Public, it is most valuable, from its intrinsic undoubted excellence, and as being
ou* Sn"        exponent of British Midwifery.  Its circulation will, I trust, be extensive throughout

  We recommend the student who desires to mas-
ter this  difficult subject with the least possible
trouble, to possess himself at once of a copy of this
work.—American Journal of the Med. Sciences.
  It stands at the head of the  long list of excellent
obstetric works published in the  lust few years in
Great Uritain, Ireland, and the Continent of Eu-
rope.  We consider this book indispensable to  the
library of every physician engaged in the practice
of midwifery.— Southern Med. and Surg. Journal.
 When  the whole profession is thus unanimous
in  placing such a work in the very first rank as
regards the extent and correctness of all the details
of the theory and practice of so important a branch
of  learning, our commendation  or condemnation
would be of little consequence;  but regarding  it
as  the most useful of all  works of the" kind, we
think it  but an act of justice to urge its claims
upon the profession.—N. O. Med. Journal.
                            RIGBY (EDWARD), M. D.
                       Physician to the General Lying-in Hospital, &c.

A  SYSTEM  OF  MIDWIFERY.   With  Notes and   Additional  Illustrations.
  Second American Edition.  One volume octavo, 422 pages.

  The repeated demands for this work, which has now for some time been out of print, have in-
duced the publishers to prepare another edition.  The reputation  which  it has acquired for the
clearness of its views,  especially as regards  the physiological portion of obstetrical science, will
secure  for it ihe confidence of the profession.  A copy of the first edition  was placed in the hands
of the late Professor Dewees, a few weeks before his death,  and obtained from him the expression
of his most favorable opinion.


                               RICORD (PH.), M. D.

HUNTER ON VENEREAL, with extensive Additions by Ricord. {Now Ready.)
  See Hunter.
                           ROYLE (J. FORBES), M.D.

MATERIA MEDICA AND THERAPEUTICS; including the Preparations of
  the Pharmacopoeias of London, Edinburgh, Dublin, and of the United  States.  With many new
  medicines.  Edited by Joseph Carson, M. D.,  Professor of Materia Medica and Pharmacy in
  the University of Pennsylvania.  With ninety-eight illustrations.  In  one large octavo volume,
  of about seven hundred pages.
  This work is, indeed, a most valuable one, and
will fill up an important vacancy that existed be-
tween Dr. Pereira's most  learned  and  complete
sj'stem of Materia Medica, and the  class of pro-
ductions on the other extreme, which are neces-
sarily imperfect from their small  extent.—British
and Foreign Medical Review.
                            REESE (G. OWEN),  M. D.

ON THE  ANALYSIS OF THE BLOOD AND URINE  IN  HEALTH AND
  DISEASE, and on the Treatment of Urinary Diseases.  Royal 12mo., with plates.   (See Blood
  and Urine, Manuals of.)

                                RICORD (P.),  M. D.

A PRACTICAL TREATISE  ON VENEREAL DISEASES.   With a Thera-
  peutical Summary and Special Formulary. Translated by Sidney Doane, M. D.  Fourth edition.
  One volume, octavo, 340 pages.
                     SKEY  (FREDERICK  C),  F. R. S.,  &.c.
OPERATIVE  SURGERY.   In one very handsome octavo volume of over 650
  pages, with about one hundred wood-cuts.
  Its literary execution is superior to most surgical
treatises.  It abounds in excellent moral hints, and
is replete with original surgical expedients and sug-
gestions.— Buffalo Med. and Surg. Journal.

  With high talents, extensive practice, and a long
experience, Mr. Skey  is perhaps competent to the
task of writing a complete work on operative sur-
gery.— Charleston Med. Journal.
  We cannot withhold from this work our high com-
mendation. Students and practitioners will find it an
invaluable teacher and guide upon every topic con-
nected with this department.—N. Y. Medical Ga-
zette.                           *

  A work of the very highest importance—a work
by itself.—London Med. Gazette. 
26
BLANCHARD & LEA'S  MEDICAL
      SHARPEY  (WILLIAM),  M. D.,  QUAIN  (JONES),  M. D.,  AND
                       QUAIN  (RICHARD),  F. R. S.,  &.C.

HUM _N  ANATOMY.   Revised, with Notes  and Additions, by Joseph Leidt,
  M.D.  Complete in  two large octavo volumes, of about thirteen hundred pages.  Beautifully
  illustrated with over five hundred engravings on wood.
                                              We have no hesitation in recommending this trea-
                                             tise on anatomy as the most complete on that sub-
                                             ject in the  English language;  and  the only one,
  It is indeed a work calculated to make an era m
anatomical study, by placing before  the  student
every  department of his science,  with a view to
the  relative importance of each ;  and so skilfully
have the different parts been interwoven,  that no
one who makes this work the basis of his studies,
will hereafter have any excuse for neglecting or
undervaluing any important particulars connected
with  the  structure of the human frame;  and
whether the bias of his mind lead him  in  a more
especial manner to surgery, physic, or physiology,
he will find here a work at once so comprehensive
and practical as to defend him from exclusiveness
on  the one hand, and pedantry  on  the other.—
Monthly Journal and Retrospect of  the Medical
Sciences.
perhaps, in any language, which brings the. state
of knowledge forward  to the most recent disco-
veries.—The Edinburgh Med. and Surg. Journal.

  Admirably calculated to fulfil the object for which
it is intended.—Provincial Medical Journal.

  The most complete Treatise on Anatomy in  the
English language.—Edinburgh Medical Journal.

  There is no work in the English language to be
preferred to Dr.  Quain's Elements of  Anatomy—
London Journal of Medicine.\
   SMITH  (HENRY  H.),  M. D., AND HORNER (WILLIAM E.)t  M. D.

AN ANATOMICAL  ATLAS, illustrative of the Structure of the Human Body.
  In one volume, large imperial octavo, with about six hundred and fifty beautiful figures.
                                             late the student upon the completion of this Atlas,
                                             as it is the most convenient work of the kind that
                                             has yet appeared ; and we must add, the very beau-
  These  figures are well  selected,  and  present a
complete and accurate representation of  that won-
derful fabric, the human body.  The plan of  this
Atlas, which renders it so peculiarly convenient
for the student, and its superb artistical execution,
have been already pointed out.  We must congratu-
tiful manner in which it is " got up" is so creditable
to  the country as to be flattering to our national
pride.—American Medical Journal.
                            SARGENT (F. W.),  M.  D.
ON BANDAGING  AND  OTHER  POINTS  OF  MINOR  SURGERY.
  one handsome royal 12mo. volume of nearly 400
  The very best manual of Minor Surgery we have
seen ; an American volume, with nearly four hundred
pages of good practical lessons, illustrated by about
one hundred and thirty wood-cuts.  In these days
of '' trial." when a doctor's reputation hangs upon
a clove hitch, or the roll of a bandage, it would be
well, perhaps,  to carry such a volume as Mr. Sar-
gent's always in our coat-pocket, or, at all  events,
to listen attentively to his instructions at home.—
Buffalo Med. Journal.
In
pages, with 128 wood-cuts.
  We have carefully examined this work, and find it
well executed and admirably adapted to the use of
the student. Besides the subjects usually embraced
in works on Minor Surgery, there is a short chapter
on bathing, another on anaesthetic agents, and an
appendix of formulae.  The author has given an ex-
cellentwork on this subject,and his publishers have
illustrated and printed it in most beautiful style.—
The Charleston Medical Journal.
                              STANLEY (EDWARD).
A TREATISE  ON  DISEASES OF THE  BONES.
  extra cloth, 286 pages.
In  one  volume, octavo,
                         SMITH (ROBERT WILLIAM).
A TREATISE  ON  FRACTURES IN THE VICINITY OF JOINTS,  AND
  ON DISLOCATIONS.  One volume octavo, with 200 beautiful wood-cuts.
                             SIMON  (JOHN), F.  R. S.

GENERAL  PATHOLOGY,  as  conducive  to  the  Establishment of  Rational
  Principles for the Prevention and Cure  of Disease.  A Course of Lectures delivered at St.
  Thomas's Hospital during the summer Session of 1850.  In one neat octavo volume.  (Lately
  Issued.)
  His views are plainly and concisely stated, and in
such an attractive manner, as to enchain the atten-
tion oV the reader, and should they be adopted by the
profession at  large, are calculated to produce im-
portant changes in medicine.  Physicians and stu-
dents will obtain from its perusal, not only the latest
discoveries in Pathology, but that which is even
more valuable, a systematic outline for the prosecu-
tion of their future studies and investigations. Alto-
gether, we look upon it as one of the most satisfactory
and rational treatises upon that branch now extant.
—Medical Examiner.
                          SMITH (TYLER  W.),  M. D.,
                  Lecturer on Obstetrics in the Hunterian School of Medicine.
ON  PARTURITION, AND  THE  PRINCIPLES  AND  PRACTICE  OF
  OBSTETRICS.  In one large duodecimo vo ume, of 400 pages.
                          SIBSON  (FRANCIS),  M. D.,
          B                  Physician to St. Mary's Hospital.

MEDICAL ANATOMY.   Illustrating the Form, Structure, and Position of the
  Internal Organs m Health and Disease.  In large imperial quarto, with splendid colored plates.
  To match "Machse's Surgical Anatomy." (Preparing.) 
AND  SCIENTIFIC  PUBLICATIONS.
27
                            SOLLY (SAMUEL), F.  R. S.
THE  HUMAN  BRAIN;   its  Structure, Physiology,  and  Diseases.   With a
  Description of the Typical Forms of the Brain  in the Animal Kingdom.  From the Second and
  much enlarged London edition.   In one octavo volume, with 120 wood-cuts.
                       SCHOEDLER (FRIEDRICH), PH.D.,
                        Professor of the Natural Sciences at AVorms, &c.

THE  BOOK  OF  NATURE;  an  Elementary  Introduction  to the  Sciences of
  Physics, Astronomy, Chemistry, Mineralogv, Geology, Botany, Zoology, and Physiology.  First
  American  edition,  with a Glossary and other  Additions and Improvements; from  the second
  English edition.  Translated from  the  sixth German edition, by Henry Mkdlock, F. C. S., &c.
  In one thick volume, small octavo, of about seven hundred pages, with 679 illustrations on wood.
  Suitable for the higher Schools and private students.  (Now Ready.)
  This volume, as its title shows, covers nearly all I seen presents the reader with so wide a range of ele-
the sciences, andI embodies a vast amount of informa-  mentary knowledge, with so full illustrations, at so
                  No  other work that we have | cheap a rate__Silliman's Journal, Nov. 1853.
tion for instruction.
                     TAYLOR  (ALFRED S.),  M.  D., F.  R. S.,
                Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital.

MEDICAL JURISPRUDENCE.   Third American, from the fourth and improved
  English Edition.  With Notes and References to American Decisions, by Edward Hartshorne,
  M. D.   In one large octavo volume, of about seven hundred pages.   (Now Ready.)
  In the preparation of the English edition, from which this has been printed, the author hasfound
it necessary to revise the whole of the chapters, as well as to make numerous alterations and addi-
tions, together with references to many recent cases of importance.  A Glossary has also been
added for the convenience of those whose studies have not been directed specially to this subject.
The notes of the American editor embrace the additions formerly made by Dr. Griffith, who revised
the work on its first appearance in this country, together with such new matter as his experience
and the progress of the science have shown to be advisable.   The work may therefore be regarded
as fully on a level with the most recent discoveries, and worthy of the reputation which it has ac-
quired as  a complete and compendious guide for the physician and lawyer.
  So well is this work known to the members borh
of the medical and legal professions, and so highly
is it appreciated by them, that it cannot be necessary
for us to say a word in its commendation ; its having
already reached a fourth edition being the best pos-
sible testimony  in its favor. The author has ob-
viously subjected the entire work  to a very careful
revision.   We find scattered through  it numerous
additions and alterations, some of them of consider-
able importance; and reference is made to a large
number of cases which have occurred since the date
of the last publication.—British and Foreign Med.-
Chirurg. Review.

  This work of Dr. Taylor's is generally acknow-
ledged to be one of the ablest extant on the subject
of medical jurisprudence.  It-is certainly one of the
most attractive books that we have met with; sup-
plying so much  both to interest and instruct, that
we do not hesitate to affirm that after having once
commenced its perusal, few could be prevailed upon
to  desist before completing it.  Jn the last London
edition, all the newly observed and accurately re-
corded facts have been inserted, including much that
is recent of Chemical, Microscopical, and Patholo-
gical research, besides papers on numerous subjects

                                  BY THE SAME AUTHOR.

ON POISONS,  IN  RELATION TO  MEDICAL  JURISPRUDENCE  AND
  MEDICINE.  Edited, with Notes and Additions, by R. E. Griffith, M. D.  In one large octavo
  volume, of 688 pages.
never before published; in the supervision of this,
the third American, one of the last labors of the la-
mented Dr. Griffith, we find a goodly number of notes
and additions.  The publishers deserve the support
of the profession for the  publication of a work of
such sterling merit.—Charleston  Medical  Journal
and Review.

  It is not excess of praise  to say that the volume
before us is the very best treatise extant on Medical
Jurisprudence.  In saying this, we do not wish to
be understood as detracting from  the merits of the
excellent  works of Beck, Ryan,  Traill, Guy, and
others; but in interest and value  we think it must
be conceded that Taylor is superior to anything that
has preceded it.  The author is already well known
to the profession by his valuable treatise on Poisons;
and the present volume will add  materially to his
high  reputation for accurate and  extensive know-
ledge and discriminating judgment. Dr Griffith has,
in his notes, added many matters of interest with
reference to American Statute Law, &c, so that the
work is brought completely up to the wants of the
physician and lawyer at the present day.—iV. IV.
Medical and Surgical Journal.
 The most elaborate work on the subject that our
literature possesses.—British and Foreign Medico-
Chirurgical Review.
 It contains a vast body of facts, which embrace
all that is important in toxicology, all  that is
  One of the most practical and trustworthy works
on Poisons in our language.—Western Journal of
Medicine.
  It is, so far as our knowledge extends, incompa-
rably the best upon the subject;  in the highest de-
an blldb  la liii|/vi.uu. in ll'AlU'lt'^,, all  UlUt JO i laui^ tilt UCQl UJJUII LUG BUMJGl^b, 111 LUC IllglllTSL UC"
necessary to the guidance of the medical jurist, and J gree creditable to the author, entirely trustworthy,
all that can be desired by the lawyer. — Medico- j and indispensable to the student and practitioner.—
Chirurgical Review.                             N. Y. Annalist.
                   THOMSON (A. T.),  M. D., F. R. S.,  &,c.
DOMESTIC MANAGEMENT  OF  THE  SICK  ROOM, necessary  in  aid  of
  Medical Treatment for the Cure of Diseases.  Edited by R. E. Griffith, M. D.   In one large
  royal 12mo. volume, with wood-cuts, 360 pages.
                            TOMES (JOHN),
A MANUAL  OF DENTAL PRACTICE.
  on wood.  In one handsome volume.   (Preparing.)
F.  R. S.
Illustrated by numerous engravings 
28
BLANCHARD &  LEA'S  MEDICAL
         TODD (R. B.),  M. D.,  AND  BOWMAN  (WILLIAM), F. R. S.

PHYSIOLOGICAL  ANATOMY  AND  PHYSIOLOGY  OF  MAN.   With
  numerous handsome wood-cuts.  Parts I, II, and III, in one octavo volume, 552 pages.  Part IV
  will complete the work.
  The distinguishing peculiarity of this work is, that the authors investigate for themselves every
fact asserted; and it  is the immense labor consequent upon  the vast number of observations  re-
quisite to carry out this plan, which has  so  long delayed the appearance of its completion.  Part
IV, with numerous original illustrations, is  now appearing in the Medical News and Library  for
1853.  Those who have subscribed since the appearance of the preceding portion of the work can
have the three parts by mail, on remittance of $2 50 to the publishers.
  TRANSACTIONS OF  THE AMERICAN  MEDICAL ASSOCIATION.

VOLUME VI, for 1853, large  8vo., of 870 pages, with numerous  colored  plates
  and wood-cuts.
Also to be had. a few sets of the Transactions from 1848 to 1853,  in six large  octavo volumes,
  price $25.  These volumes are published by and sold on account of the Association.
                        WATSON  (THOMAS),  M. D.f  &.C.

LECTURES  ON  THE  PRINCIPLES  AND  PRACTICE  OF  PHYSIC.
  Third American, from the last London edition.  Revised, with Additions, by D. Francis Condie
  M. D , author of a "Treatise on the Diseases of Children," &c.  In one octavo volume, of nearly
  eleven hundred large pages, strongly bound with raised bands.
  To say that it is the very best work on the sub-
ject now extant, is but to echo the sentiment of the
medical press throughout  the  country. — N. O.
Medical Journal.

  Of the text-books recently republished Watson is
very justly the principal  favorite.—Holmes's Rep.
to Nat. Med.  Assoc.

  By universal consent the work ranks among  the
very best text-books in our language.—Illinois and
Indiana Med. Journal.

  Regarded on all hands as  one of the very best, if
not  the very  best,  systematic treatise on practical
medicine extant.—St. Louis  Med. Journal.
  We consider this as the ablest work in the En-
glish language, on the subject of which it trents;
the author being  the first stethoscopist of the day.
—Charleston Medical Journal.

  The examination we have given the above work,
convinces us that it is a complete system or treatise
upon the great speciality of Physical Diagnosis. To
give the reader a more perfect idea of what it con-
AT  THE  BEDSIDE   AND   AFTEE
  Published under the authority of the London
  handsome volume, royal 12mo , extra cloth   (J
  Did not the perusal of the work justify the high
opinion we have of it, the names of Dr. Walshe, the
originator, and of Dr. Ballard,  as the editor of the
volume, would almost of itself have satisfied us that
it abounds in minute  clinical accuracy.  We need
not say that the execution of the whole reflects the
highest credit  not only upon  the gentlemen  men-
tioned, but upon all  those engaged upon its produc-
tion.  In conclusion, we  are  convinced that the
possession of the work will be almost necessary  to
every member of the profession—that it  will be
found indispensable to the practical physician, the
pathologist, the medical jurist,  and above all to the
medical student.—London Medical Times.

  We hail the appearance of this book as the grand
desideratum.—Charleston Medical Journal.

  This little work, if carefully read by even old
practitioners, cannot fail to be productive of much
good; as a guide to the younger members of the pro-
fession in directing  their attention specially to the
best mode of investigating  cases so as to arrive at
   Confessedly one of the very  best works on the
 principles and practice of physic in  the English or
 any other language.—Med. Examiner.
   Asa text-book it has no equal; as a compendium
 of pathology and practice no superior.—New York
 Annalist.
   We know of no work better calculated for being
 placed in the hands of-the student, and for a text-
 book; on every  important point the author seems
 to have posted  up his  knowledge to the  day.—
 Amer. Med. Journal.
   One of the most practically  useful books that
 ever was presented to the student. — N. Y. Med.
I Journal.
tains, we should be glad to copy the whole table of
contents and make some extracts from its pages, but
our limits forbid.  We have no hesitation in recom-
mending the work as one of  the most complete on
this subject in the English language; and yet it is
not so voluminous as to be objectionable on this ac-
count,  to any  practitioner,  however pressing his
engagements.—Ohio Medical and Surgical Journal.
\   DEATH,  IN   MEDICAL   CASES.
 Society for Medical Observation.  In one very
hist Issued.)

correct diagnosis,  it will prove exceedingly valua-
ble.  The great difficulty with beginners, who have
not been under the immediate training of an expe-
rienced  physician, is  continually found to be in the
appreciation of the true condition of the organs and
tissues.   Let  such provide themselves  with this
work and study it thoroughly, and they will find
much of the difficulty removed.—Southern Medical
and Surgical Journal.

  This  is truly a very capital book.  The whole
medical world will reap advantages from its publi-
cation.  The medical journals will soon show  its
influence on the character of the ;' Reports of Cases"
which they publish.  Drs. Ballard and Walshe have
given to the  world,  through  a small  but useful
medical organization, a cheap but invaluable book.
We do advise  every reader of this notice to buy it
and use  it.  Unless he is so vain as to imagine him-
self superior to the ordinary human capacity, he will
in six  months see its inestimable advantages.—
Stethoscope.
                             WALSHE  (W.  H.),  M.  D.,
         Professor of the Principles and Practice of Medicine in University College, London.
DISEASES   OF  THE  HEART,  LUNGS,  AND   APPENDAGES;   their
  Symptoms and Treatment.  In one handsome volume, large royal 12rao., 512 pages.
WHAT  TO OBSERVE 
AND SCIENTIFIC  PUBLICATIONS.                  29
                     WILSON  (ERASMUS),  M.D.,  F. R. S.,
                                Lecturer on Anatomy, London.

A SYSTEM  OF  HUMAN  ANATOMY,  General and Special.   Fourth Ameri-
  can, from the last English edition.  Edited by Paul B. Goddard, A. M., M. D.   With two hun-
  dred and fifty illustrations.  Beautifully printed, in one large octavo volume, of nearly six hun-
  dred pages.
  In many, if not all the Colleges of the Union, it
has become a standard text-book.  This, of itself,
is sufficiently expressive of its value. A work very
desirable  to  the student;  one, the  possession  of
which will greatly facilitate  his progress in the
study of Practical Anatomy.—New York Journal of
Medicine.

  Its author ranks with  the highest on Anatomy.—
Southern Medical and Surgical Journal.
  It offers to the student all the assistance that can
be expected from such a work.—Medical Examiner.
  The most complete and convenient manual for the
student we possess.—American Journal of Medical
Science.
  In  every respect, this  work as an  anatomical
guide for the student and practitioner, merits our
warmest and most decided praise.—London Medical
Gazette.
                                  BY THE SAM^ AUTHOR.

THE  DISSECTOR;   or,  Practical and  Surgical Anatomy.   Modified  and'Re-
  arranged, by Paul Beck Goddard, M. D.  A new edition, with Revisions and Additions.  In
  one large and handsome volume, royal 12mo., with one hundred and fifteen illustrations.

  In passing this work again through the press, the  editor has made such  additions and improve-
ments as the advance of anatomical knowledge  has rendered necessary to maintain the work in the
high reputation which it has acquired in the schools of the United States, as a complete and faithful
guide to the student of practical anatomy.  A number of new illustrations  have been added, espe-
cially in the portion relating to the complicated anatomy of Hernia.  In mechanical execution the
work will be found superior to former editions.
                                  BY THE SAME AUTHOR.

ON  DISEASES  OF  THE  SKIN.   Third American, from the third  London
  edition.   In  one neat  octavo volume, of about  five hundred pages, extra cloth.  (Just Issued.)

Also, to be had done up with fifteen beautiful steel  plates, of which eight are exquisitely  colored ;
  representing the Normal and Pathological Anatomy of the Skin, together with accurately colored
  delineations  of more than sixty varieties of disease, most of them the size of nature.  The Plates
  are also for sale separate, done up in boards.

  The increased size of this edition is sufficient evidence that the author has not been content
with a mere republication, but has endeavored to maintain the high character of his work as the
standard text-book on this interesting and difficult class of diseases.  He has thus introduced such
new matter as the experience of the last three or four years has suggested, and has made  such
alterations as the progress of scientific investigation has rendered expedient.  The illustrations have
also been materially augmented, the number of plates being increased from eight to sixteen.
  The "Diseases of the Skin,"  by Mr. Erasmus
Wilson, may now be regarded as the standard work
in that  department of  medical  literature.   The
plates by which this edition is accompanied leave
nothing to be desired, so far as excellence of delinea-
tion  and perfect accuracy of illustration are con-
cerned.—Medico-Chirurgical Review.

  As a practical guide to the classification, diag-
nosis, and treatment of the diseases of the skin, the
book is  complete.  We  know nothing, considered
in this aspect,  better in our language; it is a safe
authority on all  the ordinary matters which, in
this range of diseases,  engage  the practitioner's
attention, and possesses the high quality—unknown,
we believe, to every older manual—of being on a
level with science's high-water mark; <l sound book
of practice.—London Med. Times.

  Of these plates it is impossible to speak too highly.
The representations of the various forms of cuta-
neous disease are singularly accurate, and the color-
ing exceeds almost anything we have  met with in
point of delicacy and finish.—British and Foreign
Medical Review.
BY THE SAME  AUTHOR.
OX   CONSTITUTIONAL  AND  HEREDITARY   SYPHILIS,  AND   ON
  SYPHILITIC ERUPTIONS.  In one small octavo volume, beautifully printed, with four exqui-
  site colored plates, presenting more than thirty varieties of syphilitic eruptions.
 This, in many respects, is a remarkable work, pre-
senting views of theory and principles of practice
which, if true, must change completely the existing
state of professional opinion.—New York Journal of
Medicine.

 Dr. Wilson's views on  the general  subject of
Syphilis appear to us in the main  sound and judi-
cious, and we commend the book  as  an excellent
monograph on the subject.  Dr. Wilson has pre-
sented  us a very faithful and lucid description of
Syphilis and  has cleared up many obscure points in
connection with its  transmissihility, pathology and
sequelae. His facts and references will, we are satis-
fied, be  received  us decisive,  in regard to many
questiones vexutre.  They appear to  us entitled  to
notice at some length. We have perhaps been some-
w at prodigal of space in our abstract of this book.
But it is certainly a very good resume of received
opinions on Syphilis, and presents, to many, original
and striking views on the subject —Med. Examiner.
                  WHITEHEAD  (JAMES),  F. R. C. S.f  &.c.

THE CAUSES  AND  TREATMENT  OF  ABORTION  AND  STERILITY;
  being the Result of an Extended Practical Inquiry into the Physiological and Morbid Conditions
  of the Uterus.  In one volume, octavo, 368 pages. 
30
BLANCHARD  & LEA'S MEDICAL
                                  WILDE (W.  R.),
                 Surgeon to St. Mark's Ophthalmic and Aural Hospital, Dublin.
AURAL  SURGERY, AND THE NATURE  AND  TREATMENT OF  DIS-
  EASES OF  THE EAR.  In one handsome octavo volume, with illustrations.. (Now Ready.)
  So little is generally known in this country concerning the causes, symptoms, and treatment of
aural affections, that a practical and scientific  work on that subject,  from  a practitioner of Mr.
Wilde's great experience, cannot  fail to be productive of  much benefit, by attracting attention
to this obscure class of diseases, which too frequently escape attention until past relief.  The im-
mense  number of cases which have come under Mr. Wilde's observation for many years, have
afforded him opportunities rarely enjoyed for investigating this  branch  of medical science, and hii
work may therefore be regarded as of the highest authority.


                           WEST  (CHARLES),  M. D.,
                   Senior Physician to the Royal Infirmary for Children, &c.

LECTURES  ON  THE  DISEASES OF  INFANCY  AND  CHILDHOOD.
  In one volume, octavo, of four hundred and fifty pages.
                                             Every portion of these lectures is marked by a ge-
                                            neral accuracy of description, and by the soundness
                                            of the views set forth in relation to the pathology
  The Lectures of Dr. West, originally published in
the London Medical Gazette, form a most valuable
addition to this branch of practical medicine. For
many years physician to the Children's Infirmary,
his opportunities for observing their diseases have
been  most extensive, no  less than 14,000 children
having been brought under his notice during the past
nine years. These have evidently been studied with
great care, and the result has been the production of
the very best work in our language, so far as it goes,
on the diseases of this class  of our patients. The
symptomatology and pathology of their diseases are
especially exhibited most clearly; and we are con-
vinced that no one can read with care these lectures
without deriving  from them instruction of the most
important kind.—Charleston Med. Journal.
and therapeutics of the several maladies treated of.
The lectures on the diseases of the respiratory ap-
paratus, about one-third of the whole number, are
particularly excellent, forming one of  the fullest
and most able accounts of these affections, as they
present themselves during infancy and childhood,
in the English language.  The history of the  seve-
ral forms of phthisis during these periods of exist-
ence, with  their management, will be read by all
with deep  interest.—The American Journal of the
Medical Sciences.
                    WILLIAMS (C.  J.  B.i, M. D., F.  R. S.,
                Professor of Clinical Medicine in University College, London, &c.

PRINCIPLES  OF  MEDICINE;  comprising General  Pathology and  Therapeu-
  tics, and a brief general view of Etiology, Nosology, Semeiology, Diagnosis,  Prognosis, and
  Hygienics.  Edited, with Additions, by Meredith Clymer, M.D.  Fourth American, from the
  last and enlarged London edition.   In one octavo volume, of nearly five hundred pages.   Now
  Ready.  This new edition has been materially enlarged and brought up by the editor.
  It possesses the strongest claims to the  attention of the medical student and practitioner, from
the admirable manner in which the various inquiries in the  different branches of pathology are
investigated, combined, and generalized by an experienced practical physician, and directly applied
to the investigation  and treatment of disease.—Editor's Preface.
  The best exposition in  our language, or, we be- I  Few books have proved more useful, or met with
lieve, in  any language, of rational medicine, in its | a more ready sale  than  this, and  no practitioner
present improved  and  rapidly improving  state.— I should regard his library as complete without it.
British and Foreign Medico-Chirurg. Review.     \ —Ohio Med. and Surg. Journal.

                                 BY THE SAME AUTHOR.

A PRACTICAL  TREATISE  ON DISEASES  OF THE  RESPIRATORY
  ORGANS;  including Diseases of the Larynx,  Trachea, Lungs, and Pleurae. With numerous
  Additions and Notes, by M. Clymer, M. D.  With wood-cuts.  In one octavo volume, pp. 508.
                           YOUATT (WILLIAM),  V. S.

THE  HORSE.    A  new edition, with numerous illustrations;  together  with  a
  general history of the Horse; a Dissertation on the American Trotting Horse; how Trained and
  Jockeyed; an Account of his Remarkable Performances; and an Es:_y on the Ass and the Mule.
  By  J.' S. Skinner, formerly Assistant  Postmaster-General,  and Editor of the Turf Register.
  One large octavo volume.

                                 BY THE SAME AUTHOR.

THE DOG.  Edited by  E. J.  Lewis,  M. D.   With  numerous  and  beautiful
  illustrations.   In one very handsome volume, crown 8vo., crimson cloth, gilt.



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the postage p'aid, on application to the Publishers, by inclosing a three cent postage stamp. 
AND SCIENTIFIC  PUBLICATIONS.                   31
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